“Untreatable” is the eighth part of a project called Terminally Unique. It features what was originally the fourth chapter from a piece I first published in 2013 called Believed to Be Seen. For more background on what this series is, I suggest starting from the beginning with the introduction titled “A New Pair of Glasses.” And now, to continue on, here is “Untreatable”…
“When a well-packaged web of lies has been sold gradually to the masses over generations, the truth will seem utterly preposterous.” —Dresden James
“Our 1992 Survey showed that only 5% of newcomers to A.A. are still attending meetings after 12 months. This is a truly terrible statistic.” These words are widely attributed to Ron Whitington, Chairman of A.A. Australia’s General Service Board, who is suggested to have been quoted as such from the A.A. Around Australia quarterly newsletter in 1994. Alcoholics Anonymous’ 1989 Triennial Membership Survey is also widely claimed to suggest that very same 5% success rate. Yet while “no one among us has been able to maintain anything like perfect adherence to these principles,” reads The Big Book, it is also “a statistical fact that alcoholics almost never recovered on their own resources.” If the underlying message of this data is to be believed, such assertions as these would appear to distort the reality of Alcoholics Anonymous’ success rate. But what is the truth?
It’s important to remain equally cautious about the “statistical facts” represented as evidence against A.A.’s success rate as those that represent its effectiveness. Take for example the 2011 Alcoholics Anonymous Membership Survey, in which “more than 8,000 A.A. members” participated. Considering that A.A. estimates there are more than two million members worldwide, this means the survey extrapolated data that was collected by less than one-half of one percent of the organization’s total members. The sample size is simply too small to represent much of anything, and its findings are meaningless. What is to be made of the 5% statistic, though?
The basis for the number can be followed back through a few key sources: Rational Recovery, a prominent abstinence program, and a Harvard University report titled “Why People Drop Out of A.A.” Nearly all public reference to the Harvard report funnels back through Rational Recovery’s literature though. As for the other point of evidence, the newsletter featuring Chairman Whitington’s statements is also unavailable. (Alcoholics Anonymous Australia’s National Archivist did however relay the following in response to an inquiry I made about the validity of the statement, “One problem with the survey was that there was only a 3.24% response rate to the questionaire so in the world of statistics this is so small response that it really could not be used. There have been later surveys done in 1996, 2000 and 2005 and phamplets with these results have been produced. Again the reliability and validity of these questionaires have not been tested and the response rates make them iffy. Remember 20 year old information is just that.”) Does this mean the 5% success rate is bogus? That it’s the result of misinformation and misinterpreted data from years gone by, continually resurrected to promote an anti-A.A. agenda?
When recognizing how meaningless the self-reported A.A. membership information might be, it is hardly a risky assumption to suggest the 1989 survey was every bit the questionable representation of the large group the 2011 version is. This is not even to question how a survey of actual A.A. members might somehow elaborate on the recovery trends of non-A.A. members. But the Harvard report and the 1989 survey themselves do not really stir debate here as much as the most important piece of evidence analyzing A.A.’s ongoing retention rates, which came following the 1989 member survey in an internal report titled “Comments on A.A.’s Triennial Surveys.”
Serving as “an analysis of the 1989 survey plus a review of comparable findings of previous surveys,” this report observed trends within Alcoholics Anonymous, using an average of five years of results to “show the probability that a member will remain in the Fellowship a given number of months.” After one month that rate was 19%, meaning 81% of new members did not last a single month; 10% at three months, meaning 90% left the program; and 5% at twelve months; supporting the revelation that 95% of newcomers to A.A. leave the program within their first year. “Individuals may rebel against this result as contradicting our time-honored statement that ‘half get sober right away, another 25% eventually make it’,” continues the report. “That statement applies to observations made at an earlier time, and there is no reason to doubt that changes in society and in A.A. since that time could create a different circumstance today. Like other findings of the survey, this may be a challenge to the membership to ‘change the things we can’t’.”
However eye-opening this information might be, this confusion of perceived success or failure rates only adds another detour for those seeking help in recovery to fester over, creating additional barriers to religious-debate and court-ordered conversion. No doubt the success rate of A.A. as perceived by its members is grossly exaggerated, but in reality any 5% accusations do little more than serve as a distraction by condemning A.A. for defending its process through a host of mock-truths. What might be a better question to ask is why do its members still rely on such heavily defensive statements as “Rarely have we seen a person fail who has thoroughly followed our path,” when its own statistical data suggests otherwise?
If lack of retention equates failure, and failure means that 95% of individuals who have attended A.A. stop attending within a year, such an implication suggests that everyone who left A.A. ended up no better off than they were when they sat in on their first 12 Step meeting. Such assumptions don’t allow for the possibility that within the 95% group, some might have left to pursue other more personally suitable recovery methods, some may have had their court-ordered attendance end, some might not have agreed with the principles of A.A., or some simply did not feel they needed to continue attending. Failure here might as well be considered to be a return to drinking because that’s the picture such an accusation paints, whether or not it is true.
Because of the “spiritual” nature of The Program, there is no conclusive evidence to suggest A.A. helps individuals achieve abstinence, just as there is no conclusive evidence to show that it cannot. Getting angry at A.A. members for promoting idealistic statements that defend their own personal beliefs is about as off the mark as debating how a program that has not made any foundational revisions to its treatment process since the invention of penicillin is supposed to help those seeking progressive recovery. But what is certain, is that Alcoholics Anonymous is only one of many methods for achieving recovery that all have around the same level of success, which are less than the rates of those who successfully pursue abstinence on their own, without any help whatsoever.
Coming in sharp contrast to commonly held beliefs of what it means to be an alcoholic, and supplying further evidence suggesting how significantly flawed the disease-concept is, is the widely documented fact that the majority of alcohol abusers and problem drinkers who look to quit their addiction actually do so without the help of professional treatment or mutual aid groups. Such information refutes the thread of confusion that has spanned nearly a century, weaving its way through public and private discourse, promoted by the most widely used recovery method in America and co-signed by the federal government. After all, the disease of alcoholism is so tremendously complicated that quitting drinking can’t possibly be as easy as making a personal decision to stop drinking. Right?
In 1995 the Harvard Medical School reported that a significant number of problem drinkers recover on their own, a suggestion that was later re-emphasized in the October 1995 Harvard Mental Health Letter which stated that “80 percent of all alcoholics who recover for a year or more do so on their own.” Further, “at least 50% of alcoholics eventually free themselves although only 10% are ever treated.” While it is impossible to corral definitive information in the field – equally as impossible as quantifying an individual’s spiritual growth – such conclusions are also backed by the likes of Swiss sociologist and researcher Harald Klingemann and his contemporaries who have made repeated parallel conclusions. In 2001 Klingemann assessed that 75% of those seeking recovery do so through self-healing or “spontaneous recovery,” while upwards of two-thirds of problem drinkers successfully achieve moderation. “We will see that our new attitude toward liquor has been given us without any thought or effort on our part. It just comes!” Religious conversion aside, The Big Book might have been onto something here.
Many who quit drinking do so on their own accord after negative life events prompt them to make the decision to do so. Be it legal consequences, health problems, physical accidents, excessive blackouts, financial issues, or other such harmful patterns, the majority of those who abuse alcohol only to make the decision that they are going to quit, do so on their own and are successful in doing so for a prolonged period of time. Just as important as recognizing that this information speaks in favor of a self-healing approach, it is equally essential to avoid neglecting treatment based on individual needs by giving consideration to the effectiveness of various treatment models. Even if only 10% of those who need help with their alcohol addiction actually seek it, by that time most are in a state – whether they be emotional annihilated, mentally unstable, physically withdrawn, or any combination of the three – where an outside influence is crucial to re-establishing a healthy base.
The American professional treatment process is largely built around a strong 12 Step foundation with mutual aid methods widely incorporated into inpatient (hospital, recovery center) settings. Out of necessity due to escalating health care costs, the trend is shifting toward an accommodating system that does not boast immediate financial burden on those seeking assistance (essentially, fewer people are able to pay thousands of dollars to attend glorified 12 Step meetings). As the use of outpatient treatment resources increases, so too have the number of services that employ alternative recovery methods.
One of the most underused modes of treatment also speaks to the continued stigma attached to those with alcohol dependencies in the country. “Brief interventions” remove the relationship from that of an individual and an alcoholism treatment specialist by localizing aid with a primary health care provider. Usually brief interventions last a few visits, with the physician first assessing the extent of the patient’s alcohol-related problems (including physical harm and social issues), and then relaying evidence of what further drinking consequence will entail. Once the severity of the individual’s drinking habits has been established, the physician and patient work together in developing a strategy for changing drinking patterns. Supportive evidence of the benefits of brief interventions dates back to studies first conducted by Yedy Israel and David Fleming in the 1990s. These studies separately concluded that such treatment reduced drinking and further alcohol-related problems, yet the stigma associated with the disease concept has helped distance addiction from basic health care.
Due in part to a profit-driven treatment paradigm however, such brief interventions remain something of an anomaly in the U.S. One of the most basic challenges facing the healthcare system with regards to alcohol abuse is simple education among its care providers. Similar to alcohol abuse specialists, there remains spotty standardization in the general care field regarding alcohol dependency, leaving many physicians ill prepared to assess and treat the widely-recognized dual diagnosis factors that often accompany dependency issues. However effective brief interventions may be – and however boldly they might speak to the importance of honoring individual empowerment in the field of dependency recovery – the legal system’s insistence on recognizing specialized treatment models (specifically 12 Step programs) continues to direct individuals through a formal recovery process rather than recognizing alcohol abuse for what it is: a health concern.
Due to the federal insurgence of funding for the disease-concept of alcoholism, what we’re left with is over 13,000 national programs specializing in some form of treatment for alcohol dependency. Not unlike countless other industries, the marketplace boasts both widely recognized name brands such as the Betty Ford Center, Hazelden, and Passages, as well as alternative brands that tout specialized services, like the St. Jude Program. Such businesses typically promote specialized inpatient service care based on one (or a combination) of the recovery methods. While numerous unique techniques have been developed in the country, the following remain the predominant outpatient models for achieving recovery from alcohol dependency in America:
12 Step Programs: Twelve-step treatment, as first constructed by Alcoholics Anonymous, relies on mutual aid groups that offer support primarily through a spiritual approach to recovery. Twelve Step groups rely on the submission of personal control, the examination of past behaviors, reliance on a “sponsor,” the action of making amends, and helping others under the model’s larger ideology. Some groups reshape the framework to speak to their particular faith (Millati Islami is one example of a group that reconfigured the 12 Steps to support Islamic tradition), while others avoid implied religiousness altogether. While A.A. estimates a user base of “over 108,000 groups” in “approximately 170 countries, with an estimated membership of over two million,” 12 Step programs are distinctly prevalent in America, as opposed to internationally where it remains a fringe model of recovery.
Women For Sobriety (W.F.S.): Established in 1976 by sociologist Jean Kirkpatrick, W.F.S. is “the first national self-help program for women alcoholics” and remains a dedicated “self-help program for women with alcohol and/or drug addictions.” W.F.S. recommends daily recommittal to the Thirteen Affirmations of its “New Life Program,” which is based on such fundamentals as positive thinking, metaphysics, meditation, group dynamics, and the pursuit of health through nutrition. Included in these Thirteen Affirmations are statements promoting self-recognition (“I have a life-threatening problem that once had me”), self-confidence (“I am what I think”) and self-esteem (“I am a competent woman and have much to give life”). (When contacted, a W.F.S. representative estimated that there are 150 groups nationally, while noting that such groups remain supplemental to personal growth. Women For Sobriety also offers chat rooms and an online forum for its members.)
Secular Organizations for Sobriety (S.O.S.): Alternately known as “Save Our Selves,” S.O.S. is a non-profit network of mutual support groups founded by James Christopher in 1985 in response to the religious fundamentalism of A.A. In contrast to 12-step recovery, S.O.S. offers six guidelines for sobriety that include self-identification as an alcoholic (or addict), daily reaffirmation, and personal responsibility for sobriety. S.O.S. now boasts over 20,000 members in 1,000 groups worldwide.
Moderation Management: Founded by Audrey Kishline in 1994, Moderation Management is the only group of those included here that explicitly serves to promote “controlled drinking” rather than abstinence. Moderation Management is recommended for users of alcohol who are not dependent drinkers or non-hazard drinkers who look to achieve reduced drinking in their lives. Espousing ideals including “self management,” “balance,” “moderation,” and “personal responsibility,” Moderation Management asks its members to begin with a 30-day period of sobriety before starting the “Nine Steps Toward Moderation and Positive Lifestyle Changes.” While Moderation Management meetings are not widely accessible, resources, forums, and meetings are all available online.
Motivational Enhancement Therapy (M.E.T.): Developed by clinical psychologists William Miller and Stephen Rollnick, M.E.T. is a therapist-administered treatment approach that does not lead individuals through a step-based program, but instead seeks to mobilize and support personal strengths through continual feedback. M.E.T. begins by assessing the severity of an individual’s drinking habits before developing a life strategy based around personal drinking goals.
Rational Recovery: Influenced by cognitive behavioral therapy and the work of Albert Ellis, Rational Recovery places tremendous importance on its Addictive Voice Recognition Technique (A.V.R.T.), “a very simple thinking skill that permits anyone to recover immediately and completely from addiction to alcohol or drug.” Developed by social worker Jack Trimpey in 1986, Rational Recovery adamantly opposes the “12 Step monopoly” of Alcoholics Anonymous and its “one day at a time” ideology, denying the disease concept, and denouncing labels such as “alcoholic.” Instead offering alternative guidance through The Small Book (later rendered obsolete by Rational Recovery: The New Cure for Substance Addiction), the program promotes permanent, planned abstinence through the recognition of an individual’s “addictive voice.” Rational Recovery does not support mutual aid groups, though they do exist.
SMART Recovery (Self-Management and Recovery Training): SMART Recovery offers an evidence-based form of mutual aid support that incorporates ongoing research and developing techniques into its approach. Splitting from Rational Recovery in 1994, SMART was founded with the mission of “teaching [individuals] how to change self-defeating thinking, emotions, and actions; and to work towards long-term satisfactions and quality of life.” SMART Recovery promotes scientific evidence as its main authority, using a “4-Point Program” which strives to help “individuals gain independence from addiction,” including motivational construction, coping with urges, and managing thoughts and behaviors. As of 2011 there are more than 600 SMART Recovery meetings held globally, in addition to over two-dozen weekly online meetings.
Any discussion regarding the effectiveness of one particular model must be prefaced by a quick note on “relapse.” Any number of factors that have little to do with treatment can contribute to an individual’s return to drinking, ranging from cravings to social anxiety to environmental stresses to relationship problems to negative life events to depression. Whether individual planned relapse-prevention follows 12 Step treatment’s typical recommendation of “changing everything” in one’s life to accommodate sobriety, seeks a middle ground through alternative activities to “high-risk” settings (think: Oktoberfest vs. “Oksoberfest”), or is merely written off as a non-factor as it is under Rational Recovery, it’s estimated that roughly 90% of all alcohol dependents who seek treatment are likely to experience at least one occurrence of relapse over the following four years. It’s important not to take that figure as gospel though, because whether conversation be aimed at 12 Step treatment or alternative recovery models, there is a lack of experimental evidence to support any single program’s general effectiveness.
Most evidence regarding particular treatment centers or models is typically self-reported, understandably speaking to that particular method’s comparative superiority, and typically using anecdotal evidence as its definite support. Where Alcoholics Anonymous touts numerous stories (such as a pair of salesmen “who produce as much as five normal salesmen” once recovered using A.A.), Rational Recovery reported a 65% success rate in 1996, based on a group of 250 individuals who had enrolled in its Addictive Voice Recognition Technique course. Likewise, the upscale treatment center Passages touts a 91% success rate based on internally prepared figures. The St. Jude Program recognizes itself as “the only program in the United States that has an independent research company independently verify and measure long term sobriety rates,” relating a 62% success rate of sobriety “for the last 20 years.” This is a startling figure when compared to the previously mentioned data, although the “independent research company” they are using, the Baldwin Research Institute, also happens to be “the parent company of the Saint Jude Country Retreat” – itself financially motivated by the promotion of the St. Jude Program’s high success rate.
Additionally, any assumptions regarding a recovery method’s general success rate disregards the likelihood that outcomes differ greatly from one treatment center, group, or practitioner to the next. The lack of national standards leaves discussion surrounding success rates generally moot as there are simply too many variables that are not controlled in the treatment environment. While relapse and selective sobriety rates remain flimsy indicators of any given program’s value, research has revealed numerous generalized aspects of recovery models that tend to increase the overall effectiveness of treatment.
In the 1990s Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) was designed to offer additional insight into the effectiveness of “Cognitive Behavioral Coping Skills Therapy,” “Motivational Enhancement Therapy,” and “Twelve Step Facilitation.” With some $27 million in federal funding, Project MATCH remains the largest and most expensive alcoholism treatment study on alcohol treatment that has taken place to date, developed to assess characteristics that might help predict which treatment methods are best suited for different types of drinkers.
Over 1,700 individuals previously diagnosed as alcohol dependent (without any other substance dependencies) were recruited from outpatient clinics and similar facilities for the study. These individuals were then randomly assigned to one of the treatment methods which were administered over the course of twelve weeks, and alcohol behavior was then monitored over the course of the following year. While the research did suggest a number of conclusions – individuals who had been more severely dependent on alcohol achieved better results with 12 Step programs than with cognitive behavioral therapy alone, for example – in its aftercare sample, Project MATCH showed no difference in the effectiveness of the three methods during the year that followed.
Subsequent research was critical of the conclusions which stated that “all three treatments evaluated in Project MATCH produced excellent overall outcomes.” “Are Alcoholism Treatments Effective? The Project MATCH Data” by Robert Cutler and David Fishbain thoroughly analyzed the information before making the contrasting assertion that “most of the improvement which is interpreted as treatment effect is not due to treatment.” In his 1997 Science News article “Alcoholics Synonymous,” veteran psychology, anthropology, and mental health-issues reporter Bruce Bowen elaborated on the questionable nature of the study’s findings. “The lack of a nontreatment control group that received as much regular attention and support during the 1-year follow-up as the group given treatment makes it impossible to tell whether any of the Project MATCH interventions had a specific impact.”
Bowen also gauged feedback from other professionals and addressed how the study neglected those who voluntarily enter treatment (rather than those who enroll under the order of courts or employers). Addressing feedback from psychiatrist George Vaillant, Bowen explained that “researchers need to examine differences between alcoholics who succeed in recovering and those who fail, rather than limiting themselves to a search for contrasts among professionally run treatments,” something which no individual program’s “success rate” will ever speak to. “Project MATCH was poorly designed, to say the least,” added psychologist G. Alan Marlatt in Bowen’s article. “Everybody can now project their own views about alcoholism onto this study.”
“No single treatment approach is effective for all persons with alcohol problems,” reads the directive on the Project MATCH report. “A more promising strategy involves assigning patients to alternative treatments based on specific needs and characteristics of patients.” Regardless of the breadth of its conclusions about the effectiveness of different treatment models, this statement challenges yet another of the roadblocks of the American recovery system: limited implementation of self-matching. Similar to the importance of recognizing individuality in determining the severity of alcohol dependence, that same unique personality must be considered when assessing which treatment method might be best suited toward each individual. This dilemma was at the core of MATCH’s unanswered aim, recognizing that no single treatment method is appropriate for everyone – as A.A.’s 5% figure clearly speaks to – as each person’s situation is accompanied by unique values, beliefs, and drinking goals that will all impact future use.
Self-matching is the process where individuals seek out a form of treatment they feel will be most beneficial to them, often in collaboration with therapists or physicians. Considering that people are more likely to carry through with a course of treatment they have chosen for themselves, as opposed to one chosen for them, it would only make sense that self-matching is widely-practiced. Unfortunately, such measures are not typical to legal and employment interventions which usually fail to entertain personal preference.
One of the most glaring issues that affects the outcome of treatment is something that was not overtly factored into Project MATCH. Paramount to consideration for individuality might actually be the factor of dual diagnosis among alcohol dependents, and how that tends to impact treatment’s effectiveness. Also recognized as “co-morbidity,” dual diagnosis represents the co-existence of an underlying mental illness or behavioral problem in addition to alcohol dependency. Dual diagnosis reports have shown that up to 80% of alcohol dependents suffer from neurotic disorders, up to half suffer from some form of personality disorder, and up to 10% suffer from severe mental illness. Frederick Goodwin, onetime director of the Alcohol, Drug, and Mental Health Administration, co-authored a report suggesting that at least one-third of alcoholics have been given a dual diagnosis; psychologist Michael Hogan counters this relatively low figure with an estimate of 60%, a figure which was also reported by The New York Times in 2011.
Obviously there are indefinite variables related to the prevalence and nature of dual diagnoses, but when considering such high rates among alcohol dependents when formulating an individual’s treatment plan one of the primary considerations that needs to be given is whether an individual’s psychiatric issues are independent of alcohol abuse, or if they are symptomatic of alcohol abuse. This separation is crucial. Serving as Principal Investigator of the US National Co-morbidity Survey, Harvard Medical School’s Ronald Kessler led a team which released a 1994 report revealing that, “for over 80 per cent of respondents, the[ir] mental illness disorder predated substance misuse.” Such an assessment is vital with regards to how the 12 Step model works to confuse related mental health symptoms, and how medication is handled within recovery treatment.
Bill Wilson was outspoken regarding what he felt to be the real causes of alcoholism (none of which were “drinking alcohol”). Two of the main causes of alcoholism he spoke to were “emotional maladjustment” and innate “character defects,” claims which remain widely accepted within the A.A. fellowship. “Our liquor was but a symptom.” As far as The Program is concerned, there remains hope for those who suffer from mental and behavioral disorders as well as the disease of alcoholism, as A.A. boasts of its familiarization with mental illness, “For years we have been working with alcoholics committed to institutions.” Considering such findings as Dr. Kessler’s in understanding that the majority of mental issues predate, and are only exacerbated by, alcohol misuse, for the most part these mental, behavioral, and emotional issues generally recede once individuals have experienced prolonged sobriety. This is where A.A. espouses its healing powers, “Since this book was first published, A.A. has released thousands of alcoholics from asylums and hospitals of every kind. The majority have never returned. The power of God goes deep!” When the body is able to return to a balanced state, mental disorders become less volatile, and oftentimes less pronounced. A.A. takes credit for these changes, undermining any change in well-being experienced due to the mere absence of a chemical depressant.
Not unlike the religious aspects of A.A., this would not be an issue if 12 Step programs were not so hardwired into the American treatment system. The World Health Organization recognizes depression as “the leading cause of disability worldwide,” characterized “by sustained sadness and loss of interest along with psychological, behavioral and physical symptoms.” The National Institute of Mental Health (N.I.M.H.) suggests that “depression is caused by a combination of genetic, biological, environmental, and psychological factors.” Textbook definitions aren’t tremendously important here other than to note the vague nature of what’s determined as clinical depression. The definitions are important when considering the 1994 US National Co-morbidity Survey however, which determined that minor and severe depression are two of the most commonly diagnosed mental disorders among problem drinkers. Definitive conclusions regarding depression within the treatment landscape are difficult to assess, especially considering the nature of prolonged depressant dependency, yet the past two decades have seen pharmaceuticals arise as the preeminent complement to treatment programs to combat “self-medicating.”
The U.S. is one of only two countries in the world that permit direct-to-consumer advertising of pharmaceutical drugs (New Zealand is the other). In 1997 the Food and Drug Administration (F.D.A.) installed relaxed measures which had previously required pharmaceutical companies to detail a list of side-effects in commercials and infomercials, contributing to a boom in the promotion of name-brand drugs to the public. In 2008 nearly $5 billion was spent on such marketing. Much as A.A. has created a need for spirituality to combat the disease of alcoholism, pharmaceutical companies have manufactured an accelerated demand for their products. It is no wonder that antidepressants have become the most prescribed medication in the country, with one in ten Americans taking prescription medications to combat depression.
While mental health services are used by some 13% of Americans, the effectiveness of antidepressants is still widely questioned. A 2008 analysis led by Irving Kirsch revealed that a “meta-analyses of antidepressant medications have reported only modest benefits over placebo treatment.” In fact, upwards of 80% of the effectiveness of medications such as Prozac come from this placebo effect. Mental health assessment and management plays a strong role in the recovery process for many, but the treatment for such disorders remains largely as generic as the one-size-fits-all approach of 12 Step recovery.
As anxiety and depression are two of the leading clinical diagnoses attached to alcohol dependency, it would only make sense that antidepressants are widely prescribed to assist with formal recovery. One of the most immediate concerns of this approach is that a known side-effect of various antidepressants include such unstable caveats as suicidal thought and action, questionably compounding emotional despair of those deeply trapped in their dependencies. Recognizing that alcohol misuse is associated with high rates of completed suicides – more than 75% of all suicide attempts involve either alcohol or some other drug – it would seem downright irresponsible to broadly prescribe such a violently unstable medication to such an already unstable population.
This is not to understate the importance and care demanded by the genuine necessity for medications, but only to reinforce that the business behind the pharmaceutical industry is still a business; marketing products to doctors and patients alike has created a tremendous disparity between the perceived necessity for medication and the actual need. Only making the already-nuanced prescription drug component of recovery that much more complicated is the under-examined emergence of focused medications aimed at curbing alcohol dependency.
The use of drugs in the treatment of alcohol addiction dates back to the late 1800s when opium would be used to help calm withdrawals. Despite being more than a century removed from such early practices, medicating addiction remains underused and widely misunderstood. While reactions remain clinically similar to antidepressants, in that the effects of each drug are unique based on a person’s individual chemical makeup, the majority of the hesitancy to promote pharmacotherapy as a direct aid in the treatment of alcohol dependency largely comes down to the slow approval and widespread use of newly developed drugs.
In the 1950s Bill Wilson became an enthusiastic champion of L.S.D., believing that a psychedelic experience could be the breaking point for non-believers to achieve the necessary spiritual awakening required of A.A. As radical as Wilson’s beliefs about the drug were – in fact, his experimental enthusiasm was what eventually distanced Wilson from the organization he co-founded – researchers Teri Krebs and Pal-Orjan Johansen have since identified that “a single dose of L.S.D. had a significant beneficial effect on alcohol misuse.” Similar testing has shown that ibogaine (a naturally occurring psychoactive substance) may benefit some in the treatment of alcohol dependence, if only it weren’t for the sticky legal restriction of being a Schedule One controlled substance in the U.S. While such instances as these make for interesting social debate on the legality of potent recreational drugs, this sort of fringe treatment is hardly what is at the heart of developing medicinal pharmaceuticals.
As of 2012 there are three drugs that have been approved by the F.D.A. for pharmaceutical use in the treatment of alcohol dependence in America: acamprosate (Campral), disulfiram (Antabuse), and naltrexone (Trexan), all of which have confirmed positive effects in the long-term treatment of alcohol addiction. Despite being legal in Europe since 1989, acamprosate was only approved by the F.D.A. in 2004, and works to reduce cravings by balancing brain chemistry, working to ease withdrawal symptoms such as anxiety and insomnia. First approved for use in the treatment of alcohol dependence in 1951, disulfiram is an aversive medication that creates an enhanced sensitivity to alcohol, working through the enzymes that metabolize alcohol to produce a variety of negative physical effects when consumed.
While it was given F.D.A. approval for use in the treatment of alcohol dependency in 1995, naltrexone was previously approved a decade earlier for the treatment of opiate addictions, and has since become the most widely prescribed of these three medications. The aversive drug minimizes the physical desire to continue drinking by blocking opioid receptors in the brain, reducing any associated pleasurable effects of alcohol use. Naltrexone has been prominently promoted through the work of David Sinclair, using it as the basis for his “Sinclair Method” of treatment. Unlike disulfiram, which discourages use of alcohol altogether (subsequently exhibiting little benefit over placebos in controlled studies), naltrexone capitalizes on the drug’s abilities as an opiate antagonist and works alongside drinking, discouraging the effects that would otherwise contribute to prolonged harmful use. Aside from these three drugs, benzodiazepines (Valium, Xanax) are also widely used to help with alcohol withdrawal, as is the anti-convulsant topiramate, which has been shown to act similar to naltrexone by decreasing the pleasurable effects of alcohol.
While all of these drugs have shown some proven benefit in the treatment of alcohol dependency, there has been considerable variation in conclusions made about each, with dubious evidence supporting their widespread employment. Without such broad medical incorporation, these drugs remain underused due to similar problematic conclusions as those experienced by antidepressant users: While general positive effects are recognized, each drug affects users differently; the key difference here being the decade-long marketing push which has crafted the perception that antidepressants all help. By looking to the past for an understanding of how alcohol dependency treatment has shifted in the country, where specialized treatment was once unheard of it is now central to a multi-billion dollar industry, the nature of how depression treatment has evolved in recent years might very well speak to a future of prescription-driven treatment for alcohol addiction.
Reconsider that 12% of adults claim an alcohol dependency at some point in their lives, while only 10% of those who need some support in overcoming their addiction actually seek it. Despite this limited population of dependent alcohol users relative to those who seek no treatment, the country is still able to sustain some 13,000 treatment facilities. Whether it be the stigma of being labeled an alcoholic or the personal denial of a drinking problem, the untreated community poses a massive potential market well-suited for the discrete and theologically non-confrontational method of treatment that medication provides. The disease-concept of alcoholism continues to generate a market for treatment that has proven to have scattered effectiveness, so why wouldn’t it also contribute to convenient ulterior medicinal treatment funded by the same lobbyists that have impacted antidepressant regulation, eventually marketing a revolutionary “new” model of alcohol treatment? Why go through the detox process when a doctor can give you pill that prevents unwanted side-effects of withdrawal, compiled by another prescription to aid in the moderation of negative side-effects of future problem drinking? As excessive drinking becomes not only increasingly widespread, but increasingly socially tolerable, would it not seem natural for a new line of drug to be lobbied for, aimed at the 90% of dependent users who go untreated, promising to help “casual” or “social” drinkers (both far more acceptable terms than “hazard” and “problem”) curb nasty spells of heavy use? Any thoughts on the future are, of course, speculative, but at what point does this pattern of genetic, cultural, and societal victimization stop and we actually accept that most people don’t seem to need private enterprise and government stepping in to help them quit drinking?
The S.A.M.H.S.A.’s 2007 National Survey on Drug Use and Health reported that 9.4% of the U.S. population aged twelve or older needed treatment that year for an illicit drug or alcohol problem (about the same portion of the population that uses antidepressants). All too often addiction goes untreated, and by the time many individuals do seek treatment, their addictions have reached a point of severity that requires some form of formal intervention – be it assistance from a local physician, support from a mutual aid group, or monitored detoxing at a treatment center – to help guide them back to health. While the vast majority of individuals with blossoming alcohol dependencies may be able to turn their lives around with minimal outside interference, it is entirely unrealistic to suggest that everyone can.
For instance, many have not developed the self-esteem to help drive them towards a sense of personal empowerment: to sheepishly borrow a phrase from The Big Book, some might be “constitutionally incapable” of taking steps on their own no matter how educated they become on the matter. Others have families to support, are burdened by legal stipulations or stressful living situations, or are working empty menial jobs to get by: Many people who need help do not have the immediate ability to make a change on their own volition, let alone educate themselves about what their options for help really are. So, when the national precedent has been set that A.A. is the only outlet that can help defend against the $7.99 12-pack of high gravity malt liquor at the supermarket, they do not argue and accept the outlet at face value; millions have, and millions more likely will. People who do not believe they can make a difference in their own lives are not likely to do so.
The prevailing system of aid in the U.S. has mutated into a hybrid model of support that funnels actual support through the country’s business sector, blurring distinction between well-intentioned individuals and manipulative profiteers. Intent is often not black and white, leaving it difficult to conclude what those first A.A. members hoped to accomplish by pushing for the widespread adoption of their organization’s fundamentals. While he stands as one of the primary characters in promoting the development of modern profit-driven treatment models, Senator Harold Hughes himself was hardly above realizing the confusing nature of what he was building. “The alcohol and drug industrial complex is not as powerful as its military-industrial counterpart,” he said in 1974. “But nonetheless, there are some striking similarities.”
Since that time an army of both trained and untrained counselors, therapists, scientists, administrators, government officials, judges, lawyers, lobbyists, researchers, and authors have entered the field of alcohol treatment, each projecting their personal ideals onto an already impossibly complicated system, often prompting ideological clashes not in the name of scientific discovery, but for the sake of personal righteousness. What now remains of the very alcohol and drug industrial complex that Hughes both predicted and aided is a system that markets its own need to exaggerate perception of its indispensable role in the personal recovery puzzle, prompting further market penetration and the continuation of federal and state funding.
In 2003 the National Survey of Substance Abuse Treatment Services reported that 26% of treatment centers were operated by private for-profit organizations. “On the survey response date, March 31, 2003, there were about 259,000 clients in facilities operated by for-profit organizations and about 610,000 clients in facilities operated by non-profit organizations.” So as to avoid confusion, a necessary distinction is to be made: non-profit organizations are still income-driven businesses, and those 610,000 clients represent a fine source of income. As Jack Trimpey wrote in Rational Recovery: The New Cure for Substance Addiction, “If you let your eyes follow the bouncing dollar, you may notice that addiction treatment benefits those who treat far more than those who are treated.”
This system has encouraged the emergence of thousands of smaller-statured Dr. Drews and Dr. Phils who remain free to project myths about how successful their personal brand of treatment methods are. This flourishing population of treatment profiteers prey on the general lack of knowledge about recovery, while fueling misconceptions about the real qualifications of their unstandardized facilitators. Actual recovery is not the goal of the recovery system, because if individuals become enabled to find well-being in their lives without the aid of products, therapy, and treatment, these thousands upon thousands of treatment-based establishments that service this unwell population will be without a customer base. And without customers businesses simply cannot stay in business. And since the disease concept of alcoholism has failed to reclaim “addiction” as a medical concept, its treatment methods remain myriad, and alcoholism remains a distant and untreatable enigma.
What we need is a cost-effective, standardized model that offers hazard drinkers a stepped system of care, beginning with minimally intrusive interventions including basic health education, only graduating to more intensive and expensive treatment methods as required. What we need is reform to combat decades of directionless legislation aiding professional incompetence, leaving the well-being of countless vulnerable individuals in the hands of those ill-equipped with the knowledge, skills, and credentials necessary to provide a full range of evidence-based treatment. What we need is treatment and therapy that is responsive to individual circumstance and need, able to assess, treat, and medicate co-morbidity when it exists, and standardized proficiency implemented to help recognize when it does not. What we need is an environment encouraging a therapeutic alliance between patient and caregiver, rather than an unregulated model for healing that constructs problems to spur further unnecessary treatment. What we need is integration of alcohol addiction prevention into routine health care, removing its stigma, and separating disease-concept from disease-treatment. What we need is an educated legal system that promotes educated wellness over complacent ideals. What we need is to remove focus from success rates, instead developing an evolving process that speaks to the issues that have led to individual relapse. What is needed is ethically-centered treatment that is based on transparency from educators and legislators alike. What we need, what we need, what we need… we are not likely to get. And what remains is a complicated smokescreen layered by decades of inefficiency and wayward motivation.
Treatment can be tremendously helpful if administered by caring, responsive practitioners. Mutual aid groups, 12 Step included, can also make a huge difference in the recovery process, inviting personal interaction into a world that is many times otherwise lonely and cold. But the sacred information that is standing in the way of individuals and recovery does not exist in some expensive resort facility any more than it does a dingy A.A. hall or a website on the Internet. So, in lieu of an actual treatment process that wholly places paramount value on personal wellness, it might not hurt to ask “How did people overcome alcoholism before treatment facilities?” in moving forward.
The biggest influencer on how long an individual remains sober does not come down to the relative success rates of various treatment methods, or how many mutual aid group meetings a person attends in a certain number of days, or whether or not someone dependent on alcohol has asked their Flying Monkey Ninja God to keep them sober in the morning. The most influential key to remaining sober is individual action, focused honestly on a goal, and repeated with sincere desire. If A.A. meetings help, it would be foolish not to attend. If they do not, and attendance is not legally mandated, then there should be no reservations in exploring the various other ways in which many people have found sobriety in their own lives. If walking by a neighborhood liquor store every day is enough of a trigger to spur thoughts of drinking, quit walking by the store. Take consideration for what has helped others, but don’t feel bound by established beliefs simply because they’ve been promoted as truth enough times that they start sounding true.
The United States Federal Government classifies alcohol as “one of the most dangerous drugs and the drug most frequently abused in the United States.” If we drink alcohol we have to start acknowledging that we are not victims of disease, but that we have accepted the risks of drinking it and are then liable for the outcome. We have become a culture of casual hypocrites though, failing to take responsibility for the actions we personally take. Therein lies the most imposing force standing in the way of sobriety, or personal recovery, or whatever it is we might be seeking: ourselves. To encourage individual recovery means recognizing that there are not enough “steps” in the world to ever stop someone from surrendering to a base instinct if the individual does not have the drive to make a lasting change in their life. To encourage individual recovery means to entertain the idea that there is more power to be found within individual accountability than previously imagined. As the saying goes, the difference between who you are and who you want to be is what you do.