Alcoholism 2023

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By Mary Carpenter

Editor’s Note:  Inspired by a recent play and its reviewers, Mary decided to update her 2017 post on alcoholism, officially alcohol use disorder (AUD). Together these offer eloquent insights that may reach a wider audience—for whom the topic of addiction can seem too unbearably grim. And one reviewer compares AUD rehab to the “Covid pause.”  

 “THE HARDEST and most confusing aspect is…addiction, which takes over all logic and reasoning,” wrote DC-based poet W.C. in a personal email.  “It’s inexplicable to those who aren’t addicts and even, sometimes, to those of us who are lucky to have gotten sober.” According to the National Institute for Alcohol Abuse and Alcoholism (NIAAA), one definition of AUD is having developed a high tolerance for alcohol and experiencing withdrawal symptoms if its use is suddenly stopped.

The greatest barrier to understanding AUD is that drinking alcohol usually signals relaxation, parties, friends; and for 95% of people, social drinking causes few problems. So, most everyone steers away from the topic of addiction, which includes the best books on the topic, despite being beautifully written, deeply and sensitively probing, such as Drinking: a Love Story, by Caroline Knapp; Dry: A Memoir, by Augusten Burroughs; Co-Dependent No More, by Melody Beattie.

But People, Places & Things, by Duncan MacMillan— a play that traveled from London and New York and most recently to DC’s Studio Theater—confronts the audience with intense characters and illuminating words. Explains the Doctor (who has no other name) in the Alcoholics Anonymous-based, 12-step in-patient program: “Your addiction will fight any progress. It’s a parasite and it will fight for its own survival until you’re dead.”

“Acting gives me the same thing I get from drugs and alcohol. Good parts are just harder to come by,” quips the main character Emma —“a spectacular liar [with whom] the playwright successfully hooks the audience,” writes Artsfuse reviewer, University of Maine drama lecturer David Greenham.  In her profession as an actress, Emma constructs false identities for her turns on stage but off stage completely loses track of the truth.

“You want me to conceptualize a universe in which I am the sole agent of my destiny and at the same time acknowledge my absolute powerlessness” is Emma’s evaluation of her rehab program—which makes the infamous AA request that participants give over control to a higher power. “It’s a fatal contradiction and I won’t start building foundations on a flawed premise.”  As New York Times critic Jesse Green rephrases it: “We play a large part in our own addictions, yet we are powerless over them.”

After detox and rehab, Emma leaves her program “clean,” an apparent success. Only toward the end of the play is the audience obliged to experience the most debilitating aspect of recovery—the addict’s return to the same world that was once unmanageable without the help of alcohol or drugs. Writes Green about the ending: “We are given devastating evidence that Emma’s addiction is… the mark of the world’s cruelty to sensitive souls.”

Among its dated methods that lead to poor success rates, lack of follow-up for easing participants back into the real world is a major criticism of AA-based treatment. Long-term recovery following 28 day-residence programs like Emma’s —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.   

Most AA-based  programs have no medical personnel on staff and, for countering the physical components of addiction, forbid such medication as Antabuse and naltrexone. In fact, many AA-program participants believe they must refuse all medicine, including 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.

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 reduced drinking and increased abstinence in more than a dozen clinical trials, including one large scale NIAAA-funded trial published 15 years ago.

Because Naltrexone is available in an inexpensive generic form, however, pharmaceutical companies are not promoting the drug.  Still, AUD experts are baffled by its limited use. When the Hazelden Betty Ford Foundation, previously an AA-only model, announced it would offer Naltrexone, it was 2006— and there has been little movement since.

Medication can also be essential for treating “dual diagnoses”— including depression, anxiety, and more serious bipolar disorders and schizophrenia— that affect approximately 37% of those with AUD and 53% with drug addictions, according to the National Alliance of Mental Illness. By itself, medical treatment for these conditions 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.

Despite increasing evidence of MAT’s effectiveness, only 1 to 2% of people treated for alcohol-use disorder receive anti-craving medication. The current state of addiction treatment is like “general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools,” concluded a 2012 report from Columbia University’s National Center on Addiction and Substance Abuse, described in a 2015 Atlantic Monthly article by Gabrielle Glaser. The report noted, “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

“When the facts change—and they’ve changed a lot—the minds have not,” addiction psychiatrist Mark Willenbring, director of treatment research at NIAAA from 2004 to 2009 and founder of the Minnesota outpatient clinic Alltyr told the New York Times.  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,” according to Willenbring. 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. In addition, compared to resort-based AA programs in Antigua and Malibu with monthly price tags over $50,000, “low-cost publicly funded clinics often have better-qualified therapists and better outcomes, according to Anne Fletcher in her book, Inside Rehab.

AA-based programs, on the other hand, remain the mainstay for as many as 80% of the more than 13,000 rehab facilities in the U.S. What its successful participants find most helpful is support from other addicts, in both in-patient and ongoing after-treatment meetings, with encouragement to attend “90 meetings in 90 days.” Said DC Poet W.C. about AA, “I just wanted freedom from the addiction and was willing, as they say, to go to any lengths to get it. [With AA]  there’s always a sense that you’re doing so with a supportive community whose members are available 24/7.”

Connections between People Places & Things and the ongoing Covid pandemic—which “has prompted…many of us to reexamine our identity and the roles we play..” come from  Artsfuse reviewer Greenham. “We were addicted to a lifestyle that had become too fast for reflection. We thought that’s what we needed. Emma’s narrative bubbles with similar justifications.”

“For some, the Covid pause has been a version of rehab, an opportunity for a new start—by facing the truth,” writes Greenham.  Even in a play that works hard to make this topic accessible and comprehensible, however, its main character Emma comments almost as an aside that no one can understand addiction unless they’ve been there.

Because I have had intimate experiences with alcoholics, people ask me questions. When I see them struggling but failing to understand, I recommend books and more recently this play. What remains incomprehensible, though, is the most basic question about addiction: how anyone can continue to use substances they know can change their behavior in ways their sober selves sincerely would not want to change.

—Mary Carpenter regularly reports on need-to-know topics in health and medicine.