ATTC Messenger, January 2019
Dennis McCarty, PhD
OHSU-PSU School of Public Health
Oregon Health & Science University
As the United States emerged from Prohibition, federal, state, and local policy embraced criminal justice as the primary mechanism to control public harms and nuisances related to chronic intoxication and the use of narcotics. To address narcotic dependence, the first of two “Narcotic Farms” opened in Lexington, Kentucky in 1935 to incarcerate and treat individuals convicted of a federal drug offense and individuals voluntarily seeking care for narcotic addiction (Campbell, Olsen, & Walden, 2008). The Kentucky program treated offenders living east of the Mississippi River; three years later, a similar program opened in Fort Worth,Texas treating individuals living west of the Mississippi River. The programs were co-managed by the US Bureau of Prisons and the US Public Health Services. They were the only federally funded narcotic treatment services into the 1960s (Besteman, 1992).
Prohibition dramatically reduced the demand for treatment of alcohol use disorder and most social services to address alcohol use disorders were closed. State and local communities were responsible for alcohol control and they emphasized arrest, drunk tanks, and county work farms to penalize public intoxication.
Post-World War II, a loss of low-income housing due to urban renewal initiatives enhanced the visibility of public inebriation and drug use. The criminal justice system was overwhelmed arresting, prosecuting and incarcerating alcoholics and drug addicts. Advocates for persons with alcohol and drug use disorders began filing court cases to challenge the legality of arrests for public intoxication and addiction.
Two U.S. Supreme Court decisions moved control of these disorders away from the criminal justice system and toward public health. In Robinson v. California (370 U.S. 660), the Court found a California law that made narcotic addiction a criminal offense was illegal. The primary opinion asserted that drug addiction is a disease and that punishing an illness through the use of incarceration and fines was unconstitutional. Six years later in Powell v. Texas (392 U.S. 514), the Court upheld Texas legislation making public intoxication illegal because the public behavior constituted a criminal offense. A majority of the Justices, however, held that a) alcoholism is a disease, b) chronic inebriation is an involuntary consequence of alcoholism, c) homeless alcoholics are unable to limit their drinking to private places, and, therefore, d) homeless public inebriates cannot be convicted of public intoxication (National Institute on Alcohol Abuse and Alcoholism, 1971). Together, the Robinson and Powell opinions forced states to decriminalize public intoxication and addiction, move away from use of incarceration to punish people with an illness, and to begin building publicly-funded systems of care.
States collaborated to draft guidance for their legislatures. In 1971, the National Conference of Commissioners on Uniform State Laws adopted the Uniform Alcoholism and Intoxication Treatment Act (Uniform Act). The model state legislation prohibited prosecution of alcoholics solely because of alcohol consumption and established a continuum of treatment services to promote recovery from alcoholism (NIAAA, 1971). In addition, the Uniform Act specified the creation of a state authority to a) fund, regulate, and coordinate treatment and prevention services in the state, b) prepare state plans and respond to federal funding requirements, and c) establish a citizens’ advisory council. A preference for voluntary services was stressed and involuntary commitment procedures were limited to emergency treatment. (A copy of the Uniform Act is included in the National Institute on Alcoholism and Alcohol Abuse's First Special Report to the US Congress on Alcohol and Health -- NIAAA, 1971, Appendix A.
The Uniform Act promoted a medical model for the control and treatment of public intoxication and alcoholism and (although altered by each state or territory) was fully implemented in 34 jurisdictions and essentially adopted in three additional areas (Finn, 1985). A review of the initial implementation of the Uniform Act found beneficial effects in every state or territory that passed the major features of the legislation (Scrimgeour & Palmer, 1976). Services improved and more humane care was provided for public inebriates if state appropriations increased to support the increased care. The analysis concluded that states that passed the Uniform Act dramatically altered the impact of public intoxication on the use of criminal justice resources and caused a substantial change in the health care delivery system (Scrimgeour & Palmer, 1976).
In retrospect, the Uniform Act supported the creation and empowerment of state authorities for the treatment and prevention of alcoholism and fostered the development of publicly-funded alcoholism treatment systems. Many chronic inebriates benefited from the services but homelessness and public intoxication were not erased.
The Uniform Act also operationalized a key feature of the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970 (PL 91-616). Systems of care for persons with alcohol and drug problems were relatively undeveloped when a U.S. Senator from Iowa, Harold Hughes, chaired the Special Subcommittee on Alcoholism and Narcotics for the Senate Labor and Public Welfare Committee. Although the subcommittee had no budget, Senator Hughes, a recovering alcoholic, used volunteer staff and donations to conduct 14 hearings across the nation during the summer of 1969 (Hewitt, 1995). Bill Wilson (co-founder of AA), Marty Mann (founder of the National Council on Alcoholism), and other men and women in recovery testified along with physicians, researchers, clergy, and community leaders on the extent and effects of alcoholism and alcohol-related problems and urged support for a national program to address alcoholism and alcohol abuse (Hewitt, 1995).
Following the public hearings, Senator Hughes sponsored the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970. The bill was shepherded through the Senate and House and intense lobbying secured President Nixon's signature and enacted the statute on New Year's Eve of 1970 (P.L. 91-616) (Hewitt, 1995; Lewis, 1988). The Comprehensive Act a) authorized the creation of the National Institute on Alcohol Abuse and Alcoholism within the National Institute of Mental Health to administer alcoholism prevention and treatment services and coordinate federal activities, b) created the National Advisory Council on Alcohol Abuse and Alcoholism to assist in the development of national policy, c) required the identification of a state alcoholism authority, d) established federal formula grants for states and required the development of comprehensive state plans for the treatment and prevention of alcoholism and alcohol abuse, e) mandated development of treatment and prevention services for federal civilian employees, f) encouraged hospitals to admit alcoholics, g) protected the confidentiality of patient records, and h) funded research. Some refer to the legislation as the "Alcoholic's Bill of Rights" because it created a national program to support the development and funding of alcoholism treatment and prevention services and encouraged programs of research on alcoholism and its treatment (Hewitt, 1995; Lewis, 1988).
The reauthorizations of the Hughes Act in 1974 (P.L. 93-282) and 1976 (P.L. 94-371) increased the visibility of alcohol and drug use disorders making NIAAA an independent institute within the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) (Hewitt, 1995; Lewis, 1988). The National Institute of Drug Abuse was also created and made an independent Institute within ADAMHA. State efforts were strengthened through incentive grants for adoption of the Uniform Act (Lewis, 1988). The state authorities became the federally required Single State Authorities (SSAs) for the application for and receipt of federal funds for the prevention, treatment and rehabilitation of persons with alcohol and drug use disorders.
The Single State Authorities remain important within states and their efforts to prevent and treat alcohol and drug use disorders. They have key roles to play in addressing the current opioid epidemic. In the 2016 Comprehensive Addiction Recovery Act (CARA; Public Law 1140198), Congress authorized state demonstration programs to enhance opioid prevention and education programs, provide naloxone to first responders to treat opioid overdose, and promote access to opioid agonist and opioid antagonist therapy. The 21stCentury Cures Act (Public Law 114-255) allocated $1 billion in federal funds to support the CARA demonstrations. Single State Authorities received the resources through SAMHSA’s State Targeted Response to the Opioid Crisis Grants (Opioid-STR). States with high rates of opioid overdoses are also eligible for SAMHSA’s Targeted Capacity Expansion program called Medication-Assisted Treatment for Prescription Drug and Opioid Addiction (MAT-PDOA). The state authorities are responsible for allocating funds across the state and assuring access to underserved populations. States also have a responsibility to evaluate the impact of the awards. More recently, in October 2018, President Trump signed the Support for Patients and Community Act allocating resources to states to improve access to addiction treatment in order to slow the opioid epidemic. The SSAs remain a key ingredient in efforts to prevent and treat alcohol and drug use disorders.
The Institute of Medicine’s reports on prevention and treatment of alcohol problems (Institute of Medicine,1990a) and treatment of drug problems (Institute of Medicine, 1990b) provide additional historical detail on the development of publicly-funded systems of care for alcohol and drug use disorders.
Related Resources
ASAM Summary of the Comprehensive Addiction and Recovery Act
State Targeted Response-Technical Assistance Consortium
The Narcotic Farm (film)
References
Besteman, K. J. (1992). Federal leadership in building the national drug treatment system. In D. R. Gerstein & H. J. Harwood (Eds.), Treating Drug Problems: Volume 2(pp. 63-88). Washington, D.C.: National Academy Press.
Campbell, N. D., Olsen, J. P., & Walden, L. (2008). The Narcotic Farm: The Rise and Fall of America's First Prison for Drug Addicts. New York: Harry N. Abrams, Inc.
Finn, P. (1985). Decriminalization of public drunkenness: Response of the health care system. Journal of Studies on Alcohol, 46, 7-23.
Hewitt, B. G. (1995). The creation of the National Institute on Alcohol Abuse and Alcoholism: Responding to America's alcohol problem. Alcohol Health and Research World, 19, 12 - 16.
Institute of Medicine. (1990a). Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press.
Institute of Medicine. (1990b). Treating Drug Problems. Washington, DC: National Academy Press.
Lewis, J. S. (1988). Congressional rites of passage for the rights of alcoholics. Alcohol Health and Research World, 12, 240-251.
National Institute on Alcohol Abuse and Alcoholism. (1971). First Special Report to the U.S. Congress on Alcohol & Health(Vol. DHEW Publication No. HSM 73-9031). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
Scrimgeour, G. J., & Palmer, J. A. (1976). Report on the Impact Study of the Uniform Alcoholism and Intoxication Treatment Act. Washington, DC: Council of State and Territorial Alcoholism Authorities.
About the Author
Dennis McCarty, PhD, a Professor Emeritus in the OHSU-PSU School of Public Health at Oregon Health & Science University, works at the intersection of policy, research and practice assessing the organization, financing, and quality of prevention and treatment services for alcohol and drug use disorders. He served as the co-Principal Investigator for the Western States Node of the National Drug Abuse Treatment Clinical Trials Network (UG1 DA015815), and as an Investigator for an evaluation of the impacts of Oregon’s Coordinated Care Organizations on prevention and treatment for alcohol and drug use disorders (R33 DA035640). Dr. McCarty served (2006 – 2016) as the Academic Director for the University of Amsterdam’s Summer Institute on Alcohol, Drugs and Addiction – a two week course that examined Dutch policy perspectives on drug use disorders and reviews the neuroscience, genetics, treatment and prevention of alcohol and drug use disorders. Dr. McCarty also directed the Massachusetts Bureau of Substance Abuse Services for the Massachusetts Department of Public Health (1989 – 1995) and served on the Oregon Alcohol and Drug Policy Commission (2009 – 2017). He received a doctorate in social psychology from the University of Kentucky.