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.”
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