An overview of the history and basic concepts of addiction treatment in the United States.

1. Introduction to Addiction Basics:
…What the Non-Specialist Needs to Know
By Elizabeth Kotkin, MA, LMFT,
Clinical Standards Coordinator
Department of Alcohol and Drug
Services
Santa Clara County

2. National Treatment Trends:
o 3.5 million people age 12 or older received substance abuse treatment
in 2002
o 54% were for alcohol
o 46% were for drugs
o 70% men
o 30% women
o Over 50% were white, 26% African-American, 7.7% Hispanic,
2.2% Native Americans, and less than .06%
Asian/Pacific-Islanders.

3. o Of those admitted for drug treatment, 38% were for treatment of
primary cocaine use, 25.5% for heroin use and 19.1% for
marijuana
National Treatment Trends:

4. Current Drug Trends In USA:
• Marijuana: Estimated 14.6
million users in 2002, one third
of whom used 20 or more days
during the last month.
• Hallucinogens: 1.2 million
users estimated in 2002,
including 676,000 users of
Ecstasy
• Stimulants: Estimated 2
million users of cocaine in
2002, 567,000 of whom used
crack ….Methamphetamines
show increased use in Bay
Area
• Heroin: Estimated 166,000
users, many under the age of
25 in 2002
• Prescription Drug Abuse:
Estimated 6.2 million took
prescription drugs non-
medically in 2002:
• 4.4 million use pain relievers
• 1.8 million use tranquilizers
• 1.2 million use stimulants
• 0.4 million use sedatives

5. Alcohol Trends In The USA
• Alcohol: a CNS depressant
which accounts for 85% of the
drug addiction problem in the
USA
• 10% of those who drink
consume 50% of the alcohol
used in this country. The
majority of those who do drink
currently, do so less than once
per week.
• 1996 overall per capita alcohol
consumption in USA was 2.35
gallons of pure alcohol per
person per year
• 120 million Americans 12 or
older reported being current
drinkers of alcohol in 2002.
• 54 billion (22.9 %) were binge
drinkers and 15.9 million
(6.7%) were heavy drinkers
• Prevalence of current alcohol
use is increasing in 2002:
• 2 % at age 12
• 6.5% at age 13
• 13.4 % at age 14,
• 19.9 % at age 15,
• 29 % at age 16
• 26.2% at age 17
• 70.9 % at age 21 (peak rate)

6. Monitoring the Future
Statistics: 2004
• 50,000 students in the 8th, 10th
and 12th grade were surveyed.
• Any illicit drug use in the prior
12 months continued to decline
in 2004. This trend has been
consistent since 1996 for 8th
graders (23.6% in 1996 to
15.2% in 2004)
• Marijuana is by far the most
widely reported drug used of
the illicit drugs, but it also
declined some in 2004
• There was a resurgence of
inhalant use in all grades
reported, but it was particularly
a problem for 8th graders
• The reported alcohol use by
American teens is mixed in
2004. There was an overall drop
in all grades since 2002. But for
12th graders, alcohol use tended
towards an increase.
• Any reported use of alcohol
for the past 12 months in
2004:
36.7% for 8th graders,
58.2% for 10th graders
and 70.6% of 12th graders.

7. US HISTORY: Alcohol
Colonial period:
o Before contact with Europeans, Native Americans had little
experience with alcohol
o Europeans brought alcohol to the Americas, and it pervaded
every aspect of colonial life
o Alcohol =“good creature of god”
o “Rough justice”

8. US HISTORY: Alcohol
New Nation:
1790: Quaker Reform Movement: first jail in Philadelphia
Benjamin Rush (1746-1813) Physician-General of the
Continental Army and signer of the Declaration of
Independence
Disease concept and abstinence the cure
Method: religious conversion and medical intervention
1810: Establishment of “Sober Houses”

9. Early 19th century (1790-1830):
o Highest period of alcohol consumption in
US history
o 1792: 2,579 distilleries --per capita
consumption: 2.5 gallons
o 1810: 14,191 distilleries --per capita
consumption: 4.5 gallons
o 1830: all time USA high-- per capita
consumption of 7.1 gallons
US HISTORY: Alcohol

10. Effect of Alcohol on Families

11. US HISTORY: Alcohol
1825-1850:
o Temperance Movement: a Women’s
Movement influenced by Rush and led by
Carrie Nation
o Public perception of alcohol shifted to
“demon rum”

12. Demon Rum

13. US HISTORY: Alcohol
1850-1900:
o 1841: Dorothea Dix (1802-87) reform movement
to create mental hospitals
o Institutionalization for the treatment of alcoholics
becomes popular
o 1870: American Association for the Cure of
Inebriates began with six institutions
o By 1902: there were more than 100 addiction
centers in USA

14. US HISTORY: Drugs
Colonial period:
o Enthusiastic advocacy of “therapeutic potential” of
opium by medical profession
o 1770- 1914:“Dover's powder”: most widely used
opium compound

15. US HISTORY: Drugs
19th Century:
o Between 60%-80% of opiate users were women
o Drug use widely accepted for both sexes.
o Opiates prescribed for “female problems” (painful
menstruation) and “neurasthenia”

16. 19th Century Injection Kit

17. o Cocaine: used for neurasthenia, “wasting disease” and as
a cure for opiate addiction (Freud)
o Chloral Hydrate: Sedative-hypnotic (laughing gas) used
for neurasthenia
o Cannabis: widely prescribed between 1840-1900 for
asthma, bronchitis, “women’s diseases” like headaches
and neurasthenia
Popular 19th Century Drugs

18. End of 19th — beginning of 20th Century:
o 1885-1917:, opiate use widespread -seemed
uncontrollable
o Increased advertising, over-prescription, mass
production and opium-bearing patent medicines
o Change in doctors’ attitudes: understanding of
habituation and the chemical actions of these drugs in
the body
Criminalization of Addiction:

19. Shift in Public Perception
Elizabeth Barrett Browning

20. Opium Wars, 19th Century

21. o 1909: US convenes Shanghai Opium Conference-results in
international focus on lack of drug regulation internally in
US.
o 1906: the Pure Food and Drug Act (accurate labeling of
ingredients ) led to decrease in use of patent medicines,
o Harrison Narcotic Act (1914) restricts the rights of doctors
to prescribe opiates.
Legal Remedies Enacted:

22. “Opium-Smoking New York”
Harper’s Weekly, 1881

23. o Anti-drug legislation promoted to public to counter
perceived social and economic “threats” of minorities,
primarily Asians and Blacks (and later, Mexicans in the
case of marijuana)
Racist Stereotypes :
o 19th Century view of opiate dependency as a
“misfortune” shifts to fear of the “dope fiend”

24. o Prohibition of alcohol in the 20’s (alcohol prohibition
repealed in 1933, drug prohibition is not).
o 1937: Marijuana tax act in effect makes it illegal
More Legal Remedies Enacted:

25. Anti-Marijuana Propaganda

26. Definitions
According to Gold and Miller (1994), recent research indicates that drugs
are addictive because they “reinforce drug-taking behavior…addiction
arises because prolonged use of the drug alters the basic neurochemistry of
the brain, leading to physiological and psychological changes…(which) in
turn result in continued and accelerating use of the drug.”
The American Psychiatric Association’s DSM-IV (APA, 1994) now
reflects this updated research-based definition of addictive disorder,
with core concepts including:
(1) Compulsion
(2) Loss of control
(3) Continued use despite negative consequences

30. Drugs Of Abuse: Common Terms
• Intoxication: reversible, substance-specific syndrome
• Short-acting vs. long-acting drugs: Drugs that have quick
onset are more reinforcing and more likely to be abused
• Drug “half-life”: The time it takes for a drug to become
pharmacologically inactive
• Cross-tolerance: Development of tolerance to one drug within
a class of drugs leads to tolerance to other drugs within that
same class of drugs
• Tolerance: Need to increase dosage to achieve the same effect

31. The Faces of Addiction

32. • Dimension 6: Recovery Environment
ASAM Dimensions
• Dimension 5: Relapse/Continued Use Potential
• Dimension 4: Readiness to Change
• Dimension 3: Emotional, Behavioral or Cognitive Conditions and
Complications
• Dimension 2: Biomedical Conditions and Complications
• Dimension 1: Acute Intoxication and/or Withdrawal

33. Motivational Interviewing
“Motivation can be understood not as something one has but rather
as something one does. It involves recognizing a problem, searching
for a way to change and then beginning and sticking with that
change strategy” Miller (1995)
o Motivational Interviewing is a way to minimize resistance,
resolve ambivalence and induce change.
o Readiness levels are accepted starting points for treatment rather
than reasons for elimination from treatment services.

34. Motivation: The Old Way

35. o Motivation is key to change and it is constantly in flux
o Motivation is influenced by social interaction, namely
the counselor’s style
o At all stages of change, ambivalence is seen as normal
and not pathological
o Confrontation is a goal, not a therapeutic technique
CONCEPTUALIZING MOTIVATIONAL
INTERVIEWING

36. Client Resistance
Involves feelings-actions-behaviors of an interpersonal nature
where there is a lack of collaboration

37. Stages Of Change
• Precontemplation stage
• Contemplation stage
• Preparation stage
• Action stage
• Maintenance
• Relapse

38. “There is a myth…that more is always better. More education,
more intense treatment, more confrontation will necessarily
produce more change. Nowhere is this less true than with
precontemplators. More intensity will often produce fewer results
with this group. So it is particularly important to use careful
motivational strategies, rather than mount high-intensity
programs…We cannot make precontemplators change, but we
can help motivate them to move to contemplation.” DiClemente,
(1991)

39. Stage 1: Precontemplation
• The client does not consider change. Seeks treatment due to
outside pressures such as family, job, etc., or due to legal
and/or medical concerns

40. Motivational Interviewing Tasks
Building Readiness
• A) Raise doubt about client’s belief that AOD use is
harmless
• B) Increase the client’s perception of risks and problems
with current behaviors

41. Clinical Interventions
• A) Establish rapport and trust and explore what brought
client into treatment
• B) Summarize: link the information together, especially
focusing on the client’s ambivalence. Educate about
possible links to AOD use

42. “Contemplation is often a very paradoxical stage of change…
Ambivalence is the archenemy of commitment and a prime
reason for chronic contemplation. Helping the client to work
through the ambivalence, to anticipate barriers, to decrease the
desirability of the problem behavior and to gain some increased
sense of self-efficacy to cope with this specific problem are all
stage-appropriate strategies.” DiClemente, (1991)

43. Stage 2: Contemplation
o The client is highly ambivalent about change. The client both
considers change and rejects it. The client will seesaw
between reasons for concern and justifications for continued
AOD use

44. Ambivalence
• A state of mind in which a person has coexisting but conflicting
feelings, thoughts, and actions about something
• The “I do but I don’t” dilemma

45. Motivational Interviewing Tasks:
Increasing Commitment
• A) Tip the decisional balance and strengthen self-efficacy
• B) Evoke from the client reasons to change and risks of not
changing

46. Clinical Interventions
• A) Show interest in how AOD use affects all areas of the
client’s life
• B) Reframe resentment: validate the client’s observations, but
offer a new interpretation of the data

47. Stage 3: Preparation
• The client is committed to and planning to make a change in the
near future but is still considering what to do
• Goal: Help client to get ready to make a change
• Elements of Change:…Ready….Willing….Able

48. Strategies For Preparation Stage
• Clarify goals & strategies
• Menu of options
• Offer advice
• Negotiate change plan
• Identify barriers
• Get social support
• Treatment expectations
• Publicize change plans

49. Stage 4: Action
• Client has decided to make a change
• Client has verbalized or demonstrated a firm commitment to change
• Efforts to modify behavior and/or environment are being taken
• Client demonstrates motivation and effort to achieve real change
• Client is involved in, and committed to, the change process
• Client is willing to follow suggested strategies and activities to change

50. Maintenance and Relapse