Changes in Public Perception on the State of Substance Abuse Treatment

Article Overview:

For as long as human beings have kept records, they have recorded examples of substance abuse in their communities.1 Whether it was shamans getting drunk on ritual wine, or laborers and soldiers chewing on the leaves of plants, people have always found pleasure in addictive substances. Treating instances of excess has changed over the centuries, as has the reaction to those methods, especially as their respective shortcomings have proven not only ineffective but also costly.

Public Perception on the State of Substance Abuse Treatment

The Roots of Substance Abuse Treatment

In America, alcohol consumption existed among precolonial Native Americans but primarily for ceremonial purposes; the beers and wine produced by respective tribes had an alcohol content too low to induce intoxication.2 However, contact with European colonists brought much stronger strains of alcohol, introducing the practice of recreational and excessive drinking with it. Colonists plied the natives with alcohol, making them weaker at the negotiating table and on the battlefield.3

After much ground had been lost, and much damage done to tribes reeling from what we would now recognize as alcoholism, senior tribesmen encouraged their younger tribe members to focus on their spiritual beliefs and ancestral traditions to vanquish their antisocial behavior. The tribe would sit around in a circle, as the shape was believed to help ward off the evil spirits that were working against them. The elders called on their afflicted brethren to call on their beliefs in a concept larger than themselves and to use their beliefs to overcome the temptation to drink.

Benjamin Rush

After America had been settled by colonists, the young country enjoyed a period of “unprecedented production and consumption of distilled alcoholic beverages,” according to the American Journal of Public Health.5 This made Benjamin Rush take notice. Rush, one of the nation’s Founding Fathers and signers of the Declaration of Independence, a leader of the American Enlightenment movement, a notable physician, and one of the first researchers in the field of mental health (so much so that he is known as “the father of American Psychiatry”), took objection to the prevalent system of dealing with drinkers: to condemn them as moral failures of weak well and to “treat” them by imprisoning them or sending them to a mental asylum. 6,7
Benjamin Rush wrote that alcoholism was not the problem of choiceRush felt strongly otherwise. He wrote that alcoholism was not the problem of choice and moral character of the drinker but in the properties of the alcohol itself. His Inquiry Into the Effects of Ardent Spirits Upon The Human Body and Mind, published in 1785, was the first notable rejection of the general consensus of the era: that alcohol itself was harmless, and the trouble lay with drinkers of weak wills and questionable character. Rush was one of the first authorities on the subject to put forward the idea of alcoholism being a disease, a medical condition; as such, treating this disease called for drinkers to be slowly separated from their poison, and not subjected to methods that, today, would be taken for granted as being inherently harmful, like imprisonment or forced psychiatric commitment.8

Rush’s positions were revolutionary, but his unimpeachable stature gave them unparalleled credibility. To a large degree, his writings swung the pendulum of public perception away from the general enjoyment of alcohol and empowered the temperance movement to become bolder and more vocal in its condemnation of the alcohol industry and the consumption of alcohol in general. Rush’s calls for alcoholics to be treated with more medical care also laid the foundations for the first “sober houses,” hospitals that specialized in helping heavy drinkers fight their battles. Rush believed that drinkers could be kept in these houses, safe from further temptation, until they were ready to walk out on their own again.9

Taking Substance Abuse Seriously

Thanks to Benjamin Rush, American public opinion on how to deal with alcoholics changed in a relatively short period of time. The revived temperance movement that emerged after the Civil War was instrumental in the anti-drinking campaign that saw Prohibition become the law of the land, but there was also a more compassionate side to the wave: Small organizations formed to give drinkers, turned out by their families, a place to stay, some form of financial assistance, and a rehabilitation network. Their efforts received a big boost with the opening of the New York State Inebriate Asylum in 1864, an event that marked how seriously the public and government were taking the issue of substance abuse. The asylum was, at the time, the only hospital in the United States with a single purpose: treating alcoholism as a medical condition and not a corruption of the soul.10

In 1867, the Martha Washington Home in Chicago, opened as the first treatment center for women in the country.

Evolving Treatments

Benjamin Rush introduced a sea change in how the American public perceived substance abuse, and the treatment thereof, but many lessons were yet to be learned about the best way to help alcoholics. Rush himself espoused some theories that have fallen by the wayside, such as using mercury to treat everything from addiction to Yellow Fever. Proceedings journal, out of Baylor University Medical Center, asked if Rush was “early America’s most famous doctor” (in the words of the Historical Society of Pennsylvania) or an assassin.11,12
As an example of how substance abuse treatment was still evolving, a doctor named Leslie Keeley announced in 1897 that he could cure addictions with a formula known only to himself. The formula would have to be injected into the patient four times a day, and the only ingredient of the formula that Keeley would divulge was gold.

Keeley said his formula had a 95 percent success rate for reversing addiction.13

Later research discovered that Keeley’s formula was, in reality, a combination of arsenic, cocoa, and morphine as well as strychnine, ammonia, willow bark, and aloe. Notwithstanding the effects of injecting such a concoction into patients (which caused mental imbalance, relapse, and even death), as well as criticism from other doctors, Keeley stood fast by his treatment.

The Fix listed Dr. Keeley’s “gold cure” as one of “history’s scariest addiction treatments,” but the public was so taken by his promises that he had hundreds of centers offering his cure across the country and throughout the European continent, the last of which closed as recently as 1965. Modern doctors don’t put any faith in the mixtures Keeley and his staff injected into patients. What Keeley did right, however, was requiring his patients to stay in his centers for a month, partaking in exercise and eating healthy food, and directing his people to give each client personal care and encouragement. At the time, such measures might have been considered a novel way to work with alcoholics. Today, they are the standard for substance abuse treatment and rehabilitation.14

The public opinion of how to treat addicts came a long way with the arguments made by Benjamin Rush and Leslie Keeley, but alcohol runs very deeply in the veins of American culture, and any evolution of substance abuse treatment (and its impressions) has to make room for the ubiquitousness and popularity of alcohol itself.

The End of Prohibition and the Rise of Alcoholics Anonymous

Book of 12 principles by Bill Wilson and Dr. Bob Smith for addicts to right the wrongAt no time was this made clearer than after the 21st Amendment repealed the 18th Amendment. The “noble experiment” of Prohibition turned out to be a decades-long national disaster, increasing crime rates, birthing an entire black market, and firmly entrenching alcohol as one of the most prized and valued freedoms in America. Two years after President Franklin D. Roosevelt helped himself to a beer as he signed legislation that made the production, transportation, and distribution of alcohol legal again, two reformed alcoholics decided to start a society to help other struggling drinkers overcome their demons. Bill Wilson and Dr. Bob Smith co-wrote a set of 12 principles, based on a mix of Christianity and psychology, to give addicts a platform by which they could right the wrongs that their drinking had done.

The movement started by Bill W. and Dr. Bob became Alcoholics Anonymous. The Atlantic writes that the 12 Steps at the core of the Alcoholics Anonymous phenomenon “are so deeply ingrained in the United States” that despite the non-scientific origins of the philosophy, many doctors, therapists, and members of the general public and treatment community firmly believe and support the principles.15 Pacific Standard notes how AA enjoys such positive popular perception that expressing any skepticism about its methods or results could be considered sacrilegious.16

Defending the 12 Steps

But skepticism has been voiced, by Pacific Standard itself, and a number of other publications and organizations, for espousing a faith-based approach to overcoming alcoholism (Bill W.’s conversion to Christianity is reflected in six of the 12 Steps explicitly mentioning the Christian concept of God). Salon, for example, calls Alcoholics Anonymous a “pseudo-science,” saying that even though AA is “a part of our nation’s fabric” and that it holds a “privileged place in our culture,” the complete lack of research-based support and peer-reviewed studies that show a success rate of merely 10 percent (compared to AA’s self-reported 75 percent success) cause many to temper their enthusiasm or even outright disavow AA’s strategy.17

Nonetheless, many voices within the scientific community have defended the existence and relevance of Alcoholics Anonymous. Recent Developments in Alcoholism called the 12-Step method “an ideal recovery resource,” and Alcohol Research & Health wrote that for many millions of drinkers and their family members, Alcoholics Anonymous (and other peer-established aftercare support groups) remain “the most commonly sought source for help,” running side by side with pharmacological and counseling therapies. 18,19

Peer-reviewed studies that show a success rate of merely 10 percent (compared to AA’s self-reported 75 percent success)

Such is the popularity of the Alcoholics Anonymous approach that hundreds of similar support groups, for any imaginable addiction or behavioral problem, have been formed. Using the same principles as the original ones set out by Bill W., groups like Narcotics Anonymous help people with their addictions to heroin or prescription medication; Gamblers Anonymous and Overeaters Anonymous offer support and guidance for people who are problem gamblers or eaters, respectively.20

Even the criticism of AA being too religiously oriented has been addressed by the emergence of secular and agnostic groups that replace the explicit mentions of “God” in their respective 12 Steps with more ambiguous concepts of a “higher power” or even the group members’ senses of individual “self.”21 The evolution and adaptation of AA, and the 12-Step philosophy, to changing cultures and times (the rise of secular AA groups trends with the American public gradually becoming less religious) suggests that, notwithstanding the scientific concerns about how AA works, the method itself remains unshakably popular and positively perceived.22

America’s Disease

If Benjamin Rush changed how early America thought about alcoholics and other addicts, then Bill W. had an arguably similar effect on the United States of the 20th century. One of his converts was Marty Mann, one of the first women to complete all the 12 Steps of her AA program. Mann was so galvanized by her newfound sobriety that she took on the mantle of fighting a strain of thought that persists to this day: that alcoholism is not a medical condition, but a failure of morality and character. It was from reading a copy of AA’s Big Book that Mann understood she was “suffering from an actual disease,” one that had a name and symptoms, offering the same kind of respectability and compassion a sufferer of diabetes or cancer would receive, which alcoholism didn’t engender at the time.
NCEA shows american plublics that alcoholism is a health issue not morals or character

Mann discovered that other women were reluctant to seek out help for their own alcoholism; gender roles of the mid-20th century cast addicted women as victims of psychiatric problems, and doctors would rarely take cases of female addiction seriously. But Mann was persistent, and she founded the National Committee for Education on Alcoholism (NCEA) in 1944, with some funding from the Yale Center on Alcohol Studies. Under Mann’s vision, NCEA sought to show the American public that alcoholism wasn’t an issue of morals or character but of public health; therefore, treating alcoholism, and treating alcoholics, was a matter of public responsibility.

The First Lady of Alcoholics Anonymous

Since its inception, NCEA (which has changed its name to the National Council on Alcoholism and Drug Dependence) has increased education outreaches on topics of substance abuse and rehabilitation, “engaged the medical profession” in how to treat addiction as a topic of health and medicine, and been a point of contact for the national press and general public for information about alcoholism and drug abuse. Materials and resources from NCADD have been used in schools and colleges. The organization also created Alcohol Information Week (which is now the National Drug and Alcohol Facts Week), recognized by multiple sitting presidents. April is Alcoholism Awareness Month in America, a drive launched by NCADD.

Similarly, the organization campaigned for the federal government to classify alcoholism as a treatable disease, which led to the creation of the National Institute on Alcohol Abuse and Alcoholism. NCADD was instrumental in developing the accepted “Medical Criteria for Diagnosis of Alcoholism,” which was published by both the American Journal of Psychiatry and the Annals of Internal Medicine. The move was the first time that professional standards for the diagnosis and treatment of alcoholism had been established.23

For all her work and influence, Marty Mann became known as “the First Lady of Alcoholics Anonymous.” Her legacy continued into the 21st century. Her work in removing the barriers to addiction treatment led to substance abuse services being made essential health benefits that have to be covered in the Health Insurance Marketplace under the Affordable Care Act. It is a matter of law that substance use disorder benefits are given the same standards as medical and surgical benefits, a parity that would have been considered unthinkable when Mann (who passed away in 1980) was fighting her battles.

In 1956, NCADD successfully petitioned the American Medical Association to recognize alcoholism as a disease.

In 2016, the White House celebrated and recognized “the historical contributions” Marty Mann made to American society by honoring her for that year’s Women’s History Month.24

Losing the War on Drugs

Public perception on the state of substance abuse treatment may have come a long way since the days of addiction being seen as a moral failing, but other battles are still being fought. In 1971, President Richard Nixon declared a War on Drugs, saying that the manufacturing and trade of illegal chemical substances to the United States was America’s public enemy number one. Nixon increased the size and scope of America’s anti-drug campaign, empowering American agencies (both domestic and international) to intervene as they saw fit in order to enforce the “zero-tolerance” policy that Nixon wanted.

The War on Drugs was announced to great fanfare and acclaim, but a generation later, it lies in ruins, disavowed by politicians and the public alike. It achieved none of its goals, wrote NBC News in 2010 and created a worldwide black market for the distribution of the drugs it was supposed to destroy. With that black market came gang violence and warfare that have crippled American cities and entire South American countries.25

The United States houses only 5 percent of the world’s population but 25 percent of the world’s prisoners.

The drugs themselves have been minimally affected by the War on Drugs that was supposed to wipe them out. The British Journal of Medicine wrote in 2013 that drug prices have actually dropped since 1990, while their chemical purity has increased; effectively, the drugs got better and cheaper at the same time.26 The result has been a “systematic failure of policy,” says The Guardian, and the Brookings Institution points to the American system of incarceration as being responsible for putting hundreds of thousands of people in jail on drug-related charges while doing little to nothing to actually stem the flow of drugs.27,28 This has created what the American Psychological Association calls “incarceration nation,” where the United States houses only 5 percent of the world’s population but 25 percent of the world’s prisoners.29

Disastrous Consequences

On that point, even prominent members of law enforcement have come out against the way anti-drug policy in the United States has been carried out for the better part of four decades, with the police chiefs of major metropolises like Houston, New York, Chicago, and Los Angeles saying that the War on Drugs has been a “tremendous failure.” Programs and laws devised a generation ago, which have failed to keep up with rapidly shifting cultural and demographic trends, have made low income and poorly educated people (most of whom are members of an ethnic minority) into scapegoats for easy and small-time arrests while the major drug cartels continue to operate unaffected. The situation has sowed widespread distrust between minority communities and police, giving rise to claims to systematic and institutionalized racism, and per police chiefs, making their cities much more dangerous.30 Despite comparably similar rates of drug use between races, black Americans are arrested 13 times more than white Americans across the country; in some states, the difference is 57 percent.

In 2013, black and Latino Americans accounted for 29% of the country’s population but made up over 75% of the drug offenders being housed in state and federal prisons.

The Post listed the impact on race as the first of “10 disastrous consequences” of the War on Drugs.31

As the shortcomings of the War on Drugs have become starker and graver, the public’s opinion of drugs themselves have changed, and the direction of the change has condemned Nixon’s efforts in the court of public opinion. A Gallup poll conducted in 1969, two years before Nixon’s announcement, revealed that just 12 percent of Americans supported the idea of legalizing marijuana. In 2016, however, more than half the country – 60 percent – supported legalization policies. The figure is the highest amount of support in the 47 years that Gallup has been asking the question, and “almost all age groups” now favor legalization.32

Maximum of the Americans voted against legalization of marijuana

Similarly, more and more Americans are turning away from the “tough on crime” policies of the War on Drugs and toward laws that reform outdated and biased laws, which tend to disproportionately target people of color. The Pew Research Project wrote about “America’s New Drug Policy Landscape” in 2014, finding that 67 percent of Americans wanted the government to not prosecute people who use illegal drugs but instead to provide treatment and rehabilitation services.33 Even voters in the traditionally conservative stronghold of the state of Oklahoma passed a criminal reform law, which made possession of any drug a misdemeanor, regardless of the strength of the drug and whether the user had past arrests. The money that is saved on incarceration and prosecuting a felony is redirected back to individual counties for community-based rehabilitative programs, which cover mental health and substance abuse options.

Utter Change and the Failed War

Oklahoma’s surprising move is held up by the Seattle Times as an example of the current trend of how the public responds to substance abuse treatment: “decriminalize drug use, seek public health options.”34 The shift in perception comes as communities and cities across the country reel from an epidemic of heroin abuse brought on by overprescription of opioid-based painkillers. The wave has not only changed the demographic of substance abuse (“the face of heroin has changed utterly,” writes The Economist) but also how people respond to ideas and programs meant to treat substance abusers.35

Decriminalizing drug use is seen by many as a drastic step to solve a drastic problem, but it signals how far the country has moved away from Nixon’s War on Drugs. Such has been the extent of the effort’s failure that Al Jazeera theorized that Americans not only support more lenient laws for marijuana “but also for hard drugs like cocaine and heroin,” to go along with the idea of offering more compassionate and progressive treatment for addictions (as opposed to threats of punishment and incarceration).36

 Rasmussen Reports found that “Americans still firmly believe the War on Drugs has been a failure,” with only 10 percent of respondents to a November 2015 poll feeling that the policies of the War on Drugs were successful. Seventy-seven percent of the public said that the United States was not winning its declared fight against drugs, highlighting the degree to which the public perception of the state of the effort has fallen.37

Research Articles


  1. “Historical and Cultural Aspects of Man’s Relationship with Addictive Drugs.” (December 2007). Dialogues in Clinical Neuroscience. Accessed November 26, 2016.
  2. “Historical and Cultural Roots of Drinking Problems Among American Indians.” (March 2000). American Journal of Public Health. Accessed November 26, 2016.
  3. American Indians and Alcohol.” (1998). Alcohol Research and Health. Accessed November 26, 2016.
  4. Frequently Asked Questions About A.A. History.” (n.d.) Alcoholics Anonymous. Accessed November 26, 2016.
  5. “Benjamin Rush’s Educational Campaign Against Hard Drinking.” (February 1993). American Journal of Public Health. Accessed November 26, 2016.
  6. Dr. Benjamin Rush.” (n.d.) University of Pennsylvania Health System. Accessed November 26, 2016.
  7. Addiction Treatments Past and Present.” (n.d.) University of Utah. Accessed November 26, 2016.
  8. Extracts from Benjamin Rush’s Inquiry into the Effects of Ardent Spirits Upon the Human Body and Mind.” (June 2005). University of Waterloo. Accessed November 26, 2016.
  9. Dr. Benjamin Rush and His Views on Alcoholism.” (April 2011). American Medical Network. Accessed November 26, 2016.
  10. New York State Inebriate Asylum.” (n.d.) National Historic Landmarks Program. Accessed November 26, 2016.
  11. Benjamin Rush, MD: Assassin or Beloved Healer?” (January 2000). Proceedings. Accessed November 27, 2016.
  12. “What the Doctor Ordered: Dr. Benjamin Rush Responds to Yellow Fever.” (n.d.) Historical Society of Pennsylvania. Accessed November 26, 2016.
  13. History’s Scariest Addiction Treatments.” (August 2012). The Fix. Accessed November 26, 2016.
  14. “What Was In This Mysterious ‘Cure’ For Alcoholism?” (May 2015). Io9. Accessed November 26, 2016.
  15. “The Irrationality of Alcoholics Anonymous.” (April 2015). The Atlantic. Accessed November 28, 2016.
  16. After 75 Years of Alcoholics Anonymous, It’s Time To Admit We Have a Problem.” (February 2014). Pacific Standard. Accessed November 28, 2016.
  17. “The Pseudo-science of Alcoholics Anonymous: There’s a Better Way to Treat Addiction.” (March 2014). Salon. Accessed November 28, 2016.
  18. The Impact of Alcoholics Anonymous on Other Substance Abuse Related Twelve Step Programs.” (January 2009). Recent Developments in Alcoholism. Accessed November 28, 2016.
  19. “Advances in Alcoholism Treatment.” (2011). Alcohol Research and Health. Accessed November 28, 2016.
  20. Overeaters Anonymous.” (n.d.) Accessed November 28, 2016.
  21. “AA Without the God?” (December 2014). Psychology Today. Accessed November 28, 2016.
  22. “U.S. Public Becoming Less Religious.” (November 2015). Pew Research Center. Accessed November 28, 2016.
  23. “Our History.” (August 2015). National Council on Alcoholism and Drug Dependence. Accessed November 28, 2016.
  24. “Women’s History Month: Marty Mann and Removing Barriers to Treatment.” (March 2016). The White House. Accessed November 28, 2016.
  25. U.S. Drug War Has Met None of Its Goals.” (May 2010). NBC News. Accessed November 28, 2016.
  26. “The Temporal Relationship Between Drug Supply Indicators: An Audit of International Government Surveillance Systems.” (2013). British Journal of Medicine. Accessed November 28, 2016.
  27. “The ‘War on Drugs’ in Numbers: A Systematic Failure of Policy.” (April 2016). The Guardian. Accessed November 28, 2016.
  28. “Counternarcotics Policy Overview: Global Trends & Strategies.” (October 2008). Brookings Institution. Accessed November 28, 2016.
  29. “Incarceration Nation.” (October 2014). American Psychological Association. Accessed November 28, 2016.
  30. America’s Top Cops Just Called the War on Drugs ‘A Tremendous Failure.’” (October 2015). Vice. Accessed November 28, 2016.
  31. “Connecting the Dots: 10 Disastrous Consequences of the Drug War.” (January 2013). The Huffington Post. Accessed November 29, 2016.
  32. “Support for Legal Marijuana Use Up to 60% in U.S.” (October 2016). Gallup. Accessed November 29, 2016.
  33. America’s New Drug Policy Landscape.” (April 2014). Pew Research Center. Accessed November 29, 2016.
  34. “Decriminalize Drug Use, Seek Public Health Options.” (November 2016). The Seattle Times. Accessed November 29, 2016.
  35. “The Great American Relapse.” (November 2014). The Economist. Accessed November 29, 2016.
  36. “Report Suggests US Ready to End War on Drugs.” (April 2014). Al Jazeera. Accessed November 29, 2016.
  37. “Americans Still Think War on Drugs is Failing.” (November 2015). Rasmussen Reports. Accessed November 29, 2016.
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