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A Brief History of Disease Theory and Harm Reduction Treatment in the US

As past is prologue, we need to review the last 50 to 80 years of how we have dealt with addiction and alcoholism in the United States to understand our current situation and what our choices are going forward.

  • 1935-1965: Growth of AA/12 steps disease view dominates the field.

By the mid-1960s, AA had reached a million members and was universally accepted by American medicine and society as the primary – the only – treatment for alcoholism and increasingly for other addictions. AA’s message is that alcoholism is a disease and its primary focus is on absolute abstinence.

  • 1966-80: The Rand Report counterpoint to AA – epidemiological and behavioral (controlled drinking) evolution.

With the creation of the Alcohol Research Group in Berkeley in the 1960s, studies of people’s drinking problems over time were initiated. These studies found that (a) the number of those who met the full criteria for inevitable loss-of-control drinking was quite small, perhaps one percent of the population, and (b) people’s drinking histories showed considerable movement as their life circumstances varied, generally shifting in a more positive direction.

This vociferous counterattack to scientific research like Rand was to cement America in its abstinence fixation for 50 years.-Stanton Peele

The most significant epidemiological survey of alcoholism was the Rand Report in 1976. Rand researchers (who weren’t clinicians) studied alcoholics treated at National Institute on Alcohol Abuse and Alcoholism-funded treatment centers. The men were highly dependent drinkers (consuming a median of 17 drinks daily). Yet they often reduced their drinking substantially over a four-year follow-up period.

On the day of its release, the National Council on Alcoholism denounced the Rand Report as being “dangerous, misleading, and not scientific.” Thus began a campaign against the Rand Report and its results for which it is difficult to find a recent parallel in science. This vociferous counterattack to scientific research like Rand was to cement America in its abstinence fixation for 50 years.

  • 1981-84-2015: Massive counter-assault stifles harm reduction alternatives to abstinence.

The aftermath of the attack on Rand by the NCA (now the NCADD, the National Council on Alcoholism and Drug Dependence) was poison for non-abstinence approaches to addiction.

What’s Happening in Indiana?
Indiana’s Governor, Mike Pence, is being pilloried for his support of anti-gay legislation in his state. But this stance is rivaled by his and Indiana’s anti-scientific, anti-humane treatment of drug users. When an epidemic of H.I.V. was identified in a rural area, Pence reversed – for 30 days! – his and the Republican legislature’s ban on clean needle programs.

I am reminded of the 1950s George Burns and Gracie Allen TV show, in which Allen plays a dim-witted blonde (it goes without saying that Burns always conceded the genius in their duo was Allen’s). One day, when next-door neighbor Woody asked the time, Gracie plugged in an electric clock. “George says our electric bill is too high – so I only plug the clock in when I need to know what time it is.”

In 1982, the prestigious journal Science published an all-out attack on a key 1970s study by husband and wife team Mark and Linda Sobell. The Sobells had shown that teaching alcohol dependent individuals controlled-drinking techniques reduced the number of explosive drinking episodes they experienced (this is now called relapse prevention).

The publication of the Science article made clear that recognizing or encouraging improvements without abstinence was to risk one’s professional reputation and career (this happened to me).

In a parallel development, the United States was the last Western country to adopt needle exchanges – and many states still oppose this public health position. This anti-scientific bias resulted in tens of thousands of deaths from AIDS.

  • 1985-2005: The sub-rosa re-emergence of harm reduction.

For instance, DSM-IV… does not define remission in terms of abstinence, but strictly the absence of problems.-Stanton Peele

With my books, The Meaning of Addiction (1985), Diseasing of America (1989), and The Truth About Addiction and Recovery (1991), supported by Bill Miller’s early work on controlled drinking, and by Europeans like Nick Heather and Ian Robertson (Controlled Drinking, 1983), I was part of a small campaign to maintain a harm reduction approach in America. This harm reduction resurgence, while sub-rosa, was actually influential in American clinical practice. For instance, DSM-IV, published in 1994 and on which I was a consultant, does not define remission in terms of abstinence, but strictly the absence of problems. When I asked the editors of the volume to make this stance explicit, they told me it wasn’t necessary to do so.

  • 2006-15: Diversification and fundamental conflicts between the treatment community and harm reduction policy.

If one jumps from standard treatment protocols to public health policy positions, one is in danger of suffering vertigo. For, in the former case, it is virtually impossible to receive non-abstinence-oriented treatment in the United States. At the same time public health approaches to substance use uniformly endorse the value of harm reduction techniques such as safe injection procedures, wet housing for alcoholics, resuscitation packages for overdoses, etc. Meanwhile, even as the disease theory holds sway throughout the United States, a series of recent popular books undercuts the disease theory, including those by Carl Hart (High Price), Lance Dodes (The Sober Truth), Johann Hari (Chasing the Scream), Marc Lewis (The Biology of Desire), and Maia Szalavitz (Unbroken Brain), in addition to my own (Recover!). All of these authors emphasize the role of self, choice, and society in addiction and recovery.

If one jumps from standard treatment protocols to public health policy positions, one is in danger of suffering vertigo.-Stanton Peele

Bill Miller – the originator of motivational interviewing therapy – embodies this internal conflict in America as he here, in the same quote, endorses the incompatible choice and AA disease models of addiction:

  • That substance use is behavior, subject to the same learning, environmental, social, and cultural influences as any other behavior. Drugs also have pharmacological effects, of course, but even severely dependent people change or suspend their use in response to what’s happening around them. Drug use is a choice. We certainly treat it as such within the legal system; intoxication usually exacerbates rather than mitigates an offense. With all the window-dressing of a “disease model,” people still ultimately decide for themselves to continue or to abstain. “One day at a time” is a decision… there is no animal model for the kind of recovery that one sees in AA. (emphasis added)

How we resolve these incompatible models of addiction will be the story of addiction treatment and policy in the 21st Century.