ANTIGUA, MALIBU, Tucson, anyone? The attraction of a four-week stay at an upscale resort with the likelihood of a celebrity or two is undeniable — even if the days are packed with therapy based on the 12 steps of Alcoholics Anonymous (AA), the monthly price tag as high as $50,000, and the likelihood of success very low.
Long-term success rates of AA-based-treatment — including resort rehab and regular 12-step meetings — may be as low as 5%, according to retired Harvard psychiatrist Lance Dodes in his book, “The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry.” Furthermore, low-cost publicly funded clinics often have better-qualified therapists and better outcomes than high-end residential centers, according to Anne Fletcher in her book, “Inside Rehab.”
A 2012 report from Columbia University’s National Center on Addiction and Substance Abuse “compared the current state of addiction treatment to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools,” according to a 2015 Atlantic Monthly article by Gabrielle Glaser. The report’s conclusion: “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.” Glaser also cites “The Handbook of Alcoholism Treatment Approaches,” published more than ten years ago, that ranks AA 38th out of 48 methods.
Of more than 13,000 rehab facilities in the U.S., however, as many as 80% follow the Alcoholics Anonymous model and recommend AA follow-up — 90 meetings in 90 days is the mantra — for what’s now called “Alcohol-Use Disorder” (AUD). Many people have been helped by AA and by the ready solace of its ongoing groups.
About 18 million adults in the U.S.— as many as 20% of patients seen in primary care of hospital settings — abuse alcohol, and the numbers are rising, according to the National Institute for Alcohol Abuse and Alcoholism (NIAAA). One definition of AUD: having developed a high tolerance for alcohol and experiencing withdrawal symptoms if its use is suddenly stopped.
Research-based conclusions about AUD that run counter to the AA model are ignored by most practitioners, says addiction psychiatrist Mark Willenbring, director of treatment research at NIAAA from 2004 to 2009 and founder of the Minnesota outpatient clinic Alltyr. “When the facts change — and they’ve changed a lot — the minds have not,” he told the New York Times.
AA keeps no records of participants but claims to have more than two million members worldwide. According to the “Big Book,” AA’s bible, the program works for 75% of those who go to meetings. Critics deem this claim a tautology since most of those who go to meetings have already stopped drinking and attend to maintain rather than achieve sobriety — but in fact all that’s actually required of attendees is the intention to stop, and willingness to join in the group’s serenity prayer is considered a personal pledge.
AA’s blame-the-victim ethos considers alcohol abuse a personal failure of will. According to the Big Book, “Those who do not recover are people who cannot or will not completely give themselves to this simple program…who are constitutionally incapable of being honest with themselves.”
This morality stigmatizes people who fail to overcome addiction — as it does with obesity. Fear of the stigma as well as the abstinence-only goal of AA keep people from asking for help until their problems become so serious that treatment is more challenging. Only about 10% with alcohol and substance-use disorders ever seek treatment.
More successful approaches than AA, available since the early 2000s, are individualized; involve medical professionals — who can treat co-occurring disorders such as depression as well as prescribe anti-abuse medication; and offer help for as long as necessary — usually a lot longer than 28 days.
A key reason for failure of the 28-day/AA model is dual diagnoses — that is, when addiction is accompanied by disorders of depression, anxiety, or more serious conditions like bipolar disorder and schizophrenia. Co-occurring conditions affect approximately 37% of those with AUD and 53% with drug addictions, according to the National Alliance of Mental Illness.
In fact, treating the co-occurring conditions with medication and/or therapy can reduce cravings for alcohol. Most experts agree that about half of a person’s vulnerability to alcohol-use disorder is hereditary and that co-occurring conditions play a role.
But the AA model approach advises against taking any anti-abuse medication as well as potentially “mood-altering” drugs; many AA participants believe they should refuse all medicine, even aspirin for headaches. Medication-assisted-treatment (MAT) “has never been quite as controversial a subject as it is today,” according to the Substance Abuse and Mental Health Services Administration website. Despite increasing evidence of MAT’s effectiveness, only 1 to 2% of people treated for alcohol-use disorder receive anti-craving medication.
The drug Antabuse, which causes nausea when combined with alcohol, can be given only to patients who have completed withdrawal from alcohol and are committed to abstinence. In contrast, Naltrexone, which blocks the opiate receptors involved in the pleasurable effects of drinking as well as in cravings for alcohol, is considered a “treatment” drug and can be offered to those struggling to recover.
Over time, constant consumption of alcohol changes the brain, in particular altering the release of chemicals such as GABA and dopamine that create the feelings of warmth, contentment and good humor associated with alcohol; and strengthening the synaptic connections that increase the likelihood of thinking about and eventually craving alcohol, until drinking becomes compulsive.
Naltrexone has been shown to reduce drinking and increase abstinence in more than a dozen clinical trials, including one large scale NIAAA-funded trial published ten years ago. Because it’s available in an inexpensive generic form, however, drug companies are not promoting it. Still, AUD experts are baffled by its limited use.
For her article, Glaser tried Naltrexone (ordered with no RX online) and, sipping her evening glass of wine, “felt almost nothing — no calming effect, none of the warm contentment that usually signals the end of my workday … I had never found wine so uninteresting.” After taking the drug for several more nights, she wrote, “I no longer looked forward to a glass of wine with dinner.” She also lost several pounds, noting that an opioid antagonist is being tested on binge eaters in Europe.
Resort rehab also runs up against research indicating that most individuals need at least three months of treatment to significantly reduce or stop their addictions. Those with co-occurring or long-standing addictions can require 12 months or longer. Which is why successful rehab programs are local and available as long as and whenever needed.
At Alltyr, Willenbring’s Minnesota clinic, addiction is considered a chronic medical condition, and treatments include antidepressants, anti-relapse medications and psychotherapy — for as long as needed. “You don’t treat a chronic illness for four weeks and then send the patient to a support group,” Willenbring said. These individuals need treatment “that is individualized and offered continuously or intermittently for as long as they need it.”
Among patients who were helped at Alltyr, one woman had been in and out of rehab 42 times, and one young man had tried more than 20 abstinence-based programs, attempted suicide and overdosed on heroin.
AA’s one-size fits all approach “was originally intended for chronic, severe drinkers — those who may, indeed, be powerless over alcohol,” notes Glaser. But only about 15% of those with alcohol-use disorder are at the severe end of the spectrum. And whereas AA considers alcoholism a progressive disease that can only get worse, in fact as many as 20% may go on to drink at low risk of becoming more dependent, she wrote.
Any changes in this picture make news, such as when the Hazelden Betty Ford Foundation, previously an AA-only model, announced it would offer Naltrexone. But that was in 2006 — and there has been little movement since.
— Mary Carpenter
Mary Carpenter, MyLittleBird’s well-being editor, last wrote about
the dangers of hepatitis C.