His faith-based 12-step program dominates treatment in the United States. But researchers have debunked core tenets of AA doctrine and found dozens of other treatments more effective.
J.G. is a lawyerin their early 30s. He is fast-talking and has the lean, lean build of a long-distance runner. His choice of profession seems predetermined, as he speaks in fully formed paragraphs, his thoughts organized by phrasal topics. He is also a big worrier, who for years used alcohol to calm his anxiety.
J.G. he started drinking at age 15, when he and a friend experimented in his parents' liquor cabinet. He preferred gin and whiskey, but he drank what he thought his parents would be least aware of. He, too, discovered beer and loved the earthy, sour taste on his tongue when he took his first cold sip.
His alcohol use increased during college and law school. He could back off, and he did occasionally back off, losing control for weeks on end. But nothing soothed his anxious mind like alcohol, and when he didn't drink, he didn't sleep. After four or six weeks of drying it would be back at the liquor store.
As a defense attorney, J.G. (who asked to be identified only by his initials) sometimes drank nearly a pint of Jameson a day. He used to start drinking after his first court appearance in the morning and says he would love to drink even more if his schedule would allow. He defended clients accused of drunk driving and bought his own breathalyzer to avoid ending up in court for drunk driving.
In the spring of 2012, J.G. decided to seek help. He lived in Minnesota, the land of 10,000 rehab centers, as people there say, and he knew what to do: enroll in a center. He spent a month in an institution where treatment consisted of little more than attending Alcoholics Anonymous meetings. He tried to stick with the program, although, as an atheist himself, he was put off by the faith-based 12-step approach, five of which mention God. Everyone there warned him that he had a chronic, progressive illness and that if he heard the sly inner whisper promising he could only take one sip, he would go on a binge.
J.G. he says it was that message, that there were no small mistakes and that one drink might as well be 100, that sent him into a cycle of binging and withdrawal. He returned to rehab once more and later sought help at an outpatient clinic. Whenever he sobered up, he spent months working hard, his days at court and his nights at home. Night would fall and her heart would race as she thought of another sleepless night. “So I was drinking,” he says, “and the first thing that came to mind was:Now I feel better, but I'm screwed. I'm going back to where I was. I might as well drink as much as possible for the next three days..”
He felt completely defeated. And according to AA doctrine, the failure was his alone. When the 12 steps don't work for someone like J.G., Alcoholics Anonymous says that person must be deeply flawed. The Big Book, the AA bible, says:
Rarely have we seen a person who followed our path to the fullest fail. Non-recoverers are people who are unable or unwilling to give themselves fully to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not guilty; they seem to have been born that way.
J.G.'s desperation was only heightened by his apparent lack of options. “Everybody I spoke to told me there was no other way,” he says.
So ingrained are the 12 steps in America that many people, including doctors and therapists, believe that showing up to meetings, earning sobriety tokens, and never taking a drink of alcohol again is the only way to get better. Hospitals, outpatient clinics and rehabilitation centers use the 12 steps as a basis for treatment. But while few people realize it, there are alternatives, including prescription drugs and therapies aimed at helping patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been shown to work in randomized controlled trials.
For J.G. it took years of trying to “work the program”, getting back on the bandwagon only to fall again, before he finally realized that Alcoholics Anonymous was not his only, or even best, hope for recovery. But in a way he was lucky: many others never made this discovery.
Tthe debate aboutaeffectiveness of 12-step programshas been bubbling quietly for decades among addiction experts. But it took on new urgency with passage of the Affordable Care Act, which requires all insurers and state Medicaid programs to pay for alcohol and substance abuse treatment, extending coverage to 32 million Americans. coverage level for over 30 million.
Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine with general medicine at the turn of the 20th century, when charlatans worked alongside graduates of leading medical schools. The American Medical Association estimates that of the nearly 1 million physicians in the United States, only 582 self-identify as addiction specialists. (The Columbia report notes that there may be additional physicians with a subspecialty in addiction.) Most treatment providers hold an addiction or substance abuse counselor credential, for which many states require little more than a degree from the high school or GED. 🇧🇷 Many counselors are in recovery. The report stated, "The vast majority of people who need addiction treatment receive nothing approaching evidence-based care."
Alcoholics Anonymous was founded in 1935 when knowledge of the brain was in its infancy. He offers a unique path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their egos, accept that they are "powerless" over alcohol, make amends for those they have harmed, and pray.
Alcoholics Anonymous is famous for being difficult to study. Out of necessity, he does not keep records of who attends meetings; members come and go and are, of course, anonymous. There is no conclusive data on how well it works. In 2006, the Cochrane Collaboration, a health research group, reviewed studies dating back to the 1960s and found that "no experimental studies have unequivocally demonstrated the effectiveness of AA or [12-step] approaches to reducing dependence or alcohol problems .
The Big Book includes a claim first made in the second edition, published in 1955: that AA worked for 75 percent of people who went to meetings and "really tried it." He says 50% got sober right away and another 25% struggled for a while but eventually recovered. According to the AA, these numbers are based on member experiences.
In his recent book,The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, retired professor of psychiatry at Harvard Medical School, analyzed retention rates from Alcoholics Anonymous along with studies on sobriety and rates of active participation (attending regular meetings and working in the program) among AA members. Based on these data, he calculated the actual success rate of AA to be between 5 and 8%. It's just a rough estimate, but it's the most accurate I could find.
I spent three years researching a book about women and alcohol,Your Best Kept Secret: Why Women Drink and How They Can Take Back Control, which was published in 2013. During that time, doctors and psychiatrists have discredited me every time I mentioned that the success rate of Alcoholics Anonymous seems to hover in the single digits. We have become so used to the testimonials of those who say that AA has saved their lives that we believe in the effectiveness of the program. We rarely hear from those for whom the 12-step treatment doesn't work. But think about it: how many celebrities can you name who have been in and out of rehab with no improvement? Why do we assume they failed the program instead of the program failing them?
When my book was released, dozens of Alcoholics Anonymous members said that because I disputed AA's claim of a 75% success rate, I would hurt or even kill people if I discouraged meeting attendance. Some insisted that I must be an "alcoholic in denial." But most people I heard from were desperate to tell me about their experiences in the American treatment industry. Amy Lee Coy, author of the memoirs.I separate from death: how I freed myself from addiction, told me about his eight visits to rehab, starting at age 13. "It's like taking the same antibiotic for a resistant infection eight times," he told me. "Makes sense?"
“Honestly, I thought AA was the only way someone could get sober, but I learned that I was wrong.”
She and many others put their faith in a system they were led to believe was effective, even though success rates at treatment centers are nearly impossible to find: The facilities rarely publish their data or even track their patients after discharge. "Many will tell you that those who complete the program have a 'great success rate,' meaning the majority abstain from drugs and alcohol while enrolled," says Bankole Johnson, alcohol researcher and chair of the University's Department of Psychiatry. . from the Maryland School of Medicine. "Well, it's not a joke."
Alcoholics Anonymous has over 2 million members worldwide, and the structure and support it offers has helped many people. But it's not enough for everyone. The story of AA is the story of how one treatment approach took root before other options existed, inscribed itself in the national consciousness, and displaced dozens of newer methods that have since been shown to work better.
A detailed analysis of treatments, published over a decade ago inThe Handbook of Alcoholism Treatment Approachesbut still considered one of the most comprehensive comparisons, it ranks AA 38 out of 48 methods. At the top of the list are brief interventions by a medical professional; motivation enhancement, a form of counseling aimed at helping people see the need for change; and acamprosate, a drug that relieves cravings. (A much-cited 1996 study found that 12-step facilitation, a form of individual therapy aimed at getting the patient to attend AA meetings, is as effective as cognitive-behavioral therapy and motivational interviewing. But this one study, called Project Match, was heavily criticized for scientific flaws, including the lack of a control group).
As an organization, Alcoholics Anonymous has no real central authority (each AA meeting functions more or less autonomously) and refuses to take positions on issues that go beyond the scope of the 12 steps. (When I asked to speak with someone at the Office of General Services, AA's administrative headquarters, about AA's position on other treatment methods, I received an e-mail that said, "Alcoholics Anonymous does not endorse or oppose other approaches. and we cooperate extensively with the medical profession.” The office also declined to comment on whether AA) has proven to be effective.
People with alcohol problems also have higher-than-normal rates of mental health problems, and research has shown that treating depression and anxiety with medication can reduce alcohol consumption. But AA is not equipped to deal with these issues, it is a support group whose leaders lack professional training, and some meetings are more accepting than others of the idea that members may need therapy and/or medication in addition to group help. .
AA truisms have so infiltrated our culture that many people believe that heavy drinkers cannot recover until they "hit rock bottom." The researchers I spoke with say it's like offering antidepressants only to those who have attempted suicide, or prescribing insulin only after a patient has slipped into a diabetic coma. “You could also say to a man who weighs 500 pounds and has untreated high blood pressure and a cholesterol of 300, 'Don't exercise, keep eating fast food, and we'll give you a triple bypass when you have a heart attack. .'” Mark Willenbring, a psychiatrist in St. Paul and former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, told me. He raised his hands. "Absurd."
Part of the problem is our one-size-fits-all approach. Alcoholics Anonymous was originally intended for chronic heavy drinkers, those who may indeed be powerless over alcohol, but its program has since been applied much more widely. Today, for example, judges routinely require people to attend meetings following a DUI arrest; 12% of AA members are there by court order.
Although the AA teaches that alcoholism is a progressive disease that follows an inevitable trajectory, data from a federally funded survey called the National Epidemiologic Survey on Alcohol and Related Conditions show that nearly one-fifth of people dependent on alcohol continue to drink at low levels. . -risk levels without abuse symptoms. And a recent survey of nearly 140,000 adults by the Centers for Disease Control and Prevention found that nine out of 10 heavy drinkers are not dependent on alcohol and, with the help of brief intervention from a medical professional, can change small healthy habits. .
We once thought of problem drinking in binary terms: either you were in control or you weren't; either you were an alcoholic or you weren't, but experts now describe a spectrum. An estimated 18 million Americans suffer from an alcohol use disorder, such asDSM-5, calls it the latest edition of the American Psychiatric Association's diagnostic manual. (The new term replaces the oldalcohol abuseand the much olderalcoholism, which has been in disuse among researchers for decades). Only about 15 percent of people with an alcohol use disorder are on the severe end of the spectrum. The rest fall somewhere in the mild to moderate range, but have been largely ignored by researchers and clinicians. Both groups, heavy abusers and more moderate heavy drinkers, need more individualized treatment options.
“We cling to this one-size-fits-all theory even when one person has a small problem.”
The United States already spends an estimated $35 billion a year on alcohol and substance abuse treatment, yet excessive alcohol use causes 88,000 deaths a year, including deaths from traffic accidents and alcohol-related illnesses. It also costs the country hundreds of billions of dollars in expenses related to health care, criminal justice, car accidents and lost productivity in the workplace, according to the CDC. With the Affordable Care Act expanding coverage, it's time to ask some important questions: What treatments should we be willing to pay for? Has its effectiveness been proven? And for whom, just those on the extreme end of the spectrum? Or also those in the vast and long-forgotten middle?
for a lookObserving how treatment works elsewhere, I traveled to Finland, a country that shares a history of prohibition with the United States (inspired by the American temperance movement, the Finns banned alcohol from 1919 to 1932) and a culture of binge drinking. of alcohol. 🇧🇷
Finland's treatment model is largely based on the work of an American neuroscientist named John David Sinclair. I met Sinclair in Helsinki in early July. He was battling advanced prostate cancer and his thick white hair was cut short in preparation for chemotherapy. Sinclair has researched the effects of alcohol on the brain since his days as a graduate student at the University of Cincinnati, where he experimented on rats given alcohol over a long period. Sinclair hoped that after several weeks without drinking, the rats would lose their desire to drink. Instead, when he gave them alcohol again, they raged for a week, drinking far more than they had ever drunk before - more, he says, than any rat had ever drunk.
Sinclair called this the alcohol withdrawal effect, and his lab results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment: Stopping going cold turkey only intensifies cravings. This finding helped explain why relapses are common. Sinclair published his findings in various journals, and in the early 1970s he moved to Finland, attracted by the opportunity to work in what he considered the best alcohol research lab in the world, with special mice bred to prefer alcohol to water. . He spent the next decade researching alcohol and the brain.
Sinclair came to believe that people develop a drinking problem through a chemical process: every time they drink, endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person will think about alcohol and eventually crave alcohol, until almost anything can trigger a thirst for alcohol and drinking becomes compulsive.
Sinclair theorized that if you could stop the endorphins from reaching their target, the opioid receptors in the brain, you could gradually weaken the synapses and the cravings would subside. To test this hypothesis, he administered opioid antagonists (drugs that block opioid receptors) to mice specially bred for alcohol consumption. He found that if the rats took the drug every time they had alcohol, they drank less and less. He published his findings in peer-reviewed journals starting in the 1980s.
Later studies found an opioid antagonist called naltrexone to be safe and effective for humans, and Sinclair began working with doctors in Finland. He suggested prescribing naltrexone for patients to take an hour before drinking. As his cravings subsided, they learned to control their consumption. Numerous clinical trials have confirmed that the method is effective, and in 2001 Sinclair published an article in the journalAlcoholism and Alcoholismreporting a 78% success rate in helping patients reduce their alcohol intake to approximately 10 drinks per week. Some stopped drinking altogether.
I visited one of the three private treatment centers called Contral Clinics that Sinclair co-founded in Finland. (There is an additional one in Spain). Over the past 18 years, more than 5,000 Finns have come to Contral Clinics for help with their drinking problems. Seventy-five percent of them were able to reduce their consumption to a safe level.
Finns are famous for their privacy, so I had to go early in the morning, before the patients arrived, to meet with Jukka Keski-Pukkila, the CEO. He poured coffee and showed me around the clinic in central Helsinki. The most common course of treatment involves six months of cognitive behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment usually also includes a physical exam, blood tests, and a prescription for naltrexone or nalmefene, a new opioid antagonist approved in more than two dozen countries. When I asked her how much all this cost, Keski-Pukkila was worried. "Well," he told me, "it's 2,000 euros." That's about $2,500, a fraction of the cost of inpatient rehabilitation in the United States, which routinely runs into the tens of thousands of dollars for a 28-day stay.
When I told this to Keski-Pukkila, her eyes widened. “What are they doing for that money?” I ask. I listed some of the treatments offered in the best rehabilitation centers: equine therapy, art therapy, mindfulness labyrinths in the desert. "That doesn't sound scientific," he said, puzzled. I didn't mention that some basic institutions charge as much as $40,000 a month and offer no treatment other than AA sessions conducted by minimally qualified counselors.
When researching this article,I wanted to know what it would be like to try naltrexone, which the US Food and Drug Administration approved for the treatment of alcohol abuse in 1994. I asked my doctor if he would give me a prescription. As expected, he shook his head. I don't have a drinking problem and he said he couldn't offer medicine for an "experiment". So he was left with the internet, which was pretty easy. I ordered naltrexone online and received a foil-wrapped pack of 10 pills about a week later. The cost was $39.
The first night I took a pill at 6:30 am. An hour later, I had a glass of wine and felt almost nothing: no calming effect, none of the warm satisfaction that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. At the end of dinner, I looked up and saw that I had barely touched him. I had never found wine so uninteresting. Was that a placebo effect? Possibly. But so it was. On the third night, at a restaurant where my husband and I shared a bottle of wine, the waitress came to fill his glass twice; mine, not once. This had never happened before, except when I was pregnant. At the end of 10 days, I found that I no longer looked forward to a glass of wine with dinner. (Interestingly, I also felt full much faster than usual and lost a pound. In Europe, an opioid antagonist is being tested on compulsive overeaters.)
I was anorteof one, of course. My experiment was motivated by personal curiosity, not scientific research. But I certainly felt like I was unlearning something: the pleasure of that first glass? The wish of it? Both? I really can't say.
Patients taking naltrexone should be encouraged to continue taking the pill. But Sari Castrén, a psychologist at the Contral Clinic I visited in Helsinki, told me that when patients come in for treatment, they are desperate to change the role that alcohol has taken in their lives. They have tried not to drink and to control alcohol consumption without success: their cravings are too strong. But with naltrexone or nalmefene, they can drink less, and the benefits soon become apparent: they sleep better. They have more energy and less guilt. They feel proud. They can read or watch movies or play with their kids during the time they would be drinking.
In therapy sessions, Castrén asks patients to compare their pleasure in drinking with the pleasure of these new activities, helping them to see the value of change. Still, the combination of naltrexone and therapy doesn't work for everyone. Some customers choose to take Antabuse, a medication that causes nausea, dizziness and other uncomfortable reactions when combined with the beverage. And some patients cannot learn to drink without losing control. In these cases (about 10 percent of patients), Castrén recommends total abstinence from alcohol, but leaves that choice to the patients. “Sobriety is your decision, based on your own discovery,” he told me.
Claudia Christian, an actress based in Los Angeles (she is best known for appearing on the 1990s sci-fi TV showBabylon 5), discovered naltrexone when he found a leaflet for Vivitrol, an injectable form of the drug, at a detox center in California in 2009. He had tried Alcoholics Anonymous and traditional rehab without success. She researched the drug online, had a doctor prescribe it, and started taking a dose about an hour earlier than she planned to drink it, as Sinclair recommends. She says the effect was like pushing a button. For the first time in years, he managed to take a single sip and then stop. She plans to continue taking naltrexone indefinitely and has become a vocal supporter of the Sinclair Method: She has created a non-profit organization for people seeking information on the subject and has made a documentary calleda little pill.
In the United States, doctors often prescribe naltrexone for daily use and tell patients to avoid alcohol, rather than instructing them to take the drug whenever they plan to drink, as Sinclair would advise. There is disagreement among experts about which approach is better (Sinclair insists American doctors are missing out on the drug's full potential), but both seem to work: Naltrexone has been found to reduce alcohol consumption in more than a dozen clinical trials. . including a large study. one funded by the National Institute on Alcohol Abuse and Alcoholism that was published inJAMAin 2006. The results were largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug that has been shown to help control alcohol use.
To understand why, one must first understand the story.
the american approachfor the treatment of drinking problems has its roots in the country's long tradition.love-hate relationship with alcohol🇧🇷 The first settlers arrived with amucha sedfor whiskey and strong cider, and in the early days of the republic, alcohol was one of the few drinks reliably safe from contamination. (It was also cheaper than coffee or tea). Historian W. J. Rorabaugh estimated that between the 1770s and 1830s, the average American over the age of 15 consumed at least five gallons of pure alcohol a year, the equivalent of three shots of hard liquor. one day.
Religious fervor, aided by the introduction of public water filtration systems, helped to galvanize the temperance movement, which culminated in 1920 with Prohibition. That experiment ended after 14 years, but the drinking culture it fostered - secrecy and frenetic compulsion - persists.
In 1934, shortly after Prohibition was repealed, a bankrupt stockbroker named Bill Wilson staggered into a Manhattan hospital. Wilson was known to drink two liters of whiskey a day, a habit he tried to break many times. He was given the hallucinogen belladonna, an experimental treatment for addiction, and from his hospital bed he cried out to God to loosen his grip on alcohol. He reported seeing a flash of light and feeling a serenity he had never experienced before. He gave up alcohol for good. The following year, he co-founded Alcoholics Anonymous. He based his principles on the beliefs of the Oxford Evangelical Group, which taught that people were sinners who, through confession and God's help, could make their ways straight.
AA filled a void in the medical world, which at the time had few answers for heavy drinkers. In 1956, the American Medical Association classified alcoholism as a disease, but doctors continued to offer little beyond the standard treatment that had existed for decades: detoxification in state psychiatric wards or private sanitariums. As Alcoholics Anonymous grew, hospitals began creating "alcohol wards" where patients detoxed but received no other medical treatment. Instead, AA members, who, as part of the 12 steps, commit to helping other alcoholics, appeared at the bedside and invited newly sober people to meetings.
A public relations specialist and early AA member named Marty Mann worked to publicize the group's main tenet: that alcoholics had a disease that made them powerless over alcohol. His drinking was a disease, in other words, not a moral failing. Paradoxically, the prescription for this medical condition was a set of spiritual steps that required accepting a higher power, taking a “fearless moral inventory,” admitting “the exact nature of our wrongs,” and asking God to remove all character flaws.
Mann helped ensure that these ideas made it to Hollywood. in 1945the lost weekend, a struggling novelist tries to loosen his writer's block with alcohol, with devastating effect. InsideDays of wine and roses, released in 1962, Jack Lemmon descends into alcoholism with his wife, played by Lee Remick. He finds help through AA, but she rejects the group and loses her family.
Mann also collaborated with a physiologist named E. M. Jellinek. Mann was eager to bolster the scientific claims behind AA, and Jellinek wanted to make a name for himself in the growing field of alcohol research. In 1946, Jellinek published the results of a mailed survey of 1,600 AA members. Only 158 were returned. Jellinek and Mann discarded 45 that had not been completed correctly, and another 15 were completed by women, whose responses were so different from those of men that they risked complicating the results. From this small sample of 98 men, Jellinek drew sweeping conclusions about the "stages of alcoholism," which included an inevitable succession of binges that led to blackouts, "undefinable fears," and the bottom. Although the document was full of warnings about its lack of scientific rigor, it became the gospel of AA.
Jellinek, however, later tried to distance himself from that work and from Alcoholics Anonymous. His ideas were illustrated by a graph that showed how alcoholics progressed from occasional drinking to relief, to sneak drinking to guilt, and so on, until they hit rock bottom ("admitted total defeat") and then recovered. . If you could place yourself at the very beginning of the downward trajectory of this curve, you could see where your drink was going. In 1952, Jellinek pointed out that the wordalcoholicit had been adopted to describe anyone who drank to excess. He warned that excessive use of this word would undermine the concept of illness. He later pleaded with the AA to stay out of the way of scientists trying to do objective research.
But AA supporters worked to ensure its focus remained central. Marty Mann joined such prominent Americans as Susan Anthony, great-niece of Susan B. Anthony; Jan Clayton, mother ofGirl🇧🇷 and decorated military officers testifying before Congress. John D. Rockefeller Jr., a lifelong teetotaller, was one of the group's early promoters.
In 1970, AA Senator Harold Hughes of Iowa persuaded Congress to pass the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act. He called for the creation of the National Institute on Alcohol Abuse and Alcoholism and dedicated funds for the study and treatment of alcoholism. The NIAAA, in turn, funded Marty Mann's non-profit advocacy group, the National Council on Alcoholism, to educate the public. The non-profit organization has become a spokesman for AA's beliefs, especially the importance of abstinence, and has sometimes worked to quash research that challenges those beliefs.
In 1976, for example, the Rand Corporation published a study of over 2,000 men who had been patients at 44 different NIAAA-funded treatment centers. The report noted that 18 months after treatment, 22% of men were moderate drinkers. The authors concluded that some alcohol-dependent men can resume drinking in a controlled manner. Researchers from the National Council on Alcoholism claimed that the news would lead alcoholics to falsely believe they could drink safely. The NIAAA, which funded the research, rejected it. Rand repeated the study, this time looking at a four-year period. The results were similar.
After the Hughes Act was passed, insurance companies began to recognize alcoholism as a disease and pay for treatment. For-profit rehab facilities sprung up across the country, the start of what would become a multi-billion dollar industry. (Hughes became a treatment entrepreneur after retiring from the Senate.) If Betty Ford and Elizabeth Taylor could come out as alcoholics and seek help, so could ordinary people struggling with drinking. Today there are more than 13,000 rehab centers in the United States, and 70 to 80 percent of them follow the 12 steps, according to Anne M. Fletcher, author ofinternal rehabilitation, a 2013 book that delves into the treatment industry.
Tthe problem isthat nothing about the 12-step approach is based on modern science: not character building, not tough love, not even the standard 28-day stay in rehab.
Marvin D. Seppala, medical director of the Hazelden Betty Ford Foundation in Minnesota, one of the oldest inpatient rehabilitation centers in the country, described to me how 28 days became the norm: “In 1949, the founders discovered that it would take about a week to detox, another week to recover so [the patients] knew what they were doing, and after a few weeks they were fine and stable. So it was 28 days. There's no magic to it."
Tom McLellan, a professor of psychology at the University of Pennsylvania School of Medicine who has served as undersecretary of drug enforcement in the United States and is a consultant to the World Health Organization, says that while AA and other programs aimed at behavior change have value, no He will not address what we now know about the biology of the drink.
Alcohol acts on many parts of the brain, making it a bit more complex than drugs like cocaine and heroin, which target only one area of the brain. Among other effects, alcohol increases the amount ofGABA(gamma-aminobutyric acid), a chemical that slows down nervous system activity and decreases the flow of glutamate, which activates the nervous system. (That's why drinking can make you relax, let go of your inhibitions, and forget about your worries.) Alcohol also causes the brain to release dopamine, a chemical associated with pleasure.
However, over time, a heavy drinker's brain adjusts to the steady stream of alcohol producing lessGABAand more glutamate, resulting in anxiety and irritability. The production of dopamine also decreases and the person feels less pleasure in everyday things. Combined, these changes gradually cause a crucial shift: instead of drinking to feel good, people end up drinking to avoid feeling bad. Alcohol also damages the prefrontal cortex, which is responsible for assessing risk and regulating behavior, one of the reasons why some people continue to drink even when they realize the habit is destroying their lives. The good news is that the damage can be repaired if you can control consumption.
Studies of twins and adopted children suggest that about half of a person's vulnerability to alcohol use disorder is hereditary, with anxiety, depression, and the environment all considered "external issues" by many in Alcoholics Anonymous. 🇧🇷 Occupation. Still, science still cannot fully explain why some heavy drinkers become physiologically dependent on alcohol and others do not, or why some recover while others fail. We don't know how much it takes to drink to cause big changes in the brain, or ifthe brain of people dependent on alcoholthey're a little different than "normal" brains to begin with. What we do know, says McLellan, is that "alcoholics' brains are not like non-alcoholics'."
Bill Wilson, the founding father of AA, was right when he insisted 80 years ago that alcohol addiction is a disease, not a moral failing. Why, then, do we rarely treat it with medication? It's a question I've heard many times from researchers and clinicians. “Alcohol and substance use disorders are the domain of medicine,” says McLellan. "This is not the kingdom of priests."
Chen the hazelden treatment centerOpened in 1949, it embraced five goals for its patients: behave responsibly, attend 12-step lectures, make the bed, stay sober, and talk to other patients. Even today, Hazelden's website states:
People addicted to alcohol can be secretive, self-absorbed, and full of resentment. In response, Hazelden's founders urged patients to pay attention to the details of everyday life, tell their stories and listen to each other... This led to an encouraging finding, which became the cornerstone of the Minnesota Model: alcoholics and addicts can help each other.
That might be encouraging, but it's not science. As the rehab industry began to expand in the 1970s, its profit motives dovetailed well with the AA view that counseling could be provided by people struggling with addiction rather than highly qualified, trained physicians. (and well paid) and mental health professionals. No other area of medicine or counseling makes such concessions.
There is no national certification exam required for addiction counselors. Columbia University's 2012 report on addiction medicine found that only six states required alcohol and substance abuse counselors to have at least a bachelor's degree and that only one state, Vermont, required a master's degree. Fourteen states had no licensing requirements, not even a GED or introductory training course was required, and yet counselors are often called upon by the court system and medical boards to provide expert opinions on their clients' prospects for recovery.
Fourteen states had no licensing requirements for addiction counselors, not even a GED or introductory course.
Mark Willenbring, the psychiatrist from St. Paul, winced when I mentioned this. “How about,” he asked me rhetorically, “with people without qualifications or talents, plus recovering alcoholics, licensed as professionals with the authority to make decisions about whether you get arrested or lose your medical license?
“The history and current state is very, very depressing,” said Willenbring.
Perhaps even worse is the pace of research on drugs to treat alcohol use disorder. The FDA has approved just three: Antabuse, the drug that causes nausea and dizziness when taken with alcohol; acamprosate, which has been shown to be helpful in reducing cravings; and naltrexone. (There's also Vivitrol, the injectable form of naltrexone.)
Reid K. Hester, a psychologist and director of research at Behavior Therapy Associates, an organization for psychologists in Albuquerque, says there has long been resistance in the United States to the idea that alcohol use disorder can be treated with drugs. For a brief period, DuPont, which held the patent for naltrexone when the FDA approved it for the treatment of alcohol abuse in 1994, paid Hester to speak about the drug at medical conferences. “The reaction was always, 'How can you give drugs to alcoholics?'” he recalls.
Hester says this attitude dates back to the 1950s and 1960s, when psychiatrists prescribed Valium and other sedatives with high abuse potential to heavy drinkers. Many patients ended up dependent on alcohol and benzodiazepines. “They looked at me like I was promotingValley of the Dolls 2.0says Hester.
There have been some breakthroughs: Hazelden's center began prescribing naltrexone and acamprosate to patients in 2003. But that makes Hazelden a pioneer among rehab centers. “Everyone has a bias,” Marvin Seppala, the medical director, told me. “Honestly, I thought AA was the only way someone could get sober, but I learned that I was wrong.”
Stephanie O'Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol use disorder for more than two decades, calls the limited use of naltrexone "baffling."
"There was never any campaign for this drug that said, 'Ask your doctor,'" she says. “There was never any attempt to target consumers.” Few doctors accepted that it was possible to treat alcohol use disorder with a pill. And now that naltrexone is available in cheap generic form, drug companies have little incentive to promote it.
In a recent study, O'Malley found naltrexone to be effective in limiting drinking among college-aged drinkers. The drug helped subjects avoid exceeding the legal limit for intoxication, a blood alcohol content of 0.08 percent. However, naltrexone is not a panacea. We still don't know who works best for. Other drugs can help fill in the gaps. O'Malley and other researchers found, for example, that the smoking cessation drug varenicline showed promise in reducing alcohol consumption. Also take topiramate, a seizure medication, and baclofen, a muscle relaxant. “Some of these drugs should be considered in primary care offices,” says O'Malley. "And they just aren't."
At the end of August,I visited Alltyr, a clinic founded by Willenbring in St. Paul. It was here that J.G. finally found help.
After his stint in rehab, J.G. he continued to look for alternatives to 12-step programs. She read about baclofen and how it could alleviate both anxiety and alcohol cravings, but her doctor didn't prescribe it. In desperation, J.G. went to a Chicago psychiatrist who prescribed him baclofen without even knowing him personally, and ultimately had his license suspended. Then, in late 2013, J.G. He visited Alltyr's website and found, 20 minutes from his law office, a nationally known specialist in the treatment of alcohol and substance use disorders.
J.G. now he goes to Willenbring once every 12 weeks. During these sessions, Willenbring checks on JG's sleep patterns. and refills his baclofen prescription (Willenbring was familiar with the studies on baclofen and alcohol and agreed it was a viable treatment option), occasionally prescribing Valium for his anxiety. J.G. He doesn't drink anything these days, but he doesn't rule out having a beer now and then in the future.
I also spoke with another Alltyr patient, Jean, a Minnesota floral designer in her 50s who at the time visited Willenbring three or four times a month but has since cut back to once every few months. “Actually, I really want to go,” he told me. At 50, Jean (who asked to be identified by her middle name) went through a rough patch and a career change, and began to assuage her regrets with a bottle of red wine a day. When Jean confessed her addiction to her doctor last year, she was referred to an addiction counselor. At the end of the first session, the counselor gave Jean a diagnosis: “You're a drunk,” he told her, and suggested that she attend AA.
The whole idea made Jean uncomfortable. How did people get better at sharing the worst moments of their lives with strangers? Still, she went. Each member's story seemed worse than the last: a man had crashed his car into a telephone pole. Another described her abusive blackouts. A woman has taken the blame for having a child with fetal alcohol syndrome. “Everyone was talking about their 'alcoholic brain' and how their 'disease' made them act,” Jean told me. She couldn't relate. He didn't believe that his taste for pinot noir was a disease, and he chafed at the lines people read from the Big Book: "We thought we could find a smoother, easier way," they recited. "But we couldn't."
Surely, thought Jean, modern medicine had to offer a more up-to-date form of help.
Then he found Willenbring. During sessions with him, she talks about disturbing memories that she believes helped her increase her alcohol consumption. Every now and then she has a drink; Willenbring calls this "investigation," not "relapse." “There are no demotions, no labels, no judgments, no books to carry, no taking off your 'badge,'” says Jean, referring to the tokens AA members earn when they reach certain sobriety milestones.
In his treatment, Willenbring uses a combination of behavioral and drug approaches. Moderate drinking is not a possibility for all patients, and he weighs many factors when deciding whether to recommend lifelong abstinence. You are unlikely to consider moderation as a goal for patients with severe alcohol use disorder. (According toDSM-5, patients in the severe range have six or more symptoms of the disorder, such as frequently drinking more than intended, increased tolerance, unsuccessful attempts to cut back, cravings, lack of binge drinking, and continuing to drink despite negative personal or social problems consequences. .) He is also unable to suggest moderation for patients with mood, anxiety or personality disorders; chronic pain; or lack of social support. “We can provide treatment based on what stage patients are at,” said Willenbring. It's a radical change from issuing the same prescription to everyone.
The difficulty in determining which patients are good candidates for moderation is an important red flag. But promoting abstinence as the only valid treatment goal is likely to discourage people with mild or moderate alcohol use disorder from seeking help. The prospect of never taking another sip is daunting, to say the least. It comes with societal costs and can even be worse for your health than moderate alcohol consumption: Research has found that having one or two drinks a day can reduce the risk of heart disease, dementia and diabetes.
For many, however, the idea of recovery without withdrawal is anathema.
no one knows thatbetter than Mark and Linda Sobell, both psychologists. In the 1970s, the couple conducted a study with a group of 20 patients in Southern California diagnosed with alcohol dependence. Over the course of 17 sessions, they taught patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, patients had fewer heavy drinking days and more non-drinking days than a group of 20 alcohol-dependent patients who were instructed to completely abstain from drinking. (Both groups received standard hospital care, including group therapy, AA meetings, and medication.) The Sobells have published their findings in peer-reviewed journals.
In 1980, the University of Toronto recruited the couple to conduct research at its prestigious Foundation for Addiction Research. “We don't intend to challenge tradition,” Mark Sobell told me. “We just set out to do good research.” Not everyone saw it that way. In 1982, abstinence advocates attacked the Sobells in the magazineScience🇧🇷 one of the writers, a UCLA psychologist named Irving Maltzman, later accused them of falsifying their results. TheSciencearticle received wide attention, including a story inLos New York Timesand a segment in60 minutes.
In the following years, four panels of investigators in the United States and Canada cleared the couple of the accusations. His studies were accurate. But the exonerations had little impact, said Mark Sobell: "Maybe a paragraph on page 14" of the newspaper.
The United States spends $35 billion a year on substance abuse treatment, yet excessive alcohol use causes 88,000 deaths a year.
The late G. Alan Marlatt, a respected addiction researcher at the University of Washington, commented on the controversy in a 1983 article inamerican psychologist🇧🇷 “Despite the fact that the basic tenets of the [AA] disease model have yet to be scientifically verified,” wrote Marlatt, “proponents of the disease model continue to insist that alcoholism is a unitary disorder, a progressive disease that can only be be temporarily stopped. by total abstention”.
The surprising thing, 32 years later, is how little has changed.
The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University in Fort Lauderdale, Florida. They also have a clinic. Like Willenbring in Minnesota, they are among a small number of researchers and clinicians, mostly in big cities, helping some patients learn to drink in moderation.
“We cling to this one-size-fits-all theory even when a person has a little problem,” Mark Sobell told me. "The idea is, 'Well, this might be the person you are now, but this is where this is going and there's only one way to fix it.' Sobell paused. “But we have 50 years of research that say it probably isn't. We can change course."
During my visit to Finland,I interviewed P., a former Contral Clinic patient, who asked me to use only his last initial to protect his privacy. He told me that for years he drank excessively, sometimes up to 20 drinks at a time. A 38-year-old physician and university researcher, he describes himself as affable when sober. However, when he was drunk, "it was like a primitive human took over".
His wife found a Contral Clinic online and P. agreed to go. Since the first naltrexone dose, she has felt different, controlling her use for the first time. P. plans to use naltrexone for the rest of her life. He drinks two, maybe three times a month. By American standards, these episodes count as binges, as he sometimes has more than five drinks at once. But it's a sharp drop from the 80 drinks he consumed a month before starting treatment, and in Finnish eyes, it's a success.
Sari Castrén, the psychologist I met at Contral, says these trajectories are the rule among her patients. “Helping them find that path is very rewarding,” she says. “This is a softer way of looking at addiction. It doesn't have to be so black and white."
J.G. Agree He feels much more confident and stable, he says, than when he was drinking. He drank satisfactorily in moderation occasionally, with no loss of control or desire to consume more the next day. But for now, he's content not to drink. “It seems like a big risk,” he says. And now he has more at stake: his daughter was born in June 2013, about six months before he found Willenbring.
Could expanding coverage under the Affordable Care Act cause us to rethink how we treat alcohol use disorder? That remains to be seen. The Department of Health and Human Services, the main administrator of the law, is evaluating the treatments. But the legislation doesn't specify a process for deciding which methods should be approved, so states and insurers are setting their own rules. How they will make these decisions is an ongoing topic of discussion.
Still, many leaders in the field are hopeful, including Tom McLellan, a psychologist at the University of Pennsylvania. His optimism is particularly poignant: in 2008, he lost a son to a drug overdose. "If I didn't know what to do for my son, when I know these things and I'm surrounded by experts, how the hell is a teacher or a mason going to know?" he asks. Americans need to demand more, says McLellan, just as they did with breast cancer, HIV and mental illness. “It will be a mandatory benefit and insurers will want to pay for things that work,” he says. "Change is within reach."