Examples of the Evidence-Practice Gap in Addiction Treatment throughout HistoryThe use of addiction treatments that are not grounded in science has a long history. While most of these approaches have
been discredited with time, some have proven to be prescient in their foreshadowing of current treatment approaches, both
those that are evidence based and those that continue to profit from claims about being able to treat or even cure addiction in
manners that largely are not based on scientific evidence.
For example, in the late 1700s, Dr. Benjamin Rush, the “father of American psychiatry,” was the first American doctor to say
that “habitual drunkenness should be regarded not as a bad habit but as a disease”^136 that should be treated.^137 In the late 19th
century, medically-based addiction treatment mostly involved trying to cure individuals of their addiction, often with the use
of other addictive substances.^138
By 1910, private sanitariums in the United States offered specialized treatment for addicted individuals--but only for those
who could afford the expense. Similar to today, many of the “treatment experts” opening facilities were savvy businessmen
or enterprising physicians, including Harvey Kellogg (later of cereal fame) and Dr. Leslie E. Keeley. Between 1892 and
1893, almost 15,000 people with addiction were treated at the famous, yet controversial Keeley Institutes.^139 Keeley’s
treatment for addiction involved bichloride of gold remedies, a substance purportedly containing gold that would cure
addiction involving alcohol and opioids. The use of bichloride of gold became highly controversial and was opposed by the
American Medical Association (AMA). After the death of Dr. Keeley in 1900, the popularity and ultimately, the existence of
his institutes waned.^140
Although Keeley’s treatments were later discredited, his position that addiction was decidedly a disease rather than a
religious or moral failing was ahead of its time. His use of “shot treatments” or hypodermic treatments that induced vomiting
was a precursor to later aversion therapies and his introduction of clubs for addicted individuals to receive social support to
maintain sobriety was a precursor to the mutual support programs that remain prominent today. His focus on helping people
quit smoking in the 1920s was prescient in its characterization of nicotine as a harmful and addicting drug.^141
Addiction treatment tactics that are based more on the personal charisma of the founders, catchy phrases and simplistic
approaches than on the science of what works in addiction continue to proliferate and show no sign of waning. A simple
Google search produces an abundance of “rehabilitation” approaches and facilities with slogans such as: Learn how to heal
the underlying causes of dependency--and be free of addiction forever!^142 A recent study examining treatments that a panel
of experts believes qualifies as quackery in addiction treatment* found such treatments as electrical stimulation of the head,
past-life therapy, electric shock therapy, psychedelic medication and neuro-linguistic programming to be “certainly
discredited.”^143 Nevertheless, unsubstantiated interventions continue to be used to this day, many of which prey upon the
desperation of addicted individuals and their families.
In the late 1930s and early 1940s, many hospitals would not admit patients for the treatment of addiction involving alcohol,
so lay approaches became an important option.^144 Alcoholics Anonymous (AA), founded in 1935, was premised on
laypersons addicted to alcohol helping one another overcome their addiction and related problems.^145 While the mutual
support/self-help approach maintained the perspective of addiction as a disease--formalized in the development of the
principles underlying the Minnesota Model in the 1950s--the “rehabilitative model” of treatment was seen as distinct from
“the medical model.” Standard medical interventions that normally would be applied to diseases were not a significant part
of the treatment, nor were medical or other health professionals called upon to play key roles in treating the disease.^146 This
model remains the dominant approach to addressing addiction in the United States. Yet, its limitations and failure to address
addiction the way other diseases are addressed have led to a call to integrate addiction treatment into mainstream medical
care.
- Based on the composite opinions of a panel of 75 experts regarding 65 addiction treatments which they rated on a
continuum from “not at all discredited” to “certainly discredited.”