**3. Models of misuse and methods of treatment**

## **3.1. The diversification of substances**

Drug Act established the requirement that medications with opiates and other drugs must provide a list of ingredients. This made opium and cocaine were early casualties of regula‐

The Harrison Narcotic Act was passed in 1914 by the United States government. The origi‐ nal intention of the bill was to place a special tax on opium and coca, but the effect was to eliminate legal opiates. Alcohol and tobacco were also soon to be subject to growing legal pressure. Tobacco was not traditionally used in the form of modern cigarettes, but tobacco habits were fostered by the development of modern cigarettes, leading to large increases in

The battle over alcohol was even to be more visible and controversial. Andrew Volstead of Minnesota saw his name attached to the Eighteenth Amendment to the United States Constitution. The result of the "Volstead Act" (H.R. 6810) was that from 1920 until 1933, and the manufacture, sale, and consumption of alcohol were prohibited in the United States. The failure of prohibition leads to the Twentieth Amendment that repealed federal prohibition in 1933. The states gradually repealed their own legislation ending with Mississippi in 1966. As one alternative to the futility of broad prohibition, legally mandated treatment for substance abusers is now widely practiced [11], and legally mandated treatment is seen as a sensible approach for persons whose criminal offense is substance related. The intention is to direct the convicted individual to a system in which treatment is a more central focus then would be expected in a traditional correctional context. Critics of the approach question the propriety

Another common perspective on treatment of substance-related problems emerged from spiritual traditions. Spiritual traditions provided the foundation for a variety of approaches to substance-related problems. Some of this influence has been direct and some indirect. For example, a movement as broad as the American temperance movement was substantially derived from the evangelical movement. The Benjamin Rush speculated that religion by itself could "carry the day" with substance abusers [12]. The early view that religious experiences were an important path to recovery was bolstered by the perspectives of some early mental health professionals. Some professionals in health care were skeptical of religious ap‐ proaches and others opined that religious approaches were only good for certain patients. Even within psychology, there were advocates for spiritually based intervention. The prominent work of George Cutton's *The Psychology of Alcoholism* (1907) and the broad work of the pragmatist William James (non-practicing M.D. and Harvard psychologist) went far to legitimize the spiritual view. James was well known because of the variety of his contribu‐ tions related to psychology. James operationalized the center of religious conversion as anti-Christian by referring to it as "the hot place in a person's consciousness … The habitual center of one's personal energy ([13], p. 196)." Despite knowing that reports of religious conversion experiences would be met with skepticism in a professional community of materialists, James felt that the results or specific components of spiritual interventions should be considered independent of the underlying assumptions of a particular spiritual perspective. The contin‐

tion attempts [10].

tobacco use between 1900 and 1910.

146 Recent Advances in Drug Addiction Research and Clinical Applications

and efficacy of this strategy.

**2.4. Spiritual traditions and intervention**

Many types of substances have been used throughout history for a host of purposes. Early North American settlers used a variety of preparations for a variety of medicinal and recrea‐ tional purposes. Until the late 1800s, it was easy for opponents of substance use to locate their targets. Many substances began as legitimate medications and became used outside the clinic. Despite the widespread use of a variety of substances, it was not until the Controlled Substance Act of 1970 that anti-substance law began to keep up with the great variety of substances that are used. The proliferation and diversification of substance use, the variety of substance pharmacologic action, the impact of route of administration, and the host of socio-cultural factors have all been significant in the development of effective treatment methods [17].

Tobacco was first introduced to Europeans by Native Americans. Sailors adopted tobacco, both smoking the leaf and chewing it and brought tobacco home to Europe. By the time of the Civil War, alcohol and tobacco were established and clearly the most common American substan‐ ces associated with problematic use.

Marijuana use has a long and complex history. Varied types of cannabis existed long before its appearance in the United States. Cannabis sativa was available in the early days of the new world, first appearing in South America in the 1500s [16]. Varieties of cannabis were both a medicinal/recreational substance and a critical crop for the American colonies in the 1700s. Hemp was grown for its fiber, and it was a major export for farmers as well as a source of rope and sail material. In the 1800s, hemp plantations thrived in Staten Island, New York, as well as in Mississippi, Georgia, California, South Carolina, and Nebraska [17].

At the same time that Hemp was so commercially and strategically significant, cannabis sativa was becoming better known. Cannabis was known to have been used for thousands of years in China, and "marijuana" became a widely accepted medication in the nineteenth century. Limited non-medical use of cannabis began to appear and the allegedly scandalous behavior of cannabis users was a featured item in the popular press in the early decades of the 1900s [17]. Publicity associated with anti-cannabis sentiments demonized the substance and patterns of its use and manifest subtle themes of bigotry against Mexican people.

Opium was a new entry to the American scene in the 1800s. Railroad laborers from China brought their opium smoking habit with them as they were hired by railroad magnates as less

expensive labor than Americans. The connection between opium and the displacement of American workers was not to be forgotten and became a part of legislation that emerged later. However, the use of opium was not regulated by the mid-1800s, so opium and its extrac‐ tions were readily available. For medical purposes, morphine had been derived from opium in the early 1800s and became an ingredient in some patent medicines (discussed below) in the United States. A vibrant patent medicine industry developed in the United States, with widespread marketing and distribution of a many products that contained large quantities of opium. These "medicines" claimed to cure just about anything, but they were really a vehicle for opium at an inexpensive price [17]. Perhaps, the most commercially dramatic develop‐ ment among the opioids was heroin. The Bayer Company first marketed heroin in 1898 as an (allegedly) addiction-free pain medication as well as a curative for abuse of other opioids.

Cocaine has a long history that first appeared in accounts of the chewing of coca leaves by the native populations of South America [17]. By 1844, cocaine had been isolated in pure form, though little use of it was made until later in the century. In the late 1870s, cocaine was used for the treatment of alcoholism and morphine addiction. In the 1880s, Sigmund Freud became aware of the use of cocaine to sustain Bavarian soldiers and started to experiment himself. He published his exuberance quickly, but he came to see cocaine as more problematic than he originally reported. Other distinguished medical professionals saw cocaine's beneficial potential. William Stewart Halstead found the mood enhancing and anesthetic properties of cocaine in the mid-1880s.

Amphetamines were first created in the laboratory in 1887, but it took 40 years for clinical applications to be realized. Military physicians used these stimulants for various purposes in the combat theater as well as in clinics. Illicit use increased in the military in the 1950s [17], and the use was also seen in truck drivers and students for a variety of medical conditions.

By the 1870s, Native Americans had begun ritual use of peyote, as had the Aztecs before them. For the Comanches, Cheyennes, Arapahoes, and other tribes, peyote rituals were a complete‐ ly religious practice, requiring total abstinence from alcohol. Among these tribes, alcohol was considered to be a substance of considerable abuse. White land speculators sought to have peyote outlawed as a way to join with Christian missionaries and secure the Indian land. Much like other pursuits of criminalization of substances, there was a powerful motive that was different than the overt motivation [17].

As existing medications took more complex and pure forms, there was an increase in the promotion of "patent medicines." These preparations were promoted with great vigor, so had creative names and claims of effectiveness that were more associated with marketing than clinical effect. These preparations that were not actually patented were produced in England and began to appear in the colonies in the 1700s. The production of patent medications grew independently in the United States in the nineteenth century and was available through a wide range of vendors. Alcohol, cocaine, and morphine were common ingredients [18, 19]. These products included Laudanum (an alcohol preparation that originally included all of the opium alkaloids), Vin Mariani (a wine with coca leaves), and Coca-Cola (with cocaine as an ingredi‐ ent).

In 1943, Dr. Albert Hofmann discovered what came to be a popular and widely used halluci‐ nogen, lysergic acid diethylamide (LSD). Working with the fungus ergot to isolate compo‐ nents for pharmaceuticals, he accidentally ingested a small amount of the substance and had what has been described as the "first acid trip." Despite his careful account of the experience in a professional publication [20], his serendipitous discovery has been widely repeated and distorted. Hofmann went on to do further research in several areas and was persistent throughout his career in his criticisms of public claims of the great dangers of LSD.

#### **3.2. Expanding treatment in the early twentieth century**

expensive labor than Americans. The connection between opium and the displacement of American workers was not to be forgotten and became a part of legislation that emerged later. However, the use of opium was not regulated by the mid-1800s, so opium and its extrac‐ tions were readily available. For medical purposes, morphine had been derived from opium in the early 1800s and became an ingredient in some patent medicines (discussed below) in the United States. A vibrant patent medicine industry developed in the United States, with widespread marketing and distribution of a many products that contained large quantities of opium. These "medicines" claimed to cure just about anything, but they were really a vehicle for opium at an inexpensive price [17]. Perhaps, the most commercially dramatic develop‐ ment among the opioids was heroin. The Bayer Company first marketed heroin in 1898 as an (allegedly) addiction-free pain medication as well as a curative for abuse of other opioids.

148 Recent Advances in Drug Addiction Research and Clinical Applications

Cocaine has a long history that first appeared in accounts of the chewing of coca leaves by the native populations of South America [17]. By 1844, cocaine had been isolated in pure form, though little use of it was made until later in the century. In the late 1870s, cocaine was used for the treatment of alcoholism and morphine addiction. In the 1880s, Sigmund Freud became aware of the use of cocaine to sustain Bavarian soldiers and started to experiment himself. He published his exuberance quickly, but he came to see cocaine as more problematic than he originally reported. Other distinguished medical professionals saw cocaine's beneficial potential. William Stewart Halstead found the mood enhancing and anesthetic properties of

Amphetamines were first created in the laboratory in 1887, but it took 40 years for clinical applications to be realized. Military physicians used these stimulants for various purposes in the combat theater as well as in clinics. Illicit use increased in the military in the 1950s [17], and the use was also seen in truck drivers and students for a variety of medical conditions.

By the 1870s, Native Americans had begun ritual use of peyote, as had the Aztecs before them. For the Comanches, Cheyennes, Arapahoes, and other tribes, peyote rituals were a complete‐ ly religious practice, requiring total abstinence from alcohol. Among these tribes, alcohol was considered to be a substance of considerable abuse. White land speculators sought to have peyote outlawed as a way to join with Christian missionaries and secure the Indian land. Much like other pursuits of criminalization of substances, there was a powerful motive that was

As existing medications took more complex and pure forms, there was an increase in the promotion of "patent medicines." These preparations were promoted with great vigor, so had creative names and claims of effectiveness that were more associated with marketing than clinical effect. These preparations that were not actually patented were produced in England and began to appear in the colonies in the 1700s. The production of patent medications grew independently in the United States in the nineteenth century and was available through a wide range of vendors. Alcohol, cocaine, and morphine were common ingredients [18, 19]. These products included Laudanum (an alcohol preparation that originally included all of the opium alkaloids), Vin Mariani (a wine with coca leaves), and Coca-Cola (with cocaine as an ingredi‐

cocaine in the mid-1880s.

different than the overt motivation [17].

ent).

Before the Second World War, there were relatively few treatment alternatives for a person in trouble with substance use. Concerned persons and some healthcare professionals com‐ plained about the limited treatment options, but most addiction treatment centered on the management of withdrawal symptoms (now known as detoxification). The result of the lack of treatment was increased the expansion of where addicts would seek mood-altering substances. The lack of treatment and expanding drug seeking combined with advancing criminalization led to the evolution of a new category of criminal. In addition, the United States Public Health Service became involved in the problem of addiction in the 1920s. State facilities for psychiatric patients and prisons were being overcrowded because of the arrests follow‐ ing the Harrison Narcotic Act [17]. In 1929, the Porter Act was passed, allocating funds to develop to rehabilitation facilities. The first results of this legislation were the new facilities in Lexington, Kentucky (1935) and Forth Worth Texas (1938). Treatment consisted primarily of withdrawal, convalescence, and rehabilitation. Outcome studies yielded disappointing results.

Three groups were critical to the development of what has become known as the "modern alcoholism movement." The Research Council on Problems of Alcohol, the Yale Center of Alcohol Studies, and the National Committee for Education on Alcoholism combined to promote a host of initiatives aimed at promoting treatment [21]. Following the Second World War, there was increasing understanding about substance abuse disorders and the need to organize public health efforts. The "disease model" (discussed below) was instrumental in promoting significant discussions about substance-related problems. Most treatment still occurred in general hospitals, state psychiatric hospitals, and private sanitariums. It is also significant that freestanding treatment programs began to appear. Many of the early free‐ standing programs became well known because of the unique ways in which they were developed. What came to be important to all of the treatment efforts that began to emerge was the nature of each facility's connection to alcoholics anonymous.

#### **3.3. Alcoholics and narcotics anonymous**

Alcoholics anonymous was established in 1935, and the eponymously named book of the central tenets of AA was published in 1939. AA is based on 12 "steps" that are central to the process of recovery and are considered to be indispensable to success. These steps are part of a program that is codified in the "Big Book" and is very specific about being effective for 75% of the participants [21]. With an avowed spiritual foundation (e.g., Step 2: "Came to believe that a Power greater than ourselves could restore us to sanity" and Step 5: "Admitted to God, to ourselves, and to another human being the exact nature of our wrongs"), AA developed a strong following and claimed considerable success. When AA was established, the treat‐ ment industry and the understanding of addiction could reasonably describe as being in its infancy. Despite claims made in the Big Book, the efficacy of AA is very difficult to submit to rigorous empirical evaluation due to the structure and procedures of the organization [22].

As noted above, the range of substances used and the associated problems expanded in the early twentieth century. Efforts to assist users of substances other than alcohol gradually expanded. By the mid-1940s, AA's co-founder Bill Wilson discussed the possibility of a group for a drug addicts that was separate from AA.

The first realization of Wilson's idea was called NARCO; it first appeared in 1947 and met weekly at the United States Public Health Service's treatment center in the Lexington, Kentucky federal prison. By the end of the 1940s, a NARCO member started a short-lived group called "Narcotics Anonymous" in the New York Prison System. By 1953, Narcotics Anony‐ mous was clearly established in California [17]. Early members, many of whom were from AA, worked out the 12 Traditions for the new organization. Within a year, the first NA publica‐ tion was printed, called the "Little Brown Book." There was controversy in AA and NA regarding Bill Wilson's experimentation with LSD. While he experimented under the super‐ vision of a psychiatrist and a psychologist, the use of another drug (in addition to alcohol) was seen as antithetical to the letter and spirit of "Anonymous" teachings.

AA continues to foster a spiritual foundation and works to alter the thinking of alcoholics through "spiritual awakening." Studies of the effectiveness of AA have not produced clear results. AA is supported primarily by voluntary donations, and meetings are held in a vast array of facilities, including prisons, treatment facilities, hospitals, and churches. AA groups are available in most towns in the United States. Despite the relative paucity of efficacy studies, AA has been recognized by professional groups [21]. In addition, despite initial scorn by much of the medical profession, the American Medical Society recommended use of such self-help groups in 1979.

#### **3.4. The moral and disease models**

#### *3.4.1. The moral model*

Modern medical views of substance misuse claim to view the problem as a medical, rather than moral, problem. This appears to refrain from giving serious consideration to morality or values as the foundation for the problem. However, there is considerable evidence, in public opinion and its reflection in political discourse and the law, that substance misuse continues to be viewed as a moral problem. Consistent with current views, there is extensive history of morality as a dominant component of the views of substance abuse by many [23]. The moral view was, in part, a part of an absence of other useful perspectives. However, there is also substantial evidence for social control exerted from class and culture-related factors [24, 25]. Social groups who were so oriented would promote public campaigns in which misinforma‐ tion and inflammatory information were promoted related to the types of substances used, the nature of substance use, and other conduct associated with substance use. Substance use and certainly misuse was proclaimed to be a manifestation of misplaced values and lack of moral standing. Today, criminal penalty remains a dominant approach to substance-related problems, despite considerable evidence that argues against the practical value of such an approach. Some elements of faith-related perspectives, while offering assistance to some users, continue to communicate judgment of these problems.

#### *3.4.2. The disease model*

that a Power greater than ourselves could restore us to sanity" and Step 5: "Admitted to God, to ourselves, and to another human being the exact nature of our wrongs"), AA developed a strong following and claimed considerable success. When AA was established, the treat‐ ment industry and the understanding of addiction could reasonably describe as being in its infancy. Despite claims made in the Big Book, the efficacy of AA is very difficult to submit to rigorous empirical evaluation due to the structure and procedures of the organization [22]. As noted above, the range of substances used and the associated problems expanded in the early twentieth century. Efforts to assist users of substances other than alcohol gradually expanded. By the mid-1940s, AA's co-founder Bill Wilson discussed the possibility of a group

The first realization of Wilson's idea was called NARCO; it first appeared in 1947 and met weekly at the United States Public Health Service's treatment center in the Lexington, Kentucky federal prison. By the end of the 1940s, a NARCO member started a short-lived group called "Narcotics Anonymous" in the New York Prison System. By 1953, Narcotics Anony‐ mous was clearly established in California [17]. Early members, many of whom were from AA, worked out the 12 Traditions for the new organization. Within a year, the first NA publica‐ tion was printed, called the "Little Brown Book." There was controversy in AA and NA regarding Bill Wilson's experimentation with LSD. While he experimented under the super‐ vision of a psychiatrist and a psychologist, the use of another drug (in addition to alcohol) was

AA continues to foster a spiritual foundation and works to alter the thinking of alcoholics through "spiritual awakening." Studies of the effectiveness of AA have not produced clear results. AA is supported primarily by voluntary donations, and meetings are held in a vast array of facilities, including prisons, treatment facilities, hospitals, and churches. AA groups are available in most towns in the United States. Despite the relative paucity of efficacy studies, AA has been recognized by professional groups [21]. In addition, despite initial scorn by much of the medical profession, the American Medical Society recommended use of such self-help

Modern medical views of substance misuse claim to view the problem as a medical, rather than moral, problem. This appears to refrain from giving serious consideration to morality or values as the foundation for the problem. However, there is considerable evidence, in public opinion and its reflection in political discourse and the law, that substance misuse continues to be viewed as a moral problem. Consistent with current views, there is extensive history of morality as a dominant component of the views of substance abuse by many [23]. The moral view was, in part, a part of an absence of other useful perspectives. However, there is also substantial evidence for social control exerted from class and culture-related factors [24, 25]. Social groups who were so oriented would promote public campaigns in which misinforma‐ tion and inflammatory information were promoted related to the types of substances used, the

seen as antithetical to the letter and spirit of "Anonymous" teachings.

for a drug addicts that was separate from AA.

150 Recent Advances in Drug Addiction Research and Clinical Applications

groups in 1979.

*3.4.1. The moral model*

**3.4. The moral and disease models**

One of the most significant developments in the intellectual representation of substance use disorders was the "Disease Model" of addiction. The first major proponent of this approach was Morton Jellenik [26]. Jellinek had witnessed the massive failure of the Volstead Act to stem the use of alcohol and began to write from the Yale Summer School of Alcohol Studies. The Disease model posits that certain individuals are vulnerable to substance use disorders as a result of (inferred) neurochemical dysfunction. This "disease" is characterized by, in part, an inability to control/inhibit behavior, loss of control, a failure to recognize the syndrome in one's self, and predictable decline. The disease model also suggests that the substance abuse vulnerability can/does occur independent of other problems and is chronic. Thus, the enlightened practitioner refrains from judgment of the abuser, and problems with substance use should be permitted to mitigate criminal punishment when crimes are committed [27]. The disease model is not always described in the same way, and it may be seen as having evolved since its first description. For example, despite the focus on factors internal to the substance abuser in the disease model, [28] characterized the disease model as being "multidimensional" and including psychological and sociocultural factors.

The later diversification of the disease model has done little to mute its detractors. Major objections to the disease model appear to be linked to the basic assumptions of any diseaserelated approach. For example, Wallace [29] called for a move beyond the disease model in the context of Native North Americans, suggesting that the disease model is particularly toxic in its neglect of context and culture in evaluating and intervening with substance-related problems. Feminist theorists have highlighted the construction of gender in the context of research and treatment approaches in general [30]. A behaviorist approach has also made cogent arguments against the disease model [31].

Recognizing the actual physical destruction that is a possible result of substance use, some behaviorists argue that a disease model is not needed at all for there to be adequate rationale for effective treatment. Consistent with general behavioral principles, the behavioral ap‐ proach finds it more useful and even humane to view the problematic use of substances is a by-product of the interaction between unique features of virtual and reinforcement contin‐ gencies within their environment. That is, what is rewarding about the context in which a person has learned to use the substance? The behaviorist perspective also gives careful consideration to the nature of motivation, since the nature of motivation, or drive states, is critical to the reward value of environmental features.

#### **3.5. Diagnosis of the substance-related disorders**

The history of psychology and psychiatry includes a legacy of efforts to develop the most elegant and powerful nosology of disorders of psychological adaptation. There is evidence of attempts to categorize disorders as far back as the ancients, but increased focus emerged around 1900 and has accelerated since. The first comprehensive modern work was the Diagnostic and Statistical Manual (DSM) in 1952 [32]. Given that psychoanalysis still en‐ joyed hegemony in the clinical world of the late 1940s, the original DSM was relatively brief and grounded in clinical lore and psychoanalytic theory. The DSM subsequently evolved from a primarily psychoanalytic work to an atheoretical compendium that is designed to reflect the highest levels of clinical and empirical science. By the time of DSM-II (1968 [33]), the role of theory was substantially reduced and increasing specificity in diagnostic criteria was realized.

The introduction of the Diagnostic and Statistical Manual of Mental Disorders (Fifth edition: DSM-V [34]) brought revisions to previous diagnostic criteria in the DSM tradition. Most recently, the DSM-IV [35] used two main categories of substance misuse conditions, sub‐ stance abuse and substance dependence. The DSM-IV criteria were considered to be inade‐ quately descriptive of what was seen clinically, and the new criteria are claimed to be a substantial improvement. These two categories from DSM-IV were combined into one disorder in DSM-V that is diagnosed in conjunction with a rating from mild to severe. This also eliminates the "substance dependence" category, which was widely seen as easily confused with "addiction." While using the same underlying criteria, each substance is indicated as a distinct use disorder, including alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics or anxiolytics, stimulants, and tobacco. Caffeine-related syn‐ dromes are not included.

It is important to review the DSM-V criteria for substance use disorder. It is important to bear in mind that each of these eleven criteria may be manifest in different ways and will be influenced heavily by the pharmacology of the specific substance. For each of the substances, the following are the eleven possible symptoms:


The DSM-V section with substance-related disorders includes gambling, which was not in the same section as substances in prior versions of DSM. The task force members for the sub‐ stance and other addictive disorders section gathered findings that suggest that gambling disorder is similar in a number of respects to substance-related disorders. It is also thought that this development will make the accessing of treatment more likely. Other disorders that may be considered relevant (e.g., Internet, social media) have not yet been seen as having the empirical support needed for inclusion in this section.
