Self Help

The Urge Our History of Addiction - Carl Erik Fisher

Author Photo

Matheus Puppe

· 79 min read

The author recounts an experience during his stay in a psychiatric hospital for addiction treatment. He describes a violent altercation between two patients over use of a payphone, which leaves him shaken. The author reflects on how he went from being a psychiatry resident at Columbia University to being a psychiatric patient due to his own struggles with alcohol and stimulant addiction.

He opens up to his treatment team about his family history of alcoholism and admits he is an alcoholic too. After rehab, he wonders if he can ever drink again, conflicted about fully accepting that he has an addiction.

The author did go to rehab and returned to his residency program, undergoing 5 years of intensive addiction treatment and monitoring. As a physician recovering from addiction, he became curious about why addiction is treated so differently from other mental disorders. He decided to specialize in addiction medicine to understand it better.

In studying the psychology and neuroscience of addiction, the author found the field divided, with contradictory theories and no clear consensus. He set out to uncover the history of how addiction was understood and treated in Western culture across time. This book explores the social, cultural, and scientific forces that shaped the modern concept of addiction.

  • The author began working in psychiatry at a time when there was growing disillusionment with the simplistic view that all human suffering could be reduced to neurobiology. Researchers were still trying to understand what constitutes a mental disorder.

  • The author became convinced that medical science alone is insufficient for understanding addiction. Understanding addiction requires looking to history, philosophy, sociology, and other fields.

  • Addiction has been a problem across history and societies. Centuries of policy, stigma, and racism are tied up with how we treat addiction today.

  • The author distinguishes four main approaches to addiction that have recurred through history: prohibitionist, therapeutic, reductionist, and mutual-help. None has provided a lasting solution on its own.

  • The author believes a truly holistic, balanced approach that draws on the best of each is needed, along with humility and openness to multiple perspectives. The goal should be harm reduction and helping people live with and beyond their suffering.

  • Confusion, fear, and aversion often obscure the path forward. But the history provides lessons and hope for recovery and change, if we face it with open eyes.

Here is a summary of the key points from the passage:

  • Addiction is a terrifying breakdown of reason where people feel unable to control their behavior, even when they desperately want to stop.

  • Examples of addictive behaviors have existed for thousands of years across cultures, though the concept of “addiction” as we know it today did not exist.

  • Ancient examples include excessive drinking described in Chinese poetry, and gambling addiction vividly depicted in the ancient Indian Rig Veda’s “Gambler’s Lament.”

  • The gambler in the poem continues gambling despite the damage to his relationships, rationalizing his behavior, and feels powerless against the draw of the dice.

  • Though different eras and cultures understood these compulsive behaviors differently, the core struggle against unsuccessful efforts to control one’s actions has been present throughout history.

  • The author suggests addiction as we currently understand it solidified more recently, connected to particular times and places like the early United States.

  • The poem vividly depicts the mystifying and destructive power that dice (gambling) can exert over people. The dice take on a life of their own, controlling and compelling the gambler even as he swings between excitement, anger, scorn, and shame.

  • The meaning of the final stanza is ambiguous - some interpretations suggest the gambler breaks free and urges others to do the same, while others suggest he begs the dice for mercy or the dice speak of their timeless power over humanity. This ambiguity reflects the complex interplay between agency and helplessness in addiction.

  • The concept of addiction has evolved over time. It is not a simple biological fact, but a set of cultural ideas about compulsion, willpower, and choice.

  • The dichotomy between total free choice and involuntary compulsion is unsatisfactory for understanding addiction. Many people feel caught in a middle ground of disordered choice, where they make poor choices against their better judgment.

  • Philosophers like Aristotle recognized this experience of “akrasia” or weakness of will, where emotions or irrationality interfere with better judgment. The divided self is one modern explanation.

  • Treatment strategies that “nudge” choices, like contingency management programs using rewards, can be highly effective for some addictions. But relapse remains common, pointing to the persistence of complex internal forces beneath the notion of compulsion.

  • The author recounts his struggles with alcohol abuse while studying abroad in South Korea as a young man. Despite consequences like missing commitments, he denied having a real problem compared to his alcoholic parents, clinging to a false distinction between their issues and his.

  • The author discusses St. Augustine’s “Confessions” as an early addiction memoir, though Augustine’s “addiction” to lustful thoughts seems tame by today’s standards. Augustine saw his struggle with sinful urges as part of the universal human condition after the Fall, not a discrete problem.

  • Similarly, Buddhist teachings see addiction-like cravings as manifestations of the universal problem of dukkha - grasping at sensory pleasures or ideas in an attempt to escape dissatisfaction. Early Buddhist texts spoke of addiction-like “intoxicating inclinations” as a mental illness common to all humans except enlightened beings.

  • Some modern psychological theories likewise view addiction as just one instance of normal but unhelpful ways humans react to psychological pain, like avoidance. This contrasts with the view that addicts are fundamentally different from non-addicts.

  • Research increasingly shows mental disorders like addiction exist on a spectrum, with no clear dividing line between normal and abnormal. This aligns with the view of addiction as an extreme manifestation of universal human tendencies. The disease model of discrete addict/non-addict categories is being challenged.

  • The notion that mental disorders are inherently pathological is being challenged. Seeing mental disorders as part of a complex system rather than as simply “abnormal” represents an important conceptual advance.

  • People use drugs for deeply personal reasons that provide meaning, comfort, or freedom. Addiction memoirs reveal how substances can feel like a companion or provide access to emotions.

  • Definitions of addiction vary, including subjective feelings of lack of control versus more objective problem behaviors. The DSM combines both aspects into one diagnosis of substance use disorder.

  • Heterogeneity in the experience of addiction is important but often overlooked. Some figures in history seem to have struggled with inner conflict over their substance use, while others did not.

  • The term “addiction” originated centuries ago and has evolved in meaning over time. Originally a legal term linked to debt bondage, it was also used to refer to divination of the gods’ will. The modern sense emerged from drug and alcohol problems.

In summary, perspectives on addiction are shifting away from a simplistic model toward appreciating complexity and diversity in the lived experience of substance use disorders. Definitions remain debated, but recognizing heterogeneity and moving beyond a “normal vs. abnormal” dichotomy represents an important evolution in thinking.

  • The word “addict” originally referred to a strong devotion or habitual behavior, not necessarily a negative thing. Early Protestant reformers used it to describe the paradox of “willed compulsion” - a choice to give up choice.

  • The concept of addiction captures complexities like disordered choice and universality. Though now seen as a medical disorder, “addiction” was originally a broad term touching on mysteries of human agency and self-control.

  • Beginning with tobacco, Columbus’ voyages marked the start of the “psychoactive revolution”, as novel mind-altering substances arrived in Europe. Their increased use often sparked “epidemics” of drug crises and related moral panics.

  • Over time, once-rare drugs like coffee, tea, chocolate, sugar and opium became more widely used recreationally outside of medical contexts, alarming elites.

  • Each major epidemic inspired competing explanations - the drug’s inherent danger, commercial forces, or broader societal problems. Viewed historically, epidemics often triggered panics exceeding the real harms.

  • Tobacco smoking started as an elite fashion craze in England inspired by Sir Walter Raleigh, with intricate rituals around pipes and accessories. However, as it spread more widely, tobacco provoked intense fears about its foreign origins and associations with sin, leading rulers across Europe, Asia, and the Middle East to impose harsh penalties and bans.

  • The author has vivid childhood memories of his parents’ heavy smoking, including finding cigarette burns all over the pillowcases, which stemmed from their drinking as much as the smoking itself. This gave him an early awareness of the dangers of smoking and secondhand smoke.

  • Purdue Pharma played a major role in the opioid epidemic through aggressive and deceptive marketing of OxyContin, though they were part of a larger system and pattern seen throughout history. Companies selling potentially addictive substances often contribute to epidemics.

  • Psychoactive drugs are unique consumer products that don’t follow normal supply and demand laws. Addiction supply industries can cause societal harms that they don’t directly bear the costs of.

  • Throughout history, governments have often been enticed by drug revenues to overlook harms, as banning drugs cuts off tax income. The need for revenue has repeatedly defeated prohibition efforts.

Here are the key points about the harms of addiction beyond just the addiction itself:

  • Addiction has long been linked to systems of subjugation, conquest, and profit. Tobacco helped save the Jamestown settlement, then slavery was used to grow more tobacco for profit. Other addictive commodities like sugar also relied on slavery.

  • When profit is the main goal, addiction industries will promote their products aggressively despite harms. Pharmaceutical companies promoted cocaine and morphine in the 1800s, leading to “industrial epidemics.”

  • The tobacco industry is a prime example, falsely advertising the safety of smoking and manufacturing doubt about health risks. This “product defense industry” strategy has also been used by fossil fuel companies to obscure climate change risks.

  • Addiction epidemics are often not just due to addictive substances themselves but are enabled by industry tactics and deeper social conditions.

  • Societies may use drugs for their own reasons, like alcohol use among Native Americans being fueled by cultural devastation and deliberate exploitation by colonists. Addiction was then blamed on Native peoples’ supposed moral failures.

  • In summary, the harms of addiction systems extend far beyond just addiction itself, into tactics of subjugation, profit-seeking promotion of harm, obscuring scientific evidence, and taking advantage of social conditions while blaming individuals. Looking deeper shows addiction is often not just about individual choice but is enabled by systems of power and oppression.

  • Occom, a Native American minister, called attention to the role of alcohol in the oppression and dislocation of Native peoples. This counters persistent “firewater myths” that Natives are inherently vulnerable to alcohol.

  • Occom’s insights prefigured the modern “dislocation theory” which states addiction is driven more by social wounds than biological effects of drugs. Examples include opium use in China after the Opium Wars and tobacco’s spread amid 17th century crises.

  • My grandfather’s alcoholism reflected difficulties adjusting to life as an immigrant in Newark. This illustrates how addiction can arise from cultural alienation and anomie, not just material deprivation.

  • Case and Deaton identified rising deaths from addiction and suicide among working-class whites, which they tied to loss of meaning in work, declining social bonds, and inequality. This underscores the role of psychological dislocation in addiction.

  • However, persistent racial inequities dwarf these “deaths of despair.” The point is dislocation can drive addiction across lines of privilege, not that white despair is unique.

Here are the key points:

  • Alexander argues that addiction is fundamentally caused by social wounding, so the solution must be community healing that resists dominant cultural forces causing the wounding.

  • Native American communities dealing with alcoholism came to similar conclusions, developing cultural practices and mutual help groups to promote sobriety and community healing.

  • The early temperance movement lacked this community healing element, which is only recently reemerging as a priority.

  • Individual recovery can disrupt intergenerational trauma and prevent passing pain to others, a key teaching of the Native American Wellbriety movement.

  • The 18th century Gin Craze was the first urban drug epidemic, driven by inequality and the unsettled lives of the poor, especially women.

  • It prompted fears of societal decline and calls for prohibition targeted at the lower classes, though the upper classes drank as well.

  • The Gin Craze inspired a new perspective on addiction as an individual moral failing needing coercive state intervention, diverging from traditional views of communal responsibility.

  • In the 18th century, gin drinking became extremely popular in England, especially among the poor. This “Gin Craze” was seen by some as a threat to society.

  • The government tried to curb gin consumption through taxes and regulations, but these measures backfired and drinking gin became an act of political protest.

  • Doctors and scientists began describing habitual drinking as a medical problem, using words like “infection” and “epidemic.” Some saw it as a disease that spreads through the body.

  • The concept of “addiction” was used ambiguously to refer to both a sinful behavior and a disease beyond one’s control. The medical framing of addiction began to take shape.

  • Benjamin Rush, a doctor and signer of the Declaration of Independence, became concerned with alcohol problems after the Revolutionary War. He believed drunkenness threatened the ideals of individualism and self-control.

  • In 1784, Rush published An Inquiry into the Effects of Ardent Spirits, arguing that alcoholism should be seen as a disease. He described it as “a disease of the will” that takes away self-control.

  • Rush’s ideas helped shape the modern concept of addiction as a medical condition, not just a moral failing. He was instrumental in promoting the disease theory of alcoholism.

Here are the key points:

  • Benjamin Rush described habitual drunkenness as a disease in itself, resembling “hereditary, family, and contagious diseases.” This was a major step in framing addiction as a medical condition.

  • Other 18th century doctors like Thomas Trotter also described habitual drunkenness as a disease, claiming medicine was better suited to address it than religion or morality.

  • However, Rush and others were not arguing that medicine alone could cure addiction. Rush suggested medical treatments but also recognized the roles of religion, guilt, and shame.

  • The concept of addiction as a disease with impaired volition had already been discussed by doctors writing about the Gin Craze in the early 18th century.

  • Rush brought new emphasis to habitual drunkenness as an “odious disease” with many physical and mental symptoms. His contribution was calling more attention to addiction as a neglected but potentially fatal medical problem.

  • The meaning of “disease” is complex - it doesn’t necessarily mean the medical model is the only valid approach. The causes of addiction are not just biological.

  • The author relates his own struggles with alcohol during medical training, initially dismissing the possibility he could be an alcoholic. The experience led him to question reducing psychiatry just to neurobiology and technologies like brain stimulation.

  • Benjamin Rush, a physician in the late 18th century, was one of the first to propose that addiction is a disease. However, his disease theory led to harmful practices like “depletion therapy” which involved bleeding patients to calm their blood vessels.

  • In the 19th century, Leslie Keeley gained fame and fortune with his “cures” for addiction, which he also framed as a disease. He peddled ineffective injections and elixirs as miracle cures.

  • In the 1990s, the idea that addiction is a brain disease gained prominence, championed by Alan Leshner of NIDA. This neuroscience view aimed to combat stigma by framing addiction as biological rather than a moral failing.

  • However, the brain disease model has been critiqued for overemphasizing biology and underplaying psychological, social, and political factors. It remains debated whether addiction is fundamentally a brain disease or better understood more holistically.

  • Throughout history, proponents of disease models have oscillated between more modest claims that biology contributes to addiction versus stronger claims that addiction stems fundamentally from biological defects. The latter reductionist view has often been used misleadingly to market treatments.

Here are the key points:

  • Rush believed mental illness was a disorder of the mind that should be treated with psychological methods like gaining patients’ trust and helping them change habits, not just physical treatments.

  • Over time, medical thinking shifted to see mental illness as rooted in physical causes and best treated physically. Some, like Brühl-Cramer, claimed even social problems like alcoholism were biological diseases to be treated physically.

  • But the nature of the causes does not necessarily determine the best remedies. Mental and social factors are still important in treating mental illness.

  • Calling addiction a brain disease is reductionist and misleading. It oversimplifies the complex interplay of biological, psychological and social factors. It also misleadingly implies a loss of free will.

  • Rush refused to say mental illness completely removed free will. He recognized the difficulties in determining where to “draw the line” between disease and voluntary action.

  • When Rush’s own son developed mental illness and addiction, he tried desperately to help him psychologically but ultimately had to commit him to an asylum, believing he may never recover.

  • The author was a resident physician struggling with alcohol addiction. Despite treating patients with alcohol-related issues, the author was drinking dangerously and experiencing blackouts and withdrawal symptoms.

  • The author tried to self-medicate with Adderall and marijuana to counteract the effects of alcoholism. There was deep shame, exhaustion from covering up the addiction, and fear of consequences.

  • A patient named Jackson was admitted after a seizure from alcohol withdrawal. His swollen liver and family’s desperation reflected the author’s own fears.

  • The author wondered what it would take to make them change their own behavior, as the addiction progressed despite transient liver damage and attempts at moderation. There was a feeling of being trapped by the demands of residency.

  • The author and a colleague commiserated about their shared struggles with alcohol in medical training, but also a sense of hopelessness in their ability to escape or change the situation. The author’s addiction was worsening despite their awareness and efforts.

  • In the early 19th century, alcohol consumption was very high in America, with the average adult drinking around 7 gallons of pure alcohol per year. This heavy drinking alarmed many, including clergyman Lyman Beecher.

  • Beecher was especially disturbed by how alcohol was used to take advantage of Native Americans. He witnessed a “grog-seller” get local Montauks drunk on whiskey and rum in order to buy their corn cheaply.

  • Beecher became determined to combat alcohol abuse. He joined the growing temperance movement, which initially only advocated moderation in drinking rather than total abstinence.

  • Temperance drew support from the religious revivalism of the Second Great Awakening. As a leading preacher, Beecher helped spread the temperance message through his widely attended revivals.

  • Over decades, Beecher refined his anti-alcohol sermon from his early days witnessing the exploitation of the Montauks. By the 1820s, with drinking still rampant, he sensed the nation was ready for his call to temperance.

In summary, heavy drinking in the young United States, including the manipulative use of alcohol with Native Americans, spurred clergyman Beecher to join the temperance movement and preach against alcohol abuse at his popular revivals.

  • Around 1826, Lyman Beecher delivered a series of influential sermons arguing for total abstinence from alcohol, marking a major shift in thinking away from moderation. He portrayed alcohol as inherently dangerous and irresistible.

  • Beecher’s sermons sparked a popular temperance movement against alcohol. By 1833 there were over 5,000 local temperance societies with 1.25 million members. By 1835 over 2 million Americans had renounced distilled liquor.

  • The temperance movement led to a dramatic decline in American drinking. Alcohol consumption dropped by almost half between 1830-1840.

  • The movement portrayed alcohol as a demonic, corrupting force. This “demon drug” concept held that alcohol had uniquely addictive powers that determined human behavior.

  • Temperance advocates generated a flood of stories, poems, novels etc. featuring the new archetype of the tragic drunkard overcome by irresistible desire for drink. This consistent “drunkard narrative” portrayed a predictable downward spiral into desperation and death.

  • The temperance movement marked a profound shift in thinking about alcohol, from an accepted part of life to be used in moderation, to a dangerous and addictive substance to be avoided entirely. This laid the groundwork for later prohibitionist policies.

  • In the 1830s, temperance stories depicting the horrors of alcoholism became very popular, spreading the idea that alcohol itself had an irresistible power to cause addiction.

  • 150 years later, a similar narrative was told about crack cocaine and the idea of the “hijacked brain”. Journalist Bill Moyers’ documentary series promoted this metaphor.

  • The hijacking metaphor drew on decades of research linking dopamine to pleasure and reward. In the 1980s, the crack epidemic prompted researchers to hypothesize that crack was uniquely addictive because it stimulated dopamine.

  • Through the 1990s, the idea grew that addictive drugs increase dopamine but non-addictive drugs don’t. Advances in neuroimaging seemed to reveal addictive drugs hijacking the brain’s natural reward circuits.

  • The hijacking metaphor fit with older ideas of pharmacological determinism and reinforced the view of addiction as a brain disease caused by drugs themselves.

Here are the key points:

  • The “hijacked brain” narrative about dopamine and addiction has been very influential, but is an oversimplification. Dopamine does play a key role, but the science is more nuanced.

  • The hijacking metaphor suggests drugs have malevolent power to cause addiction. But addiction arises from many factors, not just drugs themselves. Only a minority of drug users become addicted.

  • The hijacking narrative reflects 1990s fears about violence and fits with “war on drugs” rhetoric. It obscures systemic factors and oppression underlying addiction epidemics.

  • The narrative risks dehumanization, portraying people as passive subjects taken over by drugs. Historical drunkard narratives also led to pessimism about people with addiction.

  • The Washingtonians of 1840s offered more hope, seeing drunkards as capable of choosing sobriety with community support. Their movement was more egalitarian than other temperance groups.

  • Overall, the hijacking narrative oversimplifies the science and causes of addiction, emphasizing drugs’ power while obscuring systemic factors and people’s agency. More nuanced understanding is needed.

Here are the key points:

  • The Washingtonians were a mutual-help group for alcoholics that emerged in the 1840s. They offered a hopeful, secular approach where alcoholics shared their personal stories of recovery. The movement gained popularity but faded quickly due to backsliding and controversies over religion and politics.

  • At the same time, the temperance movement was growing and fracturing over whether to push for legal prohibition of alcohol.

  • As debates raged over alcohol, the medical profession was gaining influence, aided by the new drug morphine derived from opium.

  • Thomas De Quincey helped popularize opium in the early 1800s by writing about his visions and experiences on the drug. But his growing addiction led to stalled productivity.

  • Opium and morphine became popular medicines in the mid-1800s, available without prescription. Their addictive potential was not yet understood.

  • The first opioid epidemic took off after the Civil War, fueled by morphine use among veterans. It reached all levels of society.

  • Addiction was seen as a “disease of the will” lacking moral fortitude. Some doctors made fortunes selling cures of injectable morphine to addicts.

  • The epidemic waned by the 1890s due to reduced opium imports and the advent of drug regulations. But many new opioid addictions were born in the process.

Here are the key points from the passage:

  • Thomas De Quincey was an early 19th century British writer who became addicted to opium. In 1821, he published his memoir Confessions of an English Opium-Eater, which was the first literary work devoted to drug addiction.

  • The book was a sensation, portraying opium in a romantic light as a pathway to transcendent experiences. However, De Quincey also acknowledged the pains and problems of habitual opium use.

  • De Quincey championed recreational, “luxurious” opium use rather than just medical use. He helped create a aura of taboo and exoticism around the drug.

  • De Quincey was influenced by the Romantic movement, which revolted against Enlightenment rationalism and instead prioritized imagination, emotions, and subjective experiences. Opium heightened these interior experiences.

  • Other Romantic writers like Coleridge also used opium and portrayed its dual pleasurable and painful effects. De Quincey inspired many literary imitators to take up opium as well.

  • In framing opium as a romantic, countercultural indulgence, De Quincey invented a new type of recreational drug use. This legacy influenced later artistic and bohemian groups to incorporate drug use as part of their identities.

  • There is a long history of a connection between creativity/art and addiction, with many famous artists and musicians struggling with substance abuse issues. Intoxication may help quiet the mind and access inspiration, but full-blown addiction rarely enhances creativity.

  • Writer Thomas De Quincey published the early autobiographical account “Confessions of an English Opium-Eater” in 1821, romanticizing his opium addiction. In truth, his addiction ruined his life.

  • Later writers like Fitz Hugh Ludlow also promoted drug experimentation in a romantic light, but Ludlow too ultimately warned against the horrors of addiction.

  • As a medical student, the author developed a drinking problem that damaged relationships and reflected deeper insecurities. A study abroad trip to Paris offered a misguided attempt to link heavy drinking with sophistication.

  • Understanding the lived reality behind the romantic myths of addiction is important. Substance abuse may signify “membership” in a counterculture, but can easily spiral from use to addiction. Creativity or “special insight” are not adequate justifications.

Here are the key points:

  • Fitz Hugh Ludlow was an early enthusiast of opioids who later became alarmed by their addictive potential. He searched widely for a cure for his own addiction before dying from it in 1870 at age 34.

  • Americans were initially arrogant about the risk of opioid addiction, but usage surged with the isolation of morphine and the invention of the hypodermic syringe in the mid-1800s.

  • The Civil War and the traumas it caused contributed greatly to the first American opioid epidemic, though addiction was already increasing before the war started.

  • There was a “honeymoon period” of uncritical opioid use followed by a backlash as the extent of addiction became clear. The same pattern occurred later with cocaine.

  • With the failure of temperance movements and lack of treatment options, doctors established the American Association for the Cure of Inebriates in 1870, the first medical group aimed at treating addiction as a disease.

Here are the key points:

  • In the late 19th century, there was a growing “inebriety movement” that viewed addiction as a medical disease that required treatment. Key figures included Benjamin Rush and the American Association for the Cure of Inebriety (AACI).

  • This led to the establishment of inebriate asylums and other facilities specifically for treating addiction. There was debate over the best approaches, with some focused on medicine and others on moral/religious reform.

  • The inebriety movement had a broad conception of addiction, encompassing not just drugs but also behaviors like gambling and sexual compulsions. This contrasts with today’s narrower focus on substance addictions.

  • However, the inebriety movement was also plagued by infighting and lack of consensus on causes and treatments. There was criticism that medical overprescribing had caused the epidemic of opioid addiction in the first place.

  • The idea of “iatrogenic addiction” - addiction caused by medical treatment - became prominent, though it was sometimes used as an excuse by more privileged addicted people.

  • Overall, while the inebriety movement represented an important early attempt to understand addiction medically, it remained divided and unable to develop an effective, coordinated response. Debates from that era continue to echo in thinking about addiction today.

  • In the 19th century, Chinese immigrants in the U.S. faced racism and discrimination. Many worked in difficult, dangerous jobs like railroad construction.

  • Opium smoking became popular recreation in Chinatowns. It provided escapism from harsh working conditions, though not all smokers became addicted.

  • As anti-immigrant sentiment grew in the late 1800s, Chinatowns and opium dens became a focus of fears about labor competition and dangerous drugs.

  • Chinese immigrants were scapegoated for opium problems, despite many being driven to America by the Opium Wars back home.

  • A powerful narrative emerged about how the “wrong kinds” of drug users were ruining society. Racism and nationalism fueled stigma against Chinese opium smokers.

  • This stigma was more about the people using drugs than the drugs themselves. It set a pattern for future drug scares focused on demonized groups rather than a public health approach.

  • In the late 19th century, there were moral panics about drugs like opium and cocaine. These panics originated many negative attitudes and beliefs about drug users.

  • Stereotypes emerged of drug users as dangerous, lazy, contagious, and irredeemable. The image was of addiction as a moral failing rather than a disease.

  • There was a divide between “good” medical drug use and “bad” recreational use. Middle class white opioid addiction was seen as accidental and deserving of compassion, while Chinese opium smoking was condemned as a voluntary vice.

  • Similar racist myths emerged about cocaine making black Americans violent and prone to rape. This justified crackdowns on black users and helped fuel mass incarceration.

  • The governing image of the irredeemable, dangerous addict originated in this era and has continued to influence drug policy focused on prohibition and control rather than public health.

  • In the late 19th century, racist and classist stereotypes emerged about cocaine and heroin users, portraying them as dangerous lower life forms threatening respectable society. This contributed to prohibitionist drug policies.

  • As a medical intern, the author initially cared deeply about helping disadvantaged patients, but grew jaded and burnt out over time as their problems seemed intractable. The author’s own growing alcoholism contributed to not caring and becoming unreliable at work.

  • In the 1980s, the “crack baby” scare portrayed babies exposed to crack cocaine in the womb as irreparably damaged. This built on earlier fears about drug use corrupting heredity, and was used to further criminalize addicted mothers, despite poverty being the greater factor.

  • In the late 19th century, the theory of “degeneration” claimed that vices like alcoholism could biologically transmit negative traits across generations. This pessimistic view of addiction as hopeless contributed to punitive policies. Throughout history, fears about drugs threatening social order have mixed with biased science to justify harsh measures against marginalized users.

Here are the key points:

  • In the late 19th century, addiction was seen through an “anti-vice” lens. Addicts were viewed as biologically and morally degenerate, predisposed to criminality.

  • This pessimistic view, combined with the failure of medical treatments, led to increased calls for prohibition as the only solution.

  • Bishop Brent brought these attitudes to the Philippines and helped catalyze the international prohibition movement.

  • Hamilton Wright used racist scare tactics to drum up support for drug prohibition in the US, greatly exaggerating addiction rates.

  • The 1914 Harrison Narcotics Act was a backdoor prohibition measure, regulating and taxing drugs heavily.

  • Its impact on medical practice was unclear, but federal prosecutors pushed to ban opioid prescriptions for addiction treatment entirely.

  • Legal challenges like Jin Fuey Moy’s case clarified the Act’s limits, but rising nationalism and prohibitionism during WWI accelerated the push for total bans.

Here is a summary of the key points regarding the motivations and consequences of alcohol prohibition in the late 19th and early 20th centuries:

  • Anti-Catholic and anti-immigrant sentiment, as well as stereotypes of drunken Irishmen, contributed to early support for temperance and prohibition movements in the 1840s-1900s.

  • The prohibition movement aligned with and helped revive the Ku Klux Klan, gaining momentum from wider nativist fears.

  • While alcohol consumption may have declined, prohibition increased crime, violence, disrespect for the law, and injuries from tainted alcohol.

  • It created an inequitable system of enforcement and a fundamental legal division between drugs associated with minorities vs those associated with whites.

  • The costs were high - it boosted the black market, encouraged more potent forms of drugs, and reinforced the racialized division between legal and illegal drugs that persists today.

  • It essentially eliminated community-based addiction treatment in the U.S. from the 1910s-1930s, fostering distrust between doctors and patients that continues now.

  • By banning alcohol and cracking down on opioids, prohibition laws have often had the perverse effect of pushing people towards more potent, deadly substitutes - a phenomenon known as the “iron law of prohibition.”

  • In the early 20th century, there was little understanding of addiction and those with addiction faced crushing stigma, being seen as subhuman “demons” and “villains”.

  • Marty Mann was an alcoholic socialite who struggled to find help, bouncing between psychiatrists who didn’t see addiction as a medical issue. After failed attempts at sobriety, she finally read a pre-publication draft of Alcoholics Anonymous in 1939 which gave her hope.

  • Alcoholics Anonymous (AA) was founded by Bill Wilson, who also struggled with alcoholism for years before getting sober. Wilson tried various medical “cures” with no success.

  • Mann became instrumental in popularizing AA, using her public relations skills to advocate for alcoholism as a disease and treatment through AA. This helped shift public attitudes.

  • The roots of modern addiction understanding come from movements like AA which recast addiction as a medical issue requiring treatment, not just a moral failing. Mann and Wilson were pioneers in promoting this view and providing a mutual help solution.

  • Bill Wilson struggled with alcoholism for years, undergoing various treatments like the “time control” method at Towns Hospital. Despite efforts to strengthen his willpower, he repeatedly relapsed.

  • Wilson had a transformative spiritual experience after being visited by his friend Ebby Thacher, who told him about finding sobriety through the Oxford Group. This led Wilson to have an epiphany where he felt free from alcohol.

  • Wilson and Dr. Bob Smith created Alcoholics Anonymous, merging medical ideas about alcoholism with spiritual practices. AA focused not just on giving up alcohol but on complete personal change through practices like group discussions and service to others.

  • Early AA was dominated by white Protestant men and not always welcoming to women. Marty Mann was an early female member who found AA enormously helpful, feeling she had found her “tribe” and was no longer alone.

  • Mann became Wilson’s sponsee and helped AA grow, joking about someday having meetings across the country. For her, the community was the most appealing part of AA.

  • Research affirms the importance of community in AA’s success. AA works in part by providing healthier opportunities for socialization.

  • The author describes experiencing denial and making excuses when confronted by supervisors about poor performance and possible alcoholism during psychiatry residency. Despite their offers of help, the author lied and denied having a problem, afraid of the stigma and change that accepting help would require.

  • The author reflects that denial is a major obstacle in treating addiction, yet is often left out of medical definitions. Some maintain denial even facing death, unable to accept they have a problem. The tendency for self-deception may have evolutionary origins in deceiving others more convincingly.

  • In the confrontation during residency, the author summoned excuses like lack of sleep and working through authority issues in therapy, even though they were untrue. The author believed them, showing the power of denial. Help was rejected to avoid accepting being “different” or “mentally ill.”

  • The author sees this as a turning point when help could have been accepted, but denial was too strong. The fear was of change and of accepting addiction, which would mean accepting being “sick.”

  • Marty Mann sought to counter such denial through her “alcoholism movement” to medically reframe alcoholism as a disease, not a moral failing. She was inspired by advocacy movements destigmatizing diseases like cancer. She wanted alcoholism to be recognized and treated compassionately like other medical conditions.

Here are the key points:

  • Marty Mann connected with Yale researchers like E. M. “Bunky” Jellinek, an eccentric but brilliant alcohol researcher. Jellinek recognized Mann’s talents and she studied alcoholism with him.

  • In 1944, Mann held a press conference announcing the National Council on Alcoholism (NCA), which would promote the view that alcoholism is a disease. This launched the modern alcoholism movement.

  • Mann was a gifted speaker and used her connections to spread the disease concept and establish alcoholism treatment centers. This helped change public and medical views on alcoholism.

  • The NCA advocated treating instead of firing alcoholics and lobbied politicians like LBJ, who declared alcoholism a disease in Congress.

  • In 1970, the Hughes Act established the National Institute on Alcohol Abuse and Alcoholism and laid groundwork for today’s addiction treatment system. This was a victory for Mann and the NCA.

  • Mann declared an end to the 150-year war between the forces of temperance and alcoholism advocates like herself. She felt the NCA had succeeded in shifting the focus to helping suffering alcoholics rather than demonizing alcohol.

  • In the 1930s, researchers in Virginia found that alcoholism was a complex problem that did not have easy policy solutions satisfying either “wet” or “dry” factions. Their report was destroyed by the state legislature.

  • The Research Council on Problems of Alcohol, seeking to avoid the wet/dry debate, pivoted to focusing only on alcoholism and accepted funding from the alcohol industry. This represented a conflict of interest but helped frame alcoholism as an individual problem separate from alcohol itself.

  • The alcohol industry played a major role in repealing Prohibition by arguing for individual freedom and responsibility. They continued to fund research that located problems in the individual rather than the substance.

  • The industry has obscured the fact that most alcohol harms come from “hazardous” drinkers, not severe alcoholics. They stand to lose significant revenue if consumption is reduced across the board.

  • Powerful alcohol companies have lobbied governments globally, even writing legislation themselves that ignores effective interventions like availability limits and advertising restrictions.

  • Alcohol and tobacco industries differentiated their products from “drugs” through advertising in the early 20th century. This created a divide between legal and illegal drugs that continues today.

Here are the key points:

  • In the 19th century, alcoholism and addiction were seen as united under the umbrella of “inebriety”.

  • Over time, a rift developed between alcohol/tobacco and other drugs, as well as between alcoholism and other addictions. This impairs a nuanced view of addiction.

  • The criminalization of drugs has enabled inequities in addiction treatment to persist.

  • Marty Mann helped popularize the disease concept of alcoholism in the mid-20th century. However, AA itself did not strongly embrace the disease label initially.

  • Mann worked tirelessly to advocate for alcoholism treatment and mutual help groups like AA. This helped shift public perceptions of alcoholism.

  • In the 1970s-80s, Betty Ford and other celebrities publicly discussed their addictions and recoveries, further reducing the stigma around addiction.

  • Twelve-step programs like AA grew rapidly, with some viewing them as a solution to societal problems.

  • However, Mann and AA had a complex relationship with disease language. Mann focused on it more than AA’s founders.

  • The disease analogy has limitations, as most diseases involve complex, interacting factors rather than being discrete entities.

In summary, shifting views of addiction as a disease enabled greater acceptance and treatment access, but also risk oversimplifying the nature of addiction. Tensions remain between medical and mutual help perspectives.

  • William Burroughs was desperate to find opioids in 1947 due to strict prohibition laws and lack of treatment options at the time. He tried various methods like forging prescriptions and stealing, but eventually checked himself into the United States Narcotic Farm (“Narco”) in Kentucky for a brief detox stay.

  • Narco served as a more humane refuge and treatment facility for people with addiction, as well as a research center where compassionate doctors and scientists like Lawrence Kolb studied addiction.

  • Kolb disproved the “antitoxin” theory of addiction and concluded it was caused by underlying psychological issues, not physiological enslavement to drugs. Though his language was harsh, this shifted the view from addiction as a moral failure to a condition arising from personality problems.

  • However, this perspective heightened the division between “good” and “bad” drugs and users. It overlooked how people across the spectrum were failed by punitive drug policies. The biases of the time blinded society to the dangers on both sides of this divide.

  • In sum, Narco represented a more enlightened approach to addiction, but the overly reductionist view of the era further entrenched the unequal treatment of people with addiction, whether marginalized or privileged. The result was a system that failed people all along the spectrum.

  • In the early 20th century, researchers like Lawrence Kolb searched for a biological or personality-based cause of addiction, reflecting trends in psychology at the time. Kolb proposed a theory of “addictive personality” to explain addiction.

  • Kolb became director of the U.S. Narcotics Farm in Lexington, Kentucky (also known as “Narco”), which aimed to treat addiction compassionately. Narco was a leading addiction research center until the mid-1900s.

  • However, Harry Anslinger, head of the Federal Bureau of Narcotics, promoted a punitive prohibitionist approach, associating drugs with crime and racial stereotypes. He prevailed over the medical view.

  • As a result, drug arrests and penalties increased dramatically, admissions to Narco soared, and it became overcrowded and punitive.

  • In the 1950s, William Burroughs also put forth a biologically deterministic view of opioids as uniquely addictive in his book Junky. He followed biases of researchers at the time.

  • The search for biological causes of addiction failed, but it lent support to punishment-based policies that prevailed over medical approaches for decades.

Here are the key points:

  • In the early 20th century, scientists dismissed problems with cocaine and other stimulants as merely “psychic addiction”, arguing that without withdrawal symptoms, drugs could not produce true addiction.

  • The Federal Narcotics Farm was established in 1935 as the only laboratory devoted to studying drug addiction. Its goal was to find a non-addictive painkiller to replace dangerous opioids.

  • Researchers used primitive tools and behaviourist methods, reducing addiction to observable stimuli and responses. They focused on measuring opioid withdrawal, seeing it as the defining sign of addiction.

  • Equating withdrawal with addiction was overly reductionist, overlooking the complexity of addiction and the harms of other substances like cocaine.

  • In the 1880s-90s, Freud naively promoted cocaine as a treatment and “cure” for morphine addiction, despite warnings. His friend Fleischl-Marxow became addicted to both cocaine and morphine.

  • Defining substances as “treatments” can insulate them from scrutiny about their addictive potential, as happened initially with cocaine. The assumption that opioids represented the essence of addiction obscured harms of other drugs.

  • The author cut down on drinking for a time, but struggled to fill the void it left, throwing himself into work and projects. Drinking crept back in and he began using more Adderall to manage the hangovers and fatigue.

  • He tried to balance the stimulants and alcohol on a vacation he dubbed “Bender November,” but his behavior became erratic and self-destructive. He realized something was wrong but denied the drug use was an issue.

  • In the 1940s, amphetamines like Benzedrine grew popular for a range of uses. Despite early warnings about addiction risk, aggressive marketing and enthusiam for new drugs allowed their use to grow unchecked.

  • Amphetamines were used extensively by militaries in WWII to enhance performance. The U.S. forces used them at much higher levels than others and brought an enthusiasm for them back home.

  • The author draws parallels to his own undisciplined use of stimulants, and society’s blindspots around “good” prescription drugs versus “bad” street drugs. This attitude enabled the growth of amphetamine use despite risks.

  • Pharmaceutical companies promoted minor tranquilizers like Librium and Valium in the 1960s, using aggressive marketing tactics pioneered by Arthur Sackler. These tactics helped turn medications into consumer goods, fueling a boom in prescription drug sales.

  • Meanwhile, amphetamines evaded tighter regulation in part by being framed as non-addictive, unlike “bad” drugs like opioids. Doctors claimed amphetamine addiction was a fault of individual psychology, not the drugs themselves.

  • A similar narrative protected barbiturates, which also cause dangerous physical withdrawal. Attempts to regulate them were opposed by Harry Anslinger and pharmaceutical companies, who claimed it would harm middle-class white anxiety patients.

  • This entrenched a false dichotomy between “good” therapeutic drugs and “bad” addictive drugs divided by race and class. It led to lax regulation of pharmaceuticals as an entitlement for whites, while minorities were criminalized for illegal drug use.

  • The opioid crisis and mass incarceration represent two sides of this system functioning as designed. Jazz musicians like Sonny Rollins were among those harmed by easy access to pharmaceutical heroin, showing the human costs.

Here are the key points from the passage:

  • There was a massive postwar heroin crisis that hit the jazz world hard, with an estimated 75% of 1940s-50s bebop musicians using heroin. The government cracked down harshly with long mandatory minimum sentences.

  • Racist policies crowded Black Americans into poor inner cities, creating a concentrated market for heroin. Anslinger blamed Black families, rather than systematic racism, for the increase in heroin use.

  • Pharmaceutical drug use was also booming among white Americans, with widespread abuse of barbiturates and amphetamines.

  • The crackdown fueled the heroin epidemic and allowed organized crime to benefit, while also worsening conditions for communities of color. The divide between legal and illegal drugs exacerbated public health issues on both sides.

  • Burroughs accidentally killed his wife Joan while drunkenly playing William Tell in Mexico in 1951. Their son Billy later struggled with addiction too, showing how the spheres of legal and illegal drugs cannot be separated.

  • The author had easy access to Adderall due to white privilege, but eventually abused it along with alcohol, leading to a drug-induced manic episode and breakdown requiring psychiatric hospitalization. This showed the dangers of such legal pharmaceutical stimulants when misused.

  • In 1960, Louie Robinson was arrested in Los Angeles for being addicted to narcotics, which was a crime at the time. His lawyer, Samuel McMorris, appealed the case to the Supreme Court, arguing that punishing addiction as a crime was unconstitutional.

  • The Supreme Court ruled 6-2 in Robinson’s favor, declaring that “even one day in prison would be a cruel and unusual punishment for the ‘crime’ of having a common cold.” They agreed addiction should be handled medically, not criminally.

  • This marked a shift away from the punitive prohibitionist approach to drug policy. Medical and legal groups began advocating for a more rehabilitative approach focused on maintenance and treatment.

  • Harry Anslinger, architect of the punitive regime, retired in 1962 after the ABA/AMA issued a report critiquing federal drug policy. The Robinson decision came the same year.

  • However, there was still uncertainty about how to effectively treat addiction. The dissenting justices in Robinson argued the law could have a therapeutic effect by compelling treatment.

  • Tragically, Robinson had died of an overdose 10 months before his case was decided. This highlighted that while views were shifting, it was not yet clear how to actually help addicted people.

  • The author was hospitalized for alcoholism and mental health issues. He was referred to a physician health program that helps doctors with addictions return to work.

  • He was pressured to go to their preferred inpatient rehab facility for an extended evaluation, despite wanting outpatient treatment. He felt caught between voluntary and involuntary care.

  • At the dreary rehab facility, he tried to convince staff he only needed outpatient treatment. But the stern, skeptical medical director doubted his story and said he would need to stay a long time.

  • The author realized he was seen as an untrustworthy addicted doctor, not a colleague. The medical director interrogated him and threatened to drug test his hair, assuming he was hiding something.

  • The author felt his only option was to comply, even though he wanted to leave. He was trapped by the system designed to help addicted physicians.

  • The author contrasts his experience with a lawyer who was harassed and attacked after suing the Synanon drug treatment cult in the 1970s. Both faced abusive systems claiming to help them.

  • Charles Dederich founded Synanon in the late 1950s as an alternative to AA that used extreme confrontation and attack therapy. He was later arrested for conspiracy to commit murder against a lawyer suing Synanon.

  • Synanon pioneered the “therapeutic community” model of addiction treatment that uses rigid hierarchy, confrontation, and discipline. This model spread and influenced many other treatment programs.

  • In the 1960s, treatment options for addiction were very limited, so AA members founded the Minnesota Model of rehab based on the 12 steps. This became the dominant model of addiction treatment.

  • Both therapeutic communities and the Minnesota Model filled a void left by medicine’s neglect of addiction treatment. They incorporated some features from AA but added more extreme confrontation.

  • There is little evidence that the confrontational practices and long stays of therapeutic communities improve outcomes. Shorter, less extreme models may be equally effective.

  • The popularity of these alternative models reflects the ongoing structural stigma of a separate addiction treatment system neglected by mainstream medicine.

  • Many people credit intensive addiction treatment with profoundly changing their lives, claiming the confrontation and focus on reshaping one’s identity is transformative. However, the author found some of the confrontational tactics at his rehab unhelpful and potentially harmful.

  • The author went back and forth between accepting and resisting the need for treatment. His mother initially agreed with him that it was overkill but later accepted he needed help.

  • Though conflicted, the author realized his attachment to his own willpower was dangerous and surrendered to the need for treatment, even if imperfect. He introduced himself as an alcoholic, which was difficult but freeing.

  • In retrospect, the author believes he needed some form of coercion but is unsure if the intensity of treatment was necessary. He found the most meaningful parts were about human connection and mutual help rather than formal treatment.

  • The author’s story segues into an account of Marie Nyswander, who pioneered a more compassionate approach to addiction treatment and later helped develop methadone maintenance. Her respect for patients’ dignity and nuanced view of addiction motivations was ahead of her time.

  • Marie Nyswander was a psychiatrist who believed psychoanalysis could help treat heroin addiction, but found her patients inevitably relapsed when they returned to struggling communities.

  • Vincent Dole was a metabolism researcher who became interested in treating addiction after seeing its effects on his commute. He hired Nyswander and they began researching treatments.

  • In 1964, they observed that methadone, a synthetic opioid, had dramatic effects - patients on methadone lost their cravings and became highly functional.

  • In 1965, they reported successful methadone treatment for 22 “mainline” heroin users who had failed other treatments. This was the first evidence of a medication that could effectively treat addiction.

  • Methadone maintenance expanded rapidly, but also faced criticism from those who favored abstinence-based approaches and social interventions over medication.

  • Dole and Nyswander defended methadone but sometimes overstated its effects, claiming it “blocked” drug effects and returned people to “normal.” This added to the controversy.

  • They sought to incorporate methadone into a broader rehabilitation program, though the biological focus sometimes overshadowed this. The opposition between medication and other approaches was unnecessary, since they could complement each other.

Here is a summary of the key points about the listic approach to addiction treatment:

  • In the late 1960s and early 1970s, there was enthusiasm for developing therapeutic responses to addiction, but efforts were dispersed across different fields with conflicting perspectives (e.g. treatment communities, rehabs, methadone clinics, doctors).

  • Richard Nixon declared a “war on drugs” in 1971 amid another heroin epidemic, but surprisingly his approach focused largely on treatment rather than just law enforcement. He appointed a drug czar to lead treatment efforts and poured massive funding into addiction treatment.

  • However, some in government like the Federal Bureau of Narcotics opposed therapeutic approaches like methadone maintenance treatment. They tried to undermine research showing its effectiveness.

  • Methadone treatment initially expanded rapidly with new funding, but oversight was lacking. This led to poorly run “methadone mills” exploiting patients, which damaged methadone’s reputation.

  • Support for rehabilitation weakened, and a harsh “zero tolerance” ideology took hold. This made its way into addiction treatment, with confrontational “boot camp” style programs. Many patients with trauma histories were harmed by these approaches.

  • The summary shows an initial openness to medical solutions for addiction, which closed off as ideology shifted towards punitive responses and funding focused on law enforcement. Even treatment became more punitive as rehabilitative ideals faded.

  • Methadone maintenance therapy was pioneered by Drs. Dole and Nyswander as a holistic treatment for opioid addiction, including job training and social supports. But “pill mill” programs often just dispensed methadone with no other services.

  • Non-medical methadone use and overdoses increased, fueled by lax oversight. Dole and Nyswander were dismayed as methadone treatment became more punitive and controlled by the government.

  • Prohibitionists used problems with methadone to further restrict its use, portraying it as an inner-city drug problem. Methadone became tightly regulated and controlled.

  • Buprenorphine was sidelined due to anti-medication stigma until the opioid epidemic affected white communities. It was then approved for office-based treatment for those with resources.

  • Anti-medication attitudes spread to 12-step programs, causing tensions with medical treatment. People in recovery are sometimes pressured to stop psychiatric medications.

  • However, methadone and buprenorphine cut overdose deaths dramatically. Stigma remains but there are some signs of softening attitudes.

  • In the 1970s, cannabis policy was more nuanced, with calls for decriminalization. But prohibitionist forces gained power, using reforms as tools for control and punishment.

Here are the key points:

  • Nixon initially took a balanced approach to drug policy, but as the Watergate scandal threatened his presidency, he shifted to more punitive policies. He drastically increased funding for drug enforcement and slashed treatment budgets. In 1973, he created the DEA to consolidate federal drug agencies.

  • The addiction treatment field was growing rapidly, fueled by federal funding and insurance coverage. But the expansion led to declining quality as unqualified staff were hired. Programs pushed abstinence-only treatment and 12-step methods.

  • In the mid-1970s, a RAND study found that some alcoholics could successfully return to moderate drinking after treatment. This contradicted the abstinence-only ideology. Advocates like Thomas Pike fought fiercely against the findings.

  • There was a broader shift toward criminalizing poverty and moving away from 1960s rehabilitative ideals. Addiction treatment was becoming intolerant of differing views, diagnosing everyone with addiction and insisting on total abstinence. This narrow view was at odds with AA’s original flexible approach.

  • In the 1970s, researchers at RAND Corporation published a report finding that many people with alcohol problems could return to nondependent drinking. This contradicted the dominant view that alcoholism was an irreversible disease requiring total abstinence. The alcoholism treatment field reacted angrily, calling the report unethical and dangerous.

  • Around the same time, psychologists Mark and Linda Sobell conducted a study finding some severe alcoholics could be trained to engage in controlled drinking. Their findings were also attacked, with allegations of fraud. Multiple investigations exonerated the Sobells, but the controversy highlighted the polarized views on addiction.

  • In the late 1970s, parent groups lobbied for greater restrictions on drugs, pushing a zero-tolerance approach. With the election of Ronald Reagan, drug policy focused on morality rather than public health. Addiction was blamed on poor individual choices rather than complex causes.

  • Reagan escalated the war on drugs, justifying an expanded role for law enforcement. The crack epidemic furthered sensationalist media portrayals of addiction. The pharmaceutical industry was deregulated, enabling the rise of prescription opioids.

  • Overall, the moralistic view of addiction as a individual failing took hold, widening divisions in the field. This set the stage for misuses of the concept of addiction, with severe consequences.

  • In the 1980s, the Reagan administration escalated the war on drugs, imposing harsh mandatory minimum sentences that disproportionately impacted people of color. Addiction was used as a pretext to crack down on marginalized communities.

  • The cultural understanding of substance use was profoundly impacted, promoting fears of addiction as a dangerous contagion. Media coverage, DARE programs, and anti-drug ads intensified anti-drug sentiment.

  • Today’s U.S. addiction treatment system has major problems - lack of regulation, low standards, exploitation. It’s disconnected from evidence-based practices and built around a flawed acute-care model.

  • The roots of these problems lie in the 1980s-90s war on drugs. Criminalization increased stigma and shaped treatment toward coercion and “tough love.” A massive arrest-referral pipeline still feeds the treatment system.

  • This represented a departure from the original Minnesota Model and 12-step approach, which was intended for people with severe addiction problems voluntarily seeking help. The system became increasingly punitive due to prohibitionist forces.

  • Alcoholics Anonymous (AA) was originally intended to help voluntary, struggling alcoholics who wanted help, not coerced people who didn’t think they had an addiction problem. As the treatment system expanded, it struggled to adapt to serving a broader population.

  • AA did not insist everyone must abstain or declare its approach superior. It recognized heterogeneity in alcohol problems and supported multiple paths to recovery.

  • Confrontational approaches common in addiction treatment by the 1980s-90s were shown by research to be less effective than supporting self-efficacy. Pushing 12-step abstinence is not appropriate for everyone.

  • The treatment system had a chance to reform when it crashed in the late 80s-early 90s, but instead it recovered largely unchanged.

  • The harm reduction movement arose in the 1980s in response to the AIDS epidemic, promoting pragmatic approaches to reduce harm without insisting on abstinence. It faced significant opposition as condoning drug use.

  • Harm reduction has expanded to include syringe exchanges, overdose prevention, drug checking, safe consumption sites, and client-centered therapy focused on improving lives without mandating abstinence up front. It aligns with a social justice framework of drug user rights and reducing negative consequences of drug control policies.

Here is a summary of why the Democratic Party’s commitment to anti-drug and pro-law-enforcement rhetoric continued into the 1990s, despite the failures of the war on drugs:

  • The war on drugs began under Republican President Nixon in the 1970s, but was escalated under Democratic President Clinton in the 1990s through policies like mandatory minimum sentences and the 1994 crime bill.

  • There was bipartisan consensus on being “tough on crime” and drugs at the time. The Democrats wanted to avoid appearing soft on crime by the Republicans.

  • The crack cocaine epidemic of the 1980s and early 1990s led to increased fear of drugs and crime, making an anti-drug and pro-law enforcement stance politically popular.

  • Powerful law enforcement lobbies and prison industry interests also pushed the Democrats to maintain the status quo of harsh anti-drug policies.

  • It was not until decades later, under Obama’s administration, that the rhetoric and policies began to shift, with a recognition that the war on drugs and mass incarceration were failing. This led to reforms like reducing mandatory minimums, allowing cannabis legalization, and promoting a public health approach through harm reduction.

  • In the early 1970s, studies by Lee Robins found high rates of recovery from addiction even without treatment, challenging the traditional disease model that addiction was progressive and permanent.

  • Other studies like George Vaillant’s also failed to find a clear division between alcoholics and the general population. High comorbidity rates between addiction and other disorders further complicated the disease model.

  • Most large-scale surveys found the majority of people with substance use problems improve spontaneously through “natural recovery.” Up to 75% of those with severe problems showed no symptoms years later.

  • The public often exaggerates biological explanations into notions that people with addiction are doomed by underlying physical abnormalities.

  • In the 1970s, researchers discovered the brain’s opioid receptors and endogenous opioids like endorphins. This kicked off an era of biological reductionism, with exaggerations about the power of genetics and brain abnormalities in addiction.

  • While biology clearly influences addiction risk, the research shows addiction cannot be reduced to brain abnormalities alone. Psychological, social, and spiritual factors also play key roles.

  • A balanced view synthesizes biological, psychological, social, and spiritual factors, avoiding exaggerated reductionism. People with addiction still have capacity for choice and growth.

Here are the key points:

  • There have been many theories over time trying to explain addiction, including “receptor fever” (abnormalities in brain receptors), genetics, and neuroscience. However, no single theory fully explains addiction.

  • Addiction likely has multiple contributing factors, including biology, environment, psychology, and trauma. There is no one dominant cause of addiction.

  • Since the early days of studying addiction, doctors have hypothesized there are different subtypes of addiction that vary in causes and courses. However, research has not clearly delineated stable, reliable subtypes.

  • The influences on addiction form a complex, dynamic matrix that changes drastically across people and over time. There is heterogeneity in the causes and manifestations of addiction.

  • Augustine, Alexander the Great, Occom’s charges, De Quincey, Coleridge and others had important differences in the factors driving their addictions.

  • Overall, the search continues for definitive explanations of addiction, but the phenomenon resists singular theories or causes. The diversity of factors influencing each case means addiction is best understood as multifactorial.

  • Addiction is complex and multifaceted. It is not just a brain disease or a social problem, but a combination of biological, psychological, and social factors that differ across individuals.

  • There is a continuum between addiction and normal behavior. The boundaries are fuzzy, and addiction is a matter of degree rather than a completely discrete category.

  • The author chose to identify as a recovering alcoholic and abstain from drinking, even though he was unsure whether he truly qualified as addicted. This was a practical decision, but also about choosing an identity.

  • The author sees commonalities between his own addiction struggles and the problems others face with behaviors like overeating or technology overuse. All people struggle with self-control and divided selves.

  • Those in recovery, while varied, share the experience of losing control, reorganizing their lives around substance use, and wanting to break free. This common experience provides a basis for mutual support.

  • Recovery involves focusing less on the treatment apparatus and more on learning to live fully. The author was able to progress in his psychiatry career while maintaining his recovery practices.

Here are the key points:

  • Ay was a stressed graduate student who had started drinking heavily to cope. When he sought help, the clinic turned him away because his drinking was considered too severe. This reflected the stigma and separation of addiction treatment from mainstream healthcare.

  • Medicine has failed to adequately treat addiction. Steps like expanding harm reduction, improving access to evidence-based treatment, and removing barriers to medications would save lives. However, stigma among providers is also a major barrier.

  • In my own recovery, I felt restless and unfulfilled at first, despite not drinking. I feared relapse. I struggled to find meaning in AA’s ideas of recovery.

  • Over time, I learned recovery is highly personal and diverse. I began focusing less on formal AA involvement and more on self-care, relationships, and service. This more flexible approach worked better for me.

  • The medical system needs to expand evidence-based addiction treatment. But recovery encompasses more - it is a personal process of growth and connection that requires flexibility. Both care and recovery are essential.

  • For a long time, recovery from addiction was seen as nearly synonymous with total abstinence and participation in 12-step programs like AA. This perspective is deeply ingrained in society.

  • In recent years, researchers and clinicians have come to appreciate the diversity of approaches to recovery. There are many paths to overcoming addiction beyond AA and total abstinence.

  • Research shows most people with substance problems recover without formal treatment. Only a minority rely on AA or abstinence-only approaches.

  • Recovery is increasingly seen as an ongoing process of positive change rather than just the absence of addiction. By this broad definition, most people do recover.

  • Neuroscience shows the brain can change back after the changes caused by addiction. The brain is not permanently damaged.

  • The author struggled to find the right path to recovery, initially trying AA but later finding a better fit in Buddhist practice and a broader spirituality. This allowed a fuller recovery.

  • Even many years into recovery, challenges like a mother’s illness can test sobriety and personal growth. But with ongoing self-reflection and Buddhist values, the author continues to deepen recovery rather than relapse.

Here are the key points:

  • The author sought therapy (Internal Family Systems) to help with addiction recovery and found it surprisingly effective, despite initial skepticism. Therapy helped the author be more self-compassionate and set boundaries with family.

  • The author’s patient Joey responded well to buprenorphine treatment but still struggled with other addictive behaviors. Therapy helped Joey explore shame and trauma from childhood which connected to current behaviors.

  • Biomedical treatments like buprenorphine and emerging options like psychedelic therapy can save lives but are just the first step - people still need to do the psychological and spiritual work of recovery.

  • Recovery is an ongoing process of positive change, not an endpoint. It requires intention, agency, and community support. Science and medication help but humility, mutual aid, and pragmatism are also crucial.

  • Addiction is profoundly ordinary and universal. The opportunity for recovery should be a right, but inequality of resources makes it inaccessible for many. Recovery is a communal experience, not just an individual journey. If addiction is part of humanity, it’s not a problem to solve but a condition to understand.

Here is a brief summary of the key points from the acknowledgements:

  • The author expresses gratitude to his patients, colleagues, friends, and all those in the addiction recovery community who shared their stories and experiences, which informed the writing of the book.

  • He thanks the professionals who helped him in his own recovery from addiction, acknowledging the treatment system and its dedicated workers.

  • He acknowledges his editor, agent, publishers, research assistants, fact-checker, and copyeditor for their work on the book.

  • He is indebted to the many experts across fields who generously shared insights and reviewed material.

  • He thanks his family and friends for their support during the long process of writing and revising the book, including during difficult personal times.

  • He expresses gratitude for the institutions that supported his research and writing efforts.

  • Finally, he thanks the reader for engaging with this challenging material, hoping the book provides deeper understanding of addiction and encouragement for recovery and flourishing.

Here is a summary of the key points about the history of thinking about addictive behaviors:

  • The word “addiction” has ancient roots, with terms like the Greek “philopotês” and Chinese “shi jiu” used to describe obsessive drinking behaviors.

  • Gambling and drinking behaviors that we might now call addictions have existed across human societies for millennia, with evidence dating back to before 1000 BC in ancient India.

  • Ancient thinkers like Plato and Aristotle wrestled with the philosophical problem of “akrasia” or weakness of will that underlies addiction. The idea of a divided self struggling with appetite and reason appears in Plato’s imagery of the chariot.

  • Christianity brought new thinking about addiction through figures like Augustine, who saw his obsessive sexual desires as sinful and evidence of corrupted human nature after the Fall.

  • Later traditions like medieval mysticism valued practices of detachment from cravings of the self, influenced by Buddhism and monastic practices.

  • Overall, the thinking about behaviors we now call addiction has a long history across multiple cultures and philosophical traditions. Theories have emphasized moral weakness, corrupted nature, or the universal suffering of desires.

  • Addiction has complex causes, including biological, psychological, social, and environmental factors. It is not just a moral failing or lack of willpower.

  • The modern disease concept of addiction emerged in the late 19th century. Before this, addiction was seen as a character flaw or sin.

  • Some historical figures like Mark Antony and Alexander the Great exhibited behaviors that resembled modern understandings of addiction. However, retroactively diagnosing them is problematic.

  • The DSM-5 defines substance use disorders as patterns of compulsive use despite negative consequences. This provides standardized diagnostic criteria but oversimplifies the complex realities of addiction.

  • Addiction exists on a spectrum. The neurodiversity movement argues against stigmatizing certain mental conditions as purely dysfunctional.

  • Addiction involves altered reward processing and dysfunction in brain systems related to motivation, inhibition, and self-control. But it is better understood as a complex disorder rather than just defects in the brain.

  • Competing philosophical models cast addiction as either a disease beyond one’s control or a failure of agency and rationality. A balanced view acknowledges elements of both while avoiding moralization.

  • Key factors include craving, habituation, isolation, existential anxiety, and “psychological inflexibility.” Addiction provides momentary freedom from these, though at great cost.

  • We should avoid moralizing addiction as a simple lack of willpower. But agency and values are still relevant, especially for recovery, which requires commitment.

  • The concept of “addiction” emerged in 16th century England, evolving from earlier notions of sin, vice, and passion. Writers like John Frith used “addicted” to indicate devoted commitment, though also recognizing the lack of control implied.

  • Tobacco, opium, and sugar gained popularity in the 16th and 17th centuries as part of the “psychoactive revolution.” Governments alternately encouraged or restricted their use.

  • Early critics saw tobacco as a dangerous vice, including King James I’s Counterblaste to Tobacco. But high taxes on tobacco, alcohol, and tea became important sources of revenue for governments.

  • Today’s concept of addiction as compulsive behavior beyond one’s control developed over centuries. Powerful economic interests have often downplayed the addictiveness of their products, from tobacco companies to opioid manufacturers like Purdue Pharma.

  • Policies like prohibition or excessive taxation have often failed to curb addiction. More effective policies recognize the complex causes of addiction in society. Addiction has also been entangled with systems of power, inequality, and profit.

Here is a summary of the key points from the sources:

  • Tobacco was introduced to Europe in the 16th century and quickly gained popularity, spreading disease in its wake. Mancall and Norton detail how tobacco became entrenched in European economies and daily life despite knowledge of its health risks.

  • Tobacco was linked to the rise of slavery, as European colonies relied on enslaved laborers to produce tobacco and other cash crops like sugar. Harrison notes how the tobacco industry obstructed antislavery efforts.

  • Tobacco companies later deliberately addicted consumers to cigarettes, even though they knew smoking caused cancer. The industry manufactured doubt about smoking’s health risks, a tactic later copied by climate change deniers.

  • Alcohol has also caused tremendous harm, as Occom describes in his sermon condemning the liquor trade’s impact on Native peoples. Addiction has often coincided with cultural displacement and loss, as Alexander’s “dislocation theory” suggests.

  • Modern spikes in deaths of despair and addiction among disadvantaged groups echo past inequities. Netherland and Hansen critique the narrow focus on white opioid users that obscures the deeper roots of addiction.

  • Some Native leaders like Papunhank and Handsome Lake pioneered early recovery programs, drawing on cultural strengths. Their efforts presaged modern Native-led anti-addiction initiatives like the Wellbriety movement.

Here is a summary of the key points from the excerpt:

  • Benjamin Rush, a signer of the Declaration of Independence and prominent physician, helped establish habitual drunkenness as a medical condition starting in the late 18th century.

  • Alcohol abuse was widespread in the new United States, fueled by profitable distilleries. Rush saw the effects firsthand during the Revolutionary War.

  • Rush built on earlier thinkers like Thomas Trotter who had called habitual drunkenness a “disease of the mind.” Rush went further, calling it an “odious disease” and likening it to an epidemic.

  • Rush advocated temperance and abstinence as cures, emphasizing religious faith and willpower. This established a pattern of viewing addiction as located in individual biology and morality.

  • Rush’s medicalization of habitual drunkenness also put physicians like himself in a prime position to treat it. He advocated controversial treatments like bloodletting.

  • Rush’s views reflected Enlightenment thinking and a desire to establish scientific expertise. But his biological reductionism set the template for later views of addiction.

Here is a summary of the key points from the passages:

  • Addiction treatments in the 19th century claimed high success rates but were often ineffective. Treatments like “bi-chloride of gold” tried to “liberate the will” but didn’t address underlying causes.

  • In the late 20th century, the “brain disease model” became dominant in understanding addiction, treating it as a biological disorder beyond individual control. This shifted responsibility from the individual to the brain.

  • Historically, views on addiction have swung between moral/spiritual and disease models. Moral views see it as a failure of willpower. Disease views see it as outside individual control.

  • Benjamin Rush pioneered the disease view in the early 19th century, calling alcoholism a “disease of the will.” But he refused to say it eliminated moral responsibility.

  • The brain disease model has faced criticisms recently for overlooking psychosocial factors and reducing motivation for change by implying lack of control.

  • Understanding addiction likely requires an integrated biopsychosocial model, recognizing biological factors while retaining a role for individual responsibility and choice. Historical views have tended toward polar opposites on this spectrum.

  • The temperance movement arose in the early 19th century, led by preachers like Lyman Beecher who condemned alcohol as a uniquely dangerous and irresistible poison that destroyed lives.

  • The movement gained momentum through emotive “drunkard narratives” in literature and sermons depicting alcoholism as a demonic possession.

  • By the 1830s-40s, temperance had become a widespread social movement, with millions joining abstinence societies. Alcohol consumption dropped sharply.

  • Temperance advocates promoted an early theory of addiction as hijacking and usurping the brain’s pleasure circuits. This “pharmacological determinism” portrayed the substance as irresistibly overpowering the individual.

  • Modern science has complicated this view, showing addiction results from a complex interplay of pharmacological, genetic, and social factors. The brain’s reward system is now seen as more neutral and complex.

  • But the basic narrative of addiction as demonic hijacking has persisted influentially through figures like Bill Moyers, shaping lasting cultural notions of irresistible craving separate from the self.

This summary examines the history of addiction science and shifting cultural attitudes towards addiction in America.

Key points:

  • The discovery that addictive drugs increase dopamine fueled the ‘hijacking’ theory of addiction. Studies in the 1970s-80s found drugs like cocaine sparked dopamine release, leading to theories that addiction hijacked the brain’s reward system.

  • However, the hijacking metaphor oversimplifies addiction. Not all addictive drugs measurably increase dopamine, and dopamine does not directly mediate pleasure/reward. The theory also promotes a view of addiction as loss of free will.

  • Temperance movements portrayed alcoholism as a moral failing rather than a disease. Alcohol was deemed poisonous; drinkers thought to have weak wills.

  • Some groups like the Washingtonians pushed back against moralizing attitudes, describing their own drinking problems in sympathetic terms rather than as individual faults.

  • The Washingtonians adopted more egalitarian approaches to addiction, but were suppressed due to their radicalism. Moralizing attitudes persisted into the 20th century war on drugs.

In summary, the dopamine hijacking theory propagated an oversimplified view of addiction as loss of agency, continuing a historical tradition of moralizing attitudes and suppression of more progressive approaches. The science challenges black-and-white notions of addiction as a moral or biological failing.

Here is a summary of the key points from the excerpt:

  • Opium was common in the 19th century for recreational and medicinal use. Thomas De Quincey’s Confessions of an English Opium-Eater (1821) described the pleasures and pains of opium addiction. It influenced later writers like Wilkie Collins, who recognized opium’s dangers.

  • De Quincey celebrated opium’s ability to enhance imagination and feeling, but also portrayed the misery of addiction. His work influenced the Romantics’ view of drugs as unshackling creativity. Later artistic groups like the Decadents also incorporated drug use.

  • In the U.S., Fitz Hugh Ludlow’s The Hasheesh Eater (1857) described the sublime visions of cannabis but also warned of the “horrible mental bondage” of addiction. Ludlow later advocated for morphine addiction to be seen as a disease.

  • Opium consumption boomed in the 19th century, especially after the isolation of morphine in the 1820s. Debates emerged on whether addiction should be seen as a moral failing or medical condition. The “Confessions” review saw it as a dangerous “intemperance.”

  • Doctors in the 19th century distinguished themselves as professionals and began widespread use of opiates, leading to an epidemic of addiction. Hypodermic needles enabled easy morphine injection, seen as entirely safe at first.

  • A huge market for patent medicines containing opiates and cocaine emerged. Specialized addiction treatment centers were founded, emphasizing moral reform and abstinence.

  • Concepts of addiction widened from alcohol to include drugs, food, sex, and other behaviors. Theories blamed addiction on weak will, neurasthenia, and other causes.

  • Many professional men like William Halsted became addicted through easy access to drugs. Doctors were blamed for creating addicts through careless prescription.

  • Addiction was seen as undermining values of restraint and self-control in an industrializing society. Temperance and public health reformers campaigned against the epidemic of addiction.

Here is a summary of the key points from the excerpts of the chapters:

  • Anti-vice activists in the late 19th and early 20th centuries distinguished between “worthy” and “unworthy” addicts. Opium smoking was seen as a corrupt vice of Chinese immigrants, while injecting morphine was viewed more as a disease among middle-class white women.

  • Racist stigma was attached to cocaine use, depicted as causing Black people to become violent. Meanwhile, heroin addiction was sensationalized as a threat to white middle-class youth.

  • Reformers sought to suppress vices like opium smoking through criminalization, while maintaining morphine and heroin access through the medical system for “legitimate” users.

  • The demonization of Chinese opium smoking and Black cocaine use was used to justify discriminatory drug policies, laying the groundwork for unequal drug enforcement still seen today.

  • While heroin and cocaine came to be seen as dangerous “demon drugs” over time, at first heroin was touted as a safe alternative to morphine, and cocaine was widely available in patent medicines and soft drinks.

Does this accurately summarize the key points from the chapters? Let me know if you would like me to expand or modify the summary.

  • In 1989, Jennifer Johnson was convicted and sentenced for giving crack cocaine to her babies through her breastmilk. Her sentence was later overturned in 1992, and she is now an advocate for pregnant women.

  • The “crack baby” phenomenon in the late 1980s sparked hysterical predictions about “biologically inferior” and “mentally useless” children, echoing earlier fears about the degenerating effects of drugs and alcohol.

  • This built on a long history of seeing addiction as causing moral and physical degeneration, leading to forced sterilization, incarceration, and racist stereotypes.

  • International efforts to control opium in the early 20th century, led by Bishop Brent, helped spur stricter domestic anti-drug laws in the U.S.

  • Prohibition led to more potent and dangerous forms of alcohol, illustrating the “iron law of prohibition.” Morphine maintenance clinics were shut down, though a gray market persisted.

  • The Harrison Act effectively criminalized addiction amid debate over whether it was a “disease” or “vice.” The crackdown continued through the 20th century war on drugs.

Here is a summarized version of the key points:

In the early 20th century, American medical opinion was divided on whether opioid addiction should be treated with indefinite maintenance doses of the drug. Some saw addicts as “carriers” of a disease, while others argued they lacked moral willpower. Racist stereotypes also influenced views, with addicts seen as subhuman, contagious, and possessed.

Alcoholics Anonymous (AA) emerged in the 1930s as an alternative, framing alcoholism as a medical issue requiring lifelong management. Key principles were powerlessness over alcohol, surrendering to a higher power, and finding strength in the group. Though AA privileged white men initially, Marty Mann led efforts to make it more inclusive.

In the 1940s, Mann founded the National Committee for Education on Alcoholism, drawing on public health advocacy models. She framed alcoholism as a disease requiring medical treatment and reduced stigma, helping spark an “alcoholism movement.” This counteracted moralistic views of addiction as a personal failing.

Here are the key points summarizing the passage on the history of alcoholism and the alcohol industry:

  • In the 1930s, some doctors began viewing alcoholism as a disease rather than a moral failing. The “Yale Center of Alcohol Studies” and the “Research Council on Problems of Alcohol” promoted the disease concept.

  • In 1944, Marty Mann became the first woman to achieve long-term sobriety in Alcoholics Anonymous (AA). She campaigned publicly for the disease concept and co-founded the National Council for Education on Alcoholism.

  • In the 1950s and 1960s, the American Medical Association and other medical groups declared alcoholism a disease. Federal legislation in 1970 also endorsed this view.

  • The alcohol industry promoted the disease concept as it helped shift focus away from the harms of alcohol itself to the behaviors of a minority of “alcoholics.” This allowed the industry to avoid blame and regulation.

  • Researchers argue the industry benefits from “heavy drinking” by a minority, which accounts for most sales and profits. The industry has lobbied globally against public health measures.

  • Parallels are drawn to the tobacco industry’s strategies. The “disease concept” is seen by some as serving industry interests over public health.

  • Betty Ford’s story of overcoming addiction was praised in the 1980s as inspiring, but some feminist critics saw it as a tale of a woman coerced into treatment for failing to meet wifely duties.

  • Elizabeth Taylor going public about her treatment for addiction in the 1980s helped reduce stigma.

  • TV shows and movies in the 1980s portrayed addiction treatment positively.

  • AA membership surged, hitting almost 1 million in 1990, embracing a spiritual mission of “healing ourselves and our planet.”

  • Research suggests that seeing addiction as a disease reduces stigma, but some argue the disease model has failed to reduce stigma.

  • In the early 20th century, addiction was seen as a personality disorder or moral failing. The US Narcotic Farm treated “patients” not “prisoners” but results were mixed.

  • Harsh anti-drug laws were passed in the early 20th century, with racist undertones. The disease concept emerged to inspire more compassionate treatment.

  • In the early 20th century, drugs like cocaine and opioids were seen as extremely dangerous and addictive. Government officials like Harry Anslinger promoted harsh anti-drug policies and portrayed addiction as a contagious disease.

  • Scientists like Lawrence Kolb dismissed addiction to stimulants like cocaine as less severe than opioids. The “junkie” was stereotyped as a dangerous criminal psychopath.

  • Research centers like the U.S. Public Health Service’s Narcotic Farm aimed to find a cure for addiction. Scientists focused on biological factors like brain waves and withdrawal symptoms.

  • The rise of behaviorism in psychology dismissed inner mental states in favor of observable behaviors. Addiction was defined by tolerance and physical dependence.

  • Landmark cases in the 1960s-70s began to shift views, recognizing addiction had biological roots separate from criminal behavior. Scientists increasingly separated the concepts of physical dependence and addiction.

  • Historical figures like Freud and Fleischl-Marxow were early cocaine addicts, drawn to its “magical” effects despite devastating consequences. Their stories illustrate the complex nature of addiction.

  • Amphetamine use surged during WWII to enhance soldiers’ alertness and performance. Though some soldiers hallucinated from overuse, the military appreciated amphetamines’ benefits and downplayed the risks of addiction.

  • After the war, pharmaceutical companies aggressively marketed amphetamines to the public as non-addictive pep pills. Use soared to epidemic levels, with about 1 in 20 American adults taking amphetamines by the 1960s.

  • Barbiturates were also mass marketed as non-addictive sedatives, leading to widespread addiction and overdose deaths among white, middle-class users. The media depicted this as a public health crisis.

  • Heroin use initially surged among marginalized groups like jazz musicians and poor minorities in the postwar period. It was criminalized and demonized as the cause of crime and delinquency.

  • In 1962, the Supreme Court ruled in Robinson v. California that it was unconstitutional to criminalize addiction as a status or illness. However, the criminalization of drugs continued.

  • Some former addicts opened therapeutic communities like Synanon to treat addiction outside the medical establishment. However, these sometimes became abusive cults themselves.

  • Synanon was founded in 1958 as a self-help community for drug addiction recovery. It pioneered confrontational group therapy techniques but eventually devolved into a violent cult.

  • In the 1960s, the “Minnesota Model” of residential rehab emerged, emphasizing a structured curriculum and 12-step principles in a medical setting. This became the dominant model.

  • Marie Nyswander and Vincent Dole pioneered methadone maintenance in 1965 as a treatment for heroin addiction. It was the first pharmacological therapy aimed at managing addiction as a chronic medical condition rather than acutely detoxifying.

  • Methadone maintenance was controversial but gained acceptance as it proved dramatically effective at reducing heroin use, overdose deaths, and crime. It helped shift understandings of addiction toward a brain disease model.

  • The emergence of non-abusive residential rehab and methadone maintenance in the 1960s marked major advances in humane, compassionate care for addiction. This contrasted with past punitive approaches and helped frame addiction as a medical rather than moral condition.

Here is a summary of the key points from the provided sources:

  • Peter Conrad argues that medicalization is driven not just by doctors and pharmaceutical companies but also by patients/consumers, policymakers, and other groups. Medicalization can be seen as positive or negative depending on one’s viewpoint.

  • In the 1960s, Vincent Dole, Marie Nyswander, and others promoted methadone maintenance as a new medical treatment for heroin addiction, framing it as treating a metabolic disorder rather than simply substituting one drug for another.

  • Critics argued methadone merely “narcotized” addicts and perpetuated their addiction rather than curing it. Some saw methadone as only treating the “ghetto malady” of poor minorities rather than addressing the root socioeconomic causes.

  • President Nixon declared drugs “public enemy number one” but also increased funding for treatment and research, establishing the Special Action Office for Drug Abuse Prevention. However, his administration still emphasized a punitive, criminal justice-based approach.

  • Foreign heroin flowed into the U.S. in the 1960s-70s, leading to fears of addicted Vietnam veterans. In response, Congress passed the Controlled Substances Act in 1970, regulating methadone and other drugs.

  • Regulations and stigma limited methadone treatment access and effectiveness. The medical model struggled to reduce stigma or change public attitudes toward addiction.

  • Methadone maintenance therapy for opioid addiction has been controversial since its introduction in the 1960s. Critics view it as merely “substituting one drug for another” rather than true recovery.

  • Racial disparities exist in access to methadone therapy. It was initially introduced in urban, non-white communities and resisted in suburban, white areas. Today it is still more accessible to white patients.

  • Twelve-step programs like Narcotics Anonymous have historically opposed medication-assisted treatment like methadone, seeing it as incompatible with the goal of total abstinence from all drugs.

  • However, research shows methadone maintenance significantly reduces the mortality rate among people with opioid addiction. Leading treatment centers like Hazelden Betty Ford have shifted their stance to become more accepting of it.

  • The misperceptions and stigma around methadone maintenance have hindered its expansion, despite evidence of its benefits. Racial bias and the ideal of being “drug-free” have shaped attitudes against this form of treatment.

The Controlled Substances Act (CSA) of 1970 imposed increasingly restrictive and punitive measures on drug use, giving law enforcement powerful new tools to crack down. Politicians like Nelson Rockefeller pushed for harsh penalties, while figures like Senator Harold Hughes argued this was misguided. The addiction treatment field grew rapidly, quintupling from 1973 to 1977, but struggled to meet demand and relied heavily on Alcoholics Anonymous (AA). Some challenged AA’s abstinence-only approach, like the Sobells’ controlled drinking therapy, but were attacked for being dangerous. Overall, the 1970s saw increased criminalization of drugs amid debates over how best to address addiction.

  • In the 1970s, some researchers like the Sobells challenged the disease model of addiction and showed that some people could engage in “controlled drinking” without abstinence. This challenged the binary view of addiction.

  • In the late 1970s, views on drugs like marijuana became more permissive.

  • In the 1980s, President Reagan escalated the war on drugs, framing drug use as a moral failing rather than a health issue. This widened the divide between illegal street drugs and pharmaceuticals.

  • Law enforcement budgets grew, asset forfeiture expanded, and radical sentencing disparities were introduced, especially for crack vs powder cocaine.

  • Myths emerged about “instant addiction” from crack cocaine. Drug prevention programs like DARE took a “just say no” approach.

  • The result was an unprecedented expansion of incarceration, disproportionately affecting minorities. The war on drugs was a major driver of mass incarceration, though not the only factor.

  • The War on Drugs led to a massive increase in arrests and incarceration for drug offenses, with a focus on low-level offenders rather than kingpins.

  • Treatment was promoted as an alternative to incarceration, leading to an expansion of treatment programs, many of which were abstinence-only, confrontational, and disconnected from evidence-based practices.

  • Coercion and criminal justice referrals became a major pathway into treatment. Patients were often kicked out for relapsing.

  • In the 1980s-90s, harm reduction emerged as a public health approach, led by activists providing clean needles, naloxone, and other lifesaving services for people who use drugs.

  • Harm reduction faced opposition and legal barriers, with federal funding banned for syringe exchange programs despite evidence they reduce HIV transmission.

  • A consumer movement led patients to demand more rights and scientifically-validated treatment. But the addiction treatment field lagged behind medicine in providing patient-centered, evidence-based care.

  • We need a new approach that integrates harm reduction and evidence-based treatment focused on patient needs rather than coercion and confrontation. More consumer voice and oversight could help transform the addiction treatment system.

  • The Vietnam veteran studies conducted by Lee Robins in the 1970s found shockingly low rates of addiction among soldiers who had used heroin in Vietnam. Only about 5-12% became re-addicted upon return, challenging the prevailing view of addiction as an inevitable downward spiral.

  • The studies highlighted the importance of environmental factors in drug use and addiction. Most soldiers did not continue using heroin when they returned to a non-combat environment in the U.S.

  • The studies also challenged the view of addiction as a discrete medical disease, showing high rates of spontaneous recovery without treatment. This contradicted the traditional disease model of addiction.

  • Robins used strict criteria focused on physical withdrawal and tolerance to define addiction, versus a loss of control or compulsion to use. This likely led to an undercounting of rates of addiction.

  • The studies had a major impact, forcing experts to reconsider beliefs about the inevitability and permanence of addiction. But they were also met with disbelief and denial.

  • The studies highlighted limitations in the traditional disease view of addiction as a discrete, uniform condition versus a complex phenomenon shaped by many factors. This view still dominates American thinking on addiction.

  • Research shows high rates of comorbidity between substance use disorders and other mental health conditions. Some studies show rates approaching 100%. This occurs across cultures.

  • Many people with substance use disorders improve without formal interventions. By age 30, most stop or moderate use. By age 37, approximately 75% of those with severe problems enter remission.

  • When narrower criteria are used, prevalence estimates of substance use disorders are much lower.

  • The 1970s discovery of brain opioid receptors led to massive funding for addiction neuroscience. It was hoped this would reveal biological causes.

  • Early research failed to find consistent receptor changes that could explain addiction. Genetic theories were also overpromised in the 1980s-90s media, but twin studies found genetics are just one factor.

  • The limited success of neurobiological explanations has led to recognition of the importance of environmental and psychosocial factors. Addiction is now seen as involving complex interactions between brains, environments, development, and social contexts.

Here are the key points:

  • Historically, there have been many attempts to categorize different types of addiction, with little consensus. Concepts like “Trunksucht”, “oinomanias”, and inherited traits have been proposed. This has actually complicated the disease notion of addiction.

  • Research now suggests there are likely different influences on addiction, with no one dominant cause. Addiction does not seem to be a categorical, fixed entity.

  • Addiction traits are on a spectrum and not absolute boundaries between addicts and non-addicts. The disease model metaphor may still be useful, but should not be taken too literally.

  • Addiction manifests in similar brain changes across substances, like changes in the dorsal and ventral striatum. This is also seen in behaviors like overeating and gambling.

  • Integrated, multidisciplinary addiction treatment is needed, but currently lacking. Only about 10% of providers can prescribe addiction medications, due to strict regulations.

  • Barriers for prescribing medications like buprenorphine include lack of knowledge, support, and time. Policy changes by the Biden administration could help increase capacity.

  • There are a wide variety of legitimate recovery experiences, not a single pathway. Total abstinence is effective for many but should not be the sole goal. Harm reduction approaches are also valid.

Here is a summary of the key points from the article:

  • The article reviews research on recovery from alcohol and other drug problems in the U.S. population. It notes that most people with drug problems recover without formal treatment interventions.

  • Recovery is increasingly seen as a long-term process with ups and downs, rather than a fixed endpoint. There are “multiple pathways” to recovery that involve different combinations of personal, social, and professional supports over time.

  • New research shows that measures of well-being increase exponentially the longer people are in recovery. This suggests recovery is associated with positive psychological and physical changes, not permanent brain damage.

  • The brain does undergo changes with extensive substance use, but is also capable of positive changes with sustained abstinence and a renewed sense of meaning and purpose.

  • Supporting recovery requires building “recovery capital” - the internal and external resources that can sustain long-term change. This includes factors like self-esteem, social supports, purpose, and access to services.

  • The article advocates for a more nuanced view of recovery as an ongoing process of growth and self-discovery, not just a fixed endpoint. This view aims to counter stigma and increase access to supportive services.

Here is a summary of the key points about “addicts” versus “non-addicts” and related topics in the book:

  • There are debates over the concept of addiction, whether it is a disease or a choice, its causes, and how to treat it. Views range from moralistic to medical.

  • Addiction has been linked to ideas of conquest, subjugation, dislocation, and social wounding. It is associated with stigma.

  • There are debates over whether addiction represents a divided self, lack of self-control, or possession.

  • The disease model treats addiction as a medical condition, often advocating abstinence-based treatment. Critics see this as reductionist.

  • There are ongoing debates over whether addiction is driven more by genetics or environment/personal history.

  • Addiction memoirs and narratives illustrate the experience from an insider’s perspective.

  • Approaches to addiction treatment have evolved over history, from punitive to medical to mutual help groups. There are critiques of the treatment industry.

  • Key figures covered include Rush, Beecher, Mann, Jellinek, Anslinger, Dederich, and Hughes. Movements covered include Washingtonians, inebriety treatment, AA, therapeutic communities, and more.

Here is a summary of the key points about Fisher in the passage:

  • Carl Erik Fisher is an addiction medicine specialist who had his own struggles with alcohol addiction.

  • He had an alcohol withdrawal seizure at one point when trying to quit drinking.

  • He did a brain research fellowship focusing on the neuroscience of addiction.

  • He worked at Bellevue Hospital and Columbia University treating patients with addiction.

  • His own drinking caused problems in his life, damaging relationships and leading to risky behavior.

  • He tried to moderate his drinking but kept relapsing.

  • He had experiences being hospitalized and going through withdrawal from alcohol.

  • He used medications like Antabuse and naltrexone to try to stay sober.

  • He attended AA meetings and had sponsors who guided his recovery.

  • His personal experiences with addiction and recovery inform his perspective as a doctor treating addicted patients.

The passage traces Fisher’s journey through medical training and specialization in addiction medicine while interweaving details about his personal struggles with alcohol addiction and recovery process.

Here is a summary of the key points about Johann Hari in Chasing the Scream:

  • Grew up in South Korea and the UK; struggled with depression and addiction issues as a young adult

  • Became addicted to and abused alcohol, cocaine, and prescription drugs

  • Went through rehab multiple times but kept relapsing

  • Eventually got sober through changes to his life circumstances, psychotherapy, spiritual practice, and support groups

  • As a journalist, researched the history of drug criminalization and addiction treatment

  • Interviewed experts, activists, and people affected by addiction around the world

  • Main arguments:

    • The war on drugs and criminalization of addiction are ineffective and harmful
    • Addiction is strongly influenced by life circumstances and social/environmental factors
    • More humane, health-based approaches to addiction treatment are needed

The book weaves together Hari’s personal story with historical research and reporting to make the case for reforming drug policies and the treatment of addiction.

Here is a summary of the key points regarding cocaine, alcohol, and opioid use discussed in the book:

  • Cocaine was used as a treatment for addiction to other substances like alcohol and opioids in the late 19th and early 20th centuries. However, it was found to be addictive itself.

  • Alcohol has long been a major focus of addiction research and policy. Prohibition banned alcohol in the early 20th century but was unsuccessful. Alcoholics Anonymous popularized the disease concept of alcoholism and a spiritually-based path to recovery.

  • Women’s alcohol use was stigmatized more than men’s. Groups like Mothers Against Drunk Driving campaigned against drunk driving.

  • Opioids like morphine and heroin were initially touted as non-addictive pain relievers but were found to be highly addictive. Efforts to develop non-addictive pain relievers largely failed. Prescription opioid painkillers led to a modern epidemic of opioid addiction and overdose deaths. Medications like methadone and buprenorphine have been used to treat opioid addiction.

  • Popular conceptions of addiction often differ from scientific understandings. The brain disease model has become dominant, but addiction involves social, psychological, and spiritual dimensions beyond just biology.

  • Alcohol has long been a major source of addiction. In colonial America, per capita alcohol consumption was triple today’s levels. Temperance movements arose in the 19th century to combat alcohol problems.

  • Opiates like morphine and heroin also have a long history of abuse, especially after the invention of the hypodermic syringe in the 1850s allowed for injection. Attempts to regulate opiates began in the early 20th century.

  • Cocaine was also popular in patent medicines in the late 1800s before being banned. Amphetamines rose to prominence mid-century, followed by barbiturates and tranquilizers.

  • The modern concept of addiction took shape in the late 1800s and early 1900s. Moral views gave way to disease models that saw addiction as involuntary. AA popularized the disease concept in the 1930s.

  • Treatments have ranged from moral suasion to medications and therapy. Views on addiction’s origins have swung between spiritual, psychological, and biological explanations. Stigma remains a major issue.

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