Alcoholics Anonymous is, by far, the largest and most venerable addiction recovery group in the world. Founded nearly 80 years ago, AA now boasts 2.1 million worldwide members, many of whom attribute their very survival to the organization. In the United States, where the 12-step program originated, AA is viewed by many as a national treasure of sorts. Social workers send patients to AA meetings. Judges condition people’s freedom on meeting attendance. Desperate spouses condition marriages on it. Everyone loves Alcoholics Anonymous. Or almost everyone.
Many patients and doctors have grumbled for years about the religion inherent in the Alcoholics Anonymous process: Half of the 12 steps involve God or “a Power greater than ourselves.”
In recent years, however, the complaints have turned scientific. Some doctors who specialize in treating alcoholism have leveled a pair of accusations against the organization. First, they claim that AA has obstructed the spread of medications to treat alcoholism. Second, they claim that the group stubbornly resists evidence that some alcoholics are better suited to a life of moderate drinking than to complete abstinence. Domenic Ciraulo, chairman of the Department of Psychiatry at Boston University School of Medicine and an advocate of the medication and moderation approach for some alcoholics, said in 2010, “We have nothing against AA, but they have something against us.” Writing in the Washington Post earlier this year, National Institutes of Health clinical researcher Markus Heilig attacked AA’s “uncompromising” philosophy of “once an alcoholic, always an alcoholic.”
The spat has significant ramifications. Alcohol abuse causes 79,000 premature deaths annually. It’s one of the leading causes of morbidity, trailing closely behind tobacco, and it costs the economy more than $220 billion annually—that’s $1.90 for every serving of alcohol consumed in the United States. The government alone spends $94 billion dealing with the fallout from alcohol abuse. To put that in perspective, the federal government spends about $138 billion on education. This is a big deal.
At first glance, the showdown appears serious. On one side are doctors favoring pharmaceutical solutions and moderate drinking. On the other side are mutual-help groups like AA, with their abiding faith in 12-step programs and total abstinence. But the situation is nuanced.
First, the battle lines aren’t clearly drawn. Addiction-medicine physicians who prescribe medications still encourage their patients to seek out support groups. In addition, abstinence remains the goal for the overwhelming majority of alcoholics. Only a select group appears capable of handling moderate drinking without relapsing into full-blown addiction.
Alcoholics Anonymous has taken no official stand on the use of prescription drugs for recovery, other than to say the issue is between a patient and her doctor. Nor does AA have an official position on whether moderation could be the solution for some. (“We’re clear on what we suggest, but if people find other directions that work for them, more power to them,” an AA spokesman told me.)
That said, AA has more than 1 million members in the United States alone, and surveys suggest that about 20 percent of them oppose the use of prescription medications to control addiction. The objectors may be the most vocal portion of the organization, and AA does nothing to prevent them from speaking their minds. Anecdotes about AA’s opposition to medication may not be representative of the group as a whole, but they aren’t fiction, either.
“When I first came to Boston 30 years ago, we recruited candidates from AA meetings for our medication studies,” says Boston University’s Ciraulo. “My poor post-docs were run out of the meetings.” Ciraulo acknowledges, however, that times have changed, and he has softened his criticism of the organization. “Today there are a lot of doctors and psychiatrists in AA,” he adds, who are part of the organization’s leadership or provide scientific guidance, indicating that the group has opened up to the evidence-based model that now dominates the medical profession.
Mutual-help groups have long had an instinctive distrust for medical solutions. The history of medical treatment of alcoholism is checkered, at best. The earliest “drugs” prescribed to treat alcoholism were pure quackery. Dr. Leslie Keeley gained fame in the late 19th century with his “double chloride of gold cure,” which he injected into patients four times daily. The injections cured nothing, and a startling number of Keeley cure recipients descended into insanity. Other 19th-century clinicians experimented with morphine, marijuana, and cocaine for the treatment of alcoholism. Early 20th-century physicians tried steroids, again with little benefit, on the theory that a malfunctioning endocrine system was responsible for alcoholism.
As recently as the 1970s and ’80s, treatments by doctors backfired spectacularly. Many doctors prescribed barbiturates or benzodiazepines for medium-term alcohol-withdrawal symptoms like anxiety, agitation, and sleeplessness.
“Valium was considered harmless and nonaddictive at the time,” notes John Kelly, director of the Recovery Research Institute at Massachusetts General Hospital and associate professor at Harvard Medical School. “These doctors were well-meaning, but many of them overprescribed and failed to monitor the outcomes.”
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.
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.