The story of the American Society of Addiction Medicine (ASAM) is one that includes a signer of the Declaration of Independence (not Hamilton), a politician fighting a death-bed promise, an alcoholic billionaire, Freedom Riders, and the Summer of Love. Interested? Read on!
Dr. Benjamin Rush, a colonial physician and signer of the Declaration of Independence, described alcoholism as a disease as early as the late 1700s, but the concept was not widespread until the 1930s when Bill Wilson and Dr. Bob Smith founded Alcoholics Anonymous (Smith, 2011). Addiction medicine got its formal start in 1954 when the ASAM’s official founder, Ruth Fox, MD, began work with the National Council of Alcoholism’s (NCA, now NCADD) medical-scientific committee. ASAM is now composed of almost 4,500 professionals dedicated to the service of others and the treatment of alcoholism and drug dependence. ASAM members work tirelessly to improve the quality of addiction treatment, increase access to care, decrease stigma, support research efforts and prevention, promote the role of physicians in treating addiction, and educate both health care professionals and the general public. ASAM also strives to further establish addiction medicine as a recognized and respected specialty by not only professional organizations, but also by governments, payers, physicians, and consumers of health care services.
“When I first joined ASAM in the 1980s, it was just incredible,” Mark Krause, MD, remembered fondly. “People were hugging and nice and sharing different projects to get involved with. These were the guys and gals in the trenches, so I asked how I could get involved and they said, ‘you just did!’ And that was it,” he said.
Behind the hugs and smiles, however, a narcissistic injury was building from lack of recognition as a credible institution. Elizabeth Howell, MD, came into ASAM like many others at the time, assuming no one ever got better and doubting the treatment options, but she quickly changed her mind upon getting involved in the field:
I was in my residency in psychiatry, I was getting divorced, I needed a moonlighting job, and the only one available was at a treatment center. I’d worked for a month in my residency on the VA addiction unit and so thought I knew everything I needed to know, which is that no one gets better and there’s not much treatment. It was very negative. I thought, “What could be so hard about working with addiction?”
I started working and I remember this one guy specifically . . . his insurance would only pay for ten days, he had a terrible stutter, and worked as a maintenance guy. I kept thinking, I don’t see how this guy is going to stay sober with all the challenges he had. The next time I saw him, though, he was speaking at an alumni event for the treatment center and he wasn’t stuttering. His whole life had transformed, and that’s when I realized maybe I didn’t know as much as I thought I did. My mentor at the program I was working at asked me if I had heard of AMSA, the American Medical Society on Alcoholism. It was right before the American Medical Society on Alcoholism and Other Drug Dependencies (AMSAODD), and my mentor said they had a meeting every year. I went and there were three hundred to four hundred people there working on addiction and I didn’t even know there were that many people working on addiction in the whole country! It grew from there and I was interested in education, so I volunteered and joined the governing committee.
Over the years I’ve seen these waves of us trying to get legitimacy. Initially there had been one wave, around the time I got involved, and then another wave when Jim Callahan, one in a series of executives of the organization, and others went to preventive medicine the first time and it didn’t pan out. The third was when we started the Medical Specialty Action Group. We were basically just sitting around complaining about it and whining a lot and I said, “Look, we’re either going to do it or not do it.” We needed to go find out if we could do it and what was involved and then we started the MSAG.
David Smith, MD, founder of the Haight-Ashbury Free Clinic in San Francisco during the 1960s (Bai, 2017), explained the tumultuous and divided beginnings that threatened the specialty’s validity:
In the beginning you had three regions of the country. You had American Society of Alcoholism in the northeast, and they were the medical scientific committee of the National Council on Alcoholics (NCA). ASAM marks its birth from the times of this organization. There was the Georgia group, which was formed with many graduates of the Professional Group of Physicians getting treatment in Atlanta, Georgia with Doug Talbott, MD. On the west coast, physicians in recovery and responding to the “Summer of Love” were organizing within the structure of the California Medical Society, a state chapter of the American Medical Association.
Those of us treating addiction were aware that the treatment of addiction was a felony, that doctors could be arrested, and that patients were considered felons—a result of the passage of the Harrison Narcotic Act in 1914. As a result of the law, most well-intentioned doctors treating addiction were committing a felony. Since the treatment of the time of opium addiction was to prescribe opioids, you might say that the first incarnation of what became the field of addiction medicine in 1914 was crushed by the law.
The Harrison Narcotic Act was a federal law passed to restrict the distribution, production, importation, and sale of opiates. Anyone involved with opiates or coca leaf derivatives had to pay a special tax and record all related transactions so that the United States government could keep track of the flow of narcotics. This Act was an attempt to limit opiate use for medical and scientific use only, while also generating revenue through taxes. One particular line in the act, however, “in the course of [a physician’s] professional practice only,” was particularly damning for individuals with substance use disorders (SUDs) and the physicians who wanted to treat them (“Harrison,” 1914). This line was interpreted by law enforcement to mean that physicians could not treat addiction with opiates because drug addiction was not considered to be a disease at the time. This meant that individuals with SUDs were not patients, meaning that they could not legally be prescribed opiates for medical or scientific reasons.
Fortunately, modern physicians have made great strides in understanding narcotics and addiction and the philosophy towards treating addiction has changed. Louis E. Baxter, MD, FASAM, remembered the deplorable conditions patients were forced to suffer through that he witnessed in the early days of his career:
I remember early on when we got into the field, some of the instructions were that you take no psychoactive substances, benzos or pain medicines under any circumstance. If you were still anxious, then you weren’t grateful enough. If you were depressed, you’re not grateful enough or going to enough meetings. If you had pain, you should just become like John Wayne, bite the bullet, and work harder on your program. Fortunately, well-trained physicians today know that people who can recover with Twelve Step meetings alone have done so. Those that we see in treatment need something more than a sponsor; that’s the medicine in addiction medicine. People who are in recovery who have acute pain conditions can get benefit from non-narcotic medications and other modalities. However, there are some circumstances where people in recovery do require narcotics or analgesics, and the art of medicine is in helping patients without degrading their recovery. This includes when opioids are needed, limited supplies taken with supervision on a schedule so as not to have to play a mind game to get more disclosure to spouses and sponsors, among other techniques.
If the pain continues beyond three to five days in a person who’s in recovery, that pain needs to be reevaluated, because most acute pain, as we know, is short-lived. We’ve learned a lot over our time since the late 1980s to the present and I think it’s doing our patients a disservice when you say that because you’re in recovery you can’t benefit from using medications.
Dr. Smith recognized the disservice during the Summer of Love and realized that incarceration and/or refusal of treatment was not the answer:
During the Summer of Love hundreds of thousands of young people flocked to Haight-Ashbury, saying life is better lived through chemistry. This created a dilemma for law enforcement who found they couldn’t arrest the hundreds of thousands of middle-class kids flocking to San Francisco.
Dr. Smith was director of the alcohol and drug abuse screening unit at San Francisco General Hospital at the time, and being at the epicenter of the epidemic, could see the immediate need for health care reform. The inpouring of hippies had created a significant, emergent need for health care services that simply were not being provided because we had not had such a situation before. The go-to response of locking up drug users was clearly not going to work, and we had never before seen such numbers of people showing up with “bad trips” and the like. Inspired by the suffering he saw around him and free movements such as the Watts Clinic and the Diggers (a group serving free meals to the needy), Smith decided to create the Haight-Ashbury Free Clinic, originally called David E. Smith, MD, and Associates.
Dr. Smith recalled,
We were detoxing about one hundred addicts a day in our community-based detox program. California didn’t have methadone maintenance, so we had the only detox program. One of the doctors who volunteered used the same techniques in a different county and was arrested. City officials said we could do it where we were in the Haight, but not in their community.
I think in terms of the history, it’s important to know that the founding slogan of the free clinic was “Health care is a right, not a privilege.” That’s become a mantra for health care reform today. But where that came from was the Civil Rights Movement, when Freedom Riders in Mississippi described segregated health care and discrimination in access. Political leaders and law enforcement said, “We don’t want the hippies in San Francisco, so we’re going to deny them health care.” If you don’t like a particular population, one of the most political acts you can do is deny them health care to drive them out.
One day, Jess Bromley, MD, another pioneer in addiction medicine, called me and said that we were under threat and needed to organize with the mainstream of medicine to get political cover. That’s how the idea of forming the specialty of addiction medicine came about; we wanted to create a union to protect ourselves from law enforcement. In other words, a lot of the early west coast roots of addiction medicine came out of the Summer of Love.
Unfortunately, creating an organized union was easier said than done. Dr. Smith explained there was a great amount of stress in getting the doctors together:
There was tremendous tension between the doctors who treated alcoholism and the doctors who treated addiction. Max Schneider, MD, one of the past presidents of ASAM, was a pioneer who was part of academic medicine and extremely well thought of. He suggested that we get together to work out our differences to form a better shield composed of higher numbers.
Bromley got the idea of organizing a meeting to be held at the Kroc Ranch and approached Joan Kroc for support. Joan Kroc’s husband, Ray Kroc, had died of alcoholism and Joan supported our work. Bromley approached her and she agreed that all factions could meet at her Ranch. So, the northeast, represented by the Medical Scientific Committee of NCA and the New York Academy of Sciences; the South and most of the recovering physicians in the US; and the California Society, with its roots in organized medicine, came together. Gail Jana was the organizer. All that ASAM is today was borne out of the Kroc Ranch Meetings. The spirit of all the people who attended those meetings is here with us today. We are all here because of those people. It wasn’t a harmonious group, but everyone got together because the AMA said we had to get together. The only group that walked out of the Kroc Ranch Meetings was the American Psychiatric Association (APA). They were very threatened by the specialty of addiction medicine.
So, the first stage of this whole process was going to the AMA and getting drug addiction accepted as a disease. That was in 1975. They said alcoholism was accepted as a disease in the 1950s, but they still didn’t think addiction was a disease. ASAM members argued that Narcotics Anonymous, which was formed in San Francisco early on, was patterned after Alcoholics Anonymous, but they still said there was no evidence that addiction was its own thing from alcoholism, so that was the beginning of the battle.
In the 1980s we saw increases in our members as individuals joined us to certify in addiction medicine. The first exam was given in 1985 in California, and the first national exam was given a year later. Members were required to work supervised for two years in the field, take review courses, and sit for a qualifying exam.
In 1988 we positioned ourselves with the AMA and advocated drug dependencies, including alcoholism. Stan Gitlow, MD—a past president and father of later past president Stu Gitlow—and a couple of the others swore to Ruth Fox on her deathbed that alcohol was going to be included in the title, so we agreed to compromise. That’s why the first organization was called the “American Medical Society on Alcoholism and Other Drug Dependencies” (AMSAODD). Dr. Gitlow at that time was very influential and without his vote the whole thing would have fallen apart. We made the concession about the title. Then we went to the AMA, knowing we had to become a part of the system to get the system to change.
Representatives to the AMA meetings would wear badges that said “AMSAODD.” We’d be lobbying to the specialty representatives who had no idea who we were, so we decided to change our name to “Addiction Medicine” and call ourselves addictionists in the 1990s. Also in the 1990s we were taking on nicotine dependence and HIV/AIDS and saw our numbers increase as we worked with physicians wanting to better treat individuals who were contracting HIV through intravenous drug use. We were still trying to achieve specialty recognition at the AMA and the only group against us still was the APA. They didn’t want us to become an AMA-recognized specialty. All the other specialties supported us because the AMA at the time had a big poster on cigarette addiction. They asked us if cigarettes were included in ASAM and we said yes—and that was the pivotal thing that got all the other specialties to support us. The cigarette companies were threatening us with legal action, but Bromley said if we shine light on lobbyists we destroy their effectiveness. The original idea was that we would be a subspecialty, but today we’re our own specialty.
The American Academy of Addiction Psychiatry (AAAP) was also in opposition to ASAM. The relationship was both smoothed and agitated when Marc Galanter became president of AAAP then became president of ASAM. It’s said both sides mistrusted him for associating with the other group. Talbott, for example, didn’t want him to be president of ASAM because he was a psychiatrist and openly opposed him. Stu Gitlow, a psychiatrist, was an ASAM president who never earned specialty recognition by ASAM.
Even though addiction psychiatry is a leading force now, Dr. Howell agreed that psychiatrists, her field of specialization, were less than helpful with the legitimization of addiction medicine:
Psychiatry wasn’t doing anything with addiction and psychiatrists were abdicating their responsibilities, in my opinion. We weren’t learning anything about addiction in our residencies, and then towards the end of the 1980s they formed AAAP. AAAP’s view was that ASAM was just a bunch of recovering addict doctors and a lot of them still think that. AAAP has a very different approach; they’re very academic and serve alcohol at their functions. ASAM has always been a lot more embracing of talking about recovery openly, whereas if you’re in recovery in AAAP you don’t really talk about it. There was and still is a cynical view of doctors who treat addiction.
Regardless of the opposition, ASAM succeeded in becoming an organization and is still thriving today. The American Board of Addiction Medicine (ABAM) officially presented the first addiction medicine board certifications in 2009 (Smith, 2011). As of 2011, ten addiction medicine residency programs have been accredited and that number is continuing to grow.
Mike Miller, MD, is proud of ASAM’s accomplishments and says the organization has great potential for growth as long as members nurture individuals looking for future careers in the field:
We need to show more support of state chapters; that’s how to engage new members in the activities of ASAM and identify emerging leaders. We also need to spend time with our future, like each year’s Ruth Fox Scholars. Also, we should do all we can to get to know those physicians completing an accredited fellowship in Addiction Medicine. Praise everyone “around you” and “under you” for all the great things they’re doing to bring about the successes that occur.
Stuart Gitlow, MD, MPH, MBA, DFAPA, emphasizes the compassionate nature of ASAM members and professionals in the field of addiction medicine as a whole:
I started to attend the field in 1974. I was eleven and I went to Salt Lake City with my dad to the University of Utah School on Alcoholism and Other Drug Dependencies and we had dinner with all the other faculty one night. We ate with Marvin Block, LeClair Bissell, and Max Weissman, and they were lovely to me. Marvin Block treated me like his own boy and it was just a wonderful time. Of course, they were all talking about addiction because they had just spent the whole day there. What I remember was that they never mentioned drugs, alcohol or pharmacology; they talked about the people and they talked about the need to get to know the individual. That stuck with me—that addiction was a disease that involved people and getting to know them as a key component of their treatment. Everything else in medical school I could’ve ignored if I’d just learned that. That was the most important thing.
Dr, Krause has watched the organization grow from its infancy and could not be prouder of the progress made so far:
Where ASAM has come in my thirty-odd years in the field is like going from being a KFC or a McDonalds to being a gourmet meal: we’ve become so incredibly advanced. The science has advanced, the recognition of the specialty has come on, and unfortunately so has the exposure to patients. To be a part of that has been a tremendous boon for me. It’s helped me to see a different side of medicine and going through it with the people in ASAM has really been special, because they not only have been mentors and friends and helpful, they’ve also given me a good standard to aspire to as a physician. It’s been a tremendous ride, and it’s an organization that really is special. We’re growing and moving out in every area—academics, science, advocacy—and I just hope that we don’t lose track of this heading. We’ve got good wind in our sail; we need to just keep going.
Through all the ups and downs of legislation and regulation, incarceration and emancipation, here’s to keeping the wind in our sail.
ASAM Presidents: A Reference Guide (* = Interviewed)
- Ruth Fox, MD (founding president, 1954–1961, 1969–1971)
- Stanley E. Gitlow, MD, FACP, DFASAM (1961–1963, 1971–1973)
- Luther A. Cloud, MD (1963–1965)
- Percy E. Ryberg, MD (1965–1967)
- Arnold S. Zentner, MD (1967–1969)
- Maxwell N. Weisman, MD (1973–1975)
- Charles S. Lieber, MD (1975–1977)
- Joseph J. Zuska, MD (1977–1979)
- Sheila B. Blume, MD, DFASAM (1979–1981)
- LeClair Bissell, MD (1981–1983)
- Irvine L. Blose, MD (1983–1985)
- Max A. Schneider, MD (1985–1987)
- Margaret Bean-Bayog, MD (1987–1989)
- Jasper G. Chen See, MD (1989–1991)
- Anthony B. Radcliffe, MD, DFASAM (1991–1993)
- Anne Geller, MD, DFASAM (1993–1995)
- *David E. Smith, MD, DFASAM (1995–1997)
- G. Douglas Talbott, MD, DFASAM (1997–1999)
- Marc Galanter, MD, DFASAM (1999–2001)
- Andrea G. Barthwell, MD, DFASAM (2001–2002)
- *Lawrence S. Brown Jr, MD, MPH, DFASAM (2002–2005)
- *Elizabeth F. Howell, MD, DFASAM (2005–2007)
- *Michael M. Miller, MD, DFASAM (2007–2009)
- *Louis E. Baxter Sr, MD, DFASAM (2009–2011)
- Donald J. Kurth, MD, MBA, MPA, DFASAM (2011–2013, leave of absence June 2011 to April 2013)
- *Stuart Gitlow, MD, MPH, MBA, DFAPA, DFASAM (2013–2015)
- R. Jeffrey Goldsmith, MD, DLFAPA, DFASAM (2015–2017)
American Society of Addiction Medicine (ASAM). (2011). Definition of addiction. Retrieved from https://www.asam.org/resources/definition-of-addiction
Bai, N. (2017). Born in the Summer of Love: The Haight-Ashbury Free Clinic transformed drug addiction treatment. Retrieved from https://www.ucsf.edu/news/2017/06/407286/born-summer-love-haight-ashbury-free-clinic-transformed-drug-addiction-treatment
“Harrison Narcotics Tax Act, 1914.” (1914). Retrieved from http://www.druglibrary.org/schaffer/history/e1910/harrisonact.htm
Smith, D. E. (2011). The evolution of addiction medicine as a medical specialty. Virtual Mentor, 13(12), 900–5.