Alcoholics Anonymous and Addiction Doctors Are Fighting an Outdated Battle

Health and medicine explained.
Jan. 15 2014 11:40 AM

Alcoholics Anonymous vs. the Doctors

Could new addiction medications replace mutual-help groups?

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The outcome, for a large number of patients, was a second layer of addiction and/or relapse into alcoholism. Groups such as AA have an institutional memory of this period, and the individual members who oppose medical treatment for alcoholism may have had personal experience with the overprescription of barbiturates.

The debate over moderation or complete abstinence goes back even further than the argument over prescription drugs. Early temperance societies were clubs of men who agreed to avoid strong spirits and to drink beer and wine only in moderation. In the 1830s, however, prohibitionists began to dominate the temperance movement. (That development explains our bizarre use of the word temperance, which suggests moderation, to describe groups of people who won’t drink a single drop of alcohol.) Temperance societies developed a religious zeal for teetotalism. The Washingtonian movement in mid-19th-century America, the forerunner to AA, held revival-style meetings, trotting out recovered alcoholics to tell the story of their deliverance from booze. Their slogan, “every man brings a man,” foreshadowed the AA sponsorship model of recovery. The groups built in-patient recovery centers in isolated areas where patients would have to walk miles to find a bottle of alcohol. Some were even built on islands. The total commitment to abstinence probably drove away many who enjoyed an afternoon warmer, and it set the stage for the interminable argument over moderation and abstinence.

That long history helps explain the controversy surrounding modern treatment options for alcoholism. There are now three Food and Drug Administration–approved drugs. The oldest and best known is disulfiram, which blocks an enzyme that helps break down alcohol. If a patient on disulfiram drinks alcohol, acetaldehyde accumulates in her body, leading to nausea, palpitations, and a general feeling of ill health. The experience creates a strong aversion to drinking and is extremely effective at preventing relapse—that is, if the patient actually takes it. Many true addicts simply stop using the medication when they want to drink and end up back on the bottle.

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Acamprosate, a newer medication, helps patients deal with the symptoms of withdrawal. Think of it as a safer, nonaddictive form of the barbiturates that doctors overprescribed in the 1970s and ’80s. It still has side effects, including a tingling or burning sensation, but it is supposed to help smooth the path from heavy drinking to abstinence.

Finally, there is naltrexone, which is thought to block brain receptors that make drunkenness feel good. This is where the debate over pharmaceutical therapy for alcoholism meets up with the argument over abstinence and moderation. Some addiction doctors permit patients on naltrexone to drink in moderation, in hopes that the lack of high will prevent them from drinking to excess. A slightly more radical approach, called the Sinclair Method after the Finland-based doctor who pioneered it, encourages patients on naltrexone to continue normal social drinking. The idea is that the alcoholic will become deconditioned to the formerly pleasurable effects of drinking.

Do the drugs work? Eh, sort of. In a large study published in 2006, for example, patients taking naltrexone abstained from drinking during 81 percent of the days in the study period. The placebo patients managed to stay clear of alcohol 75 percent of the time. That difference was statistically significant, but it also shows that naltrexone is hardly a magic bullet against alcoholism. In addition, several studies have shown no naltrexone benefit whatsoever. Acamprosate has achieved the same mixed results. The 2006 study that trumpeted the benefits of naltrexone declared acamprosate ineffective, while other studies seem to suggest a slight advantage for acamprosate.

It should be noted that certain medications originally prescribed for epileptics, such as gabapentin, are showing more promise, but the studies aren’t quite large enough yet to compare them to the approved drugs.

Do 12-step programs work? Again, sort of. A 10-year-long study published last year claimed to show a significant benefit for those attending AA meetings, while critics of the organization often point to a 2006 review article that found no quantifiable benefit from AA or other 12-step programs. In fact, researchers have been complaining for decades about the lack of data on 12-step programs. The group has released internal data on membership attrition rates, but it hasn't done enough to satisfy the demands of an evidence-based medical culture.

People looking for clear data will probably never be satisfied, because studies of prescription drugs can’t really be compared to studies of AA. Pills are tested against placebo, and neither the patients nor the doctors know who’s on the real medications. You can’t placebo-control and blind an AA trial, because it’s fairly obvious to a patient whether he has attended a support group meeting. That means people in AA benefit from the expectation that the treatment will work in addition to any benefit from the actual process of participating in the meetings.

This probably isn’t a question of either/or, but one of tailoring. Each treatment seems to have no effect on a large portion of sufferers—the trick is figuring out who can benefit from which treatment. Clinicians report, for example, that the medication-plus-moderation approach works for heavy drinkers who may not be full-blown addicts (that is, they have some control over their drinking in the face of serious consequences). Disulfiram, the aversive drug that causes drinkers to get sick, works well for an alcoholic in a long-term relationship. The spouse watches the patient take the pill every day, ensuring compliance.

Every alcoholic can be treated. The goal should be finding the right approach, for the right patient, at the right moment. Researchers are now working toward that end, looking for markers (genetics, age, and patterns of drinking) that indicate which patients are susceptible to medication and which to behavioral therapy. AA, for its part, has made an effort to meet scientists on common ground.

Today, the most vocal critics on either side of the debate are stuck in the bad old days, when medical treatments were untested and mutual-help groups demanded immunity from evidence. The prescription is now collaboration, not confrontation.

Brian Palmer is Slate's chief explainer. He also writes How and Why and Ecologic for the Washington Post. Email him at explainerbrian@gmail.com. Follow him on Twitter.