by Amy Stewart
GABRIELLE GLASER
The False Gospel of Alcoholics Anonymous
FROM The Atlantic
J.G. IS A LAWYER in his early 30s. He’s a fast talker and has the lean, sinewy build of a distance runner. His choice of profession seems preordained, as he speaks in fully formed paragraphs, his thoughts organized by topic sentences. He’s also a worrier—a big one—who for years used alcohol to soothe his anxiety.
J.G. started drinking at 15, when he and a friend experimented in his parents’ liquor cabinet. He favored gin and whiskey but drank whatever he thought his parents would miss the least. He discovered beer, too, and loved the earthy, bitter taste on his tongue when he took his first cold sip.
His drinking increased through college and into law school. He could, and occasionally did, pull back, going cold turkey for weeks at a time. But nothing quieted his anxious mind like booze, and when he didn’t drink, he didn’t sleep. After four or six weeks dry, he’d be back at the liquor store.
By the time he was a practicing defense attorney, J.G. (who asked to be identified only by his initials) sometimes drank almost a liter of Jameson in a day. He often started drinking after his first morning court appearance, and he says he would have loved to drink even more, had his schedule allowed it. He defended clients who had been charged with driving while intoxicated, and he bought his own Breathalyzer to avoid landing in court on drunk-driving charges himself.
In the spring of 2012 J.G. decided to seek help. He lived in Minnesota—the Land of 10,000 Rehabs, people there like to say—and he knew what to do: check himself into a facility. He spent a month at a center where the treatment consisted of little more than attending Alcoholics Anonymous meetings. He tried to dedicate himself to the program even though, as an atheist, he was put off by the faith-based approach of the 12 steps, 5 of which mention God. Everyone there warned him that he had a chronic, progressive disease and that if he listened to the cunning internal whisper promising that he could have just one drink, he would be off on a bender.
J.G. says it was this message—that there were no small missteps, and 1 drink might as well be 100—that set him on a cycle of bingeing and abstinence. He went back to rehab once more and later sought help at an outpatient center. Each time he got sober, he’d spend months white-knuckling his days in court and his nights at home. Evening would fall and his heart would race as he thought ahead to another sleepless night. “So I’d have one drink,” he says, “and the first thing on my mind was: I feel better now, but I’m screwed. I’m going right back to where I was. I might as well drink as much as I possibly can for the next three days.”
He felt utterly defeated. And according to AA doctrine, the failure was his alone. When the 12 steps don’t work for someone like J.G., Alcoholics Anonymous says that person must be deeply flawed. The Big Book, AA’s bible, states:
Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way.
J.G.’s despair was only heightened by his seeming lack of options. “Every person I spoke with told me there was no other way,” he says.
The 12 steps are so deeply ingrained in the United States that many people, including doctors and therapists, believe attending meetings, earning one’s sobriety chips, and never taking another sip of alcohol is the only way to get better. Hospitals, outpatient clinics, and rehab centers use the 12 steps as the basis for treatment. But although few people seem to realize it, there are alternatives, including prescription drugs and therapies that aim to help patients learn to drink in moderation. Unlike Alcoholics Anonymous, these methods are based on modern science and have been proved, in randomized, controlled studies, to work.
For J.G., it took years of trying to “work the program,” pulling himself back onto the wagon only to fall off again, before he finally realized that Alcoholics Anonymous was not his only, or even his best, hope for recovery. But in a sense, he was lucky: many others never make that discovery at all.
The debate over the efficacy of 12-step programs has been quietly bubbling for decades among addiction specialists. But it has taken on new urgency with the passage of the Affordable Care Act, which requires all insurers and state Medicaid programs to pay for alcohol- and substance-abuse treatment, extending coverage to 32 million Americans who did not previously have it and providing a higher level of coverage for an additional 30 million.
Nowhere in the field of medicine is treatment less grounded in modern science. A 2012 report by the National Center on Addiction and Substance Abuse at Columbia University compared the current state of addiction medicine to general medicine in the early 1900s, when quacks worked alongside graduates of leading medical schools. The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists. (The Columbia report notes that there may be additional doctors who have a subspecialty in addiction.) Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED. Many counselors are in recovery themselves. The report stated: “The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”
Alcoholics Anonymous was established in 1935, when knowledge of the brain was in its infancy. It offers a single path to recovery: lifelong abstinence from alcohol. The program instructs members to surrender their ego, accept that they are “powerless” over booze, make amends to those they’ve wronged, and pray.
Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are, of course, anonymous. No conclusive data exist on how well it works. In 2006 the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “no experimental studies unequivocally demonstrated the effectiveness of AA or [12-step] approaches for reducing alcohol dependence or problems.”
The Big Book includes an assertion first made in the second edition, which was published in 1955: that AA has worked for 75 percent of people who have gone to meetings and “really tried.” It says that 50 percent got sober right away, and another 25 percent struggled for a while but eventually recovered. According to AA, these figures are based on members’ experiences.
In his recent book, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, Lance Dodes, a retired psychiatry professor from Harvard Medical School, looked at Alcoholics Anonymous’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on these data, he put AA’s actual success rate somewhere between 5 and 8 percent. That is just a rough estimate, but it’s the most precise one I’ve been able to find.
I spent three years researching a book about women and alcohol, Her Best-Kept Secret: Why Women Drink—and How They Can Regain Control, which was published in 2013. During that time, I encountered disbelief from doctors and psychiatrists every time I mentioned that the Alcoholics Anonymous success rate appears to hover in the single digits. We’ve grown so accustomed to testimonials from those who say AA saved their life that we take the program’s efficacy as an article of faith. Rarely do we hear from those for whom 12-step treatment doesn’t work. But think about it: How many celebrities can you name who bounced in and out of rehab without ever getting better? Why do we assume they failed the program, rather than that the program failed them?
When my book came out, dozens of Alcoholics Anonymous members said that because I had challenged AA’s claim of a 75 percent success rate, I would hurt or even kill people by discouraging attendance at meetings. A few insi
sted that I must be an “alcoholic in denial.” But most of the people I heard from were desperate to tell me about their experiences in the American treatment industry. Amy Lee Coy, the author of the memoir From Death Do I Part: How I Freed Myself from Addiction, told me about her eight trips to rehab, starting at age 13. “It’s like getting the same antibiotic for a resistant infection—eight times,” she told me. “Does that make sense?”
Alcoholics Anonymous has more than 2 million members worldwide, and the structure and support it offers have helped many people. But it is not enough for everyone. The history of AA is the story of how one approach to treatment took root before other options existed, inscribing itself on the national consciousness and crowding out dozens of newer methods that have since been shown to work better.
A meticulous analysis of treatments, published more than a decade ago in Handbook of Alcoholism Treatment Approaches but still considered one of the most comprehensive comparisons, ranks AA 38th out of 48 methods. At the top of the list are brief interventions by a medical professional; motivational enhancement, a form of counseling that aims to help people see the need to change; and acamprosate, a drug that eases cravings. (An oft-cited 1996 study found 12-step facilitation—a form of individual therapy that aims to get the patient to attend AA meetings—as effective as cognitive-behavioral therapy and motivational interviewing. But that study, called Project Match, was widely criticized for scientific failings, including the lack of a control group.)
As an organization, Alcoholics Anonymous has no real central authority—each AA meeting functions more or less autonomously—and it declines to take positions on issues beyond the scope of the 12 steps. (When I asked to speak with someone from the General Service Office, AA’s administrative headquarters, regarding AA’s stance on other treatment methods, I received an email stating: “Alcoholics Anonymous neither endorses nor opposes other approaches, and we cooperate widely with the medical profession.” The office also declined to comment on whether AA’s efficacy has been proved.) But many in AA and the rehab industry insist the 12 steps are the only answer and frown on using the prescription drugs that have been shown to help people reduce their drinking.
People with alcohol problems also suffer from higher-than-normal rates of mental health issues, and research has shown that treating depression and anxiety with medication can reduce drinking. But AA is not equipped to address these issues—it is a support group whose leaders lack professional training—and some meetings are more accepting than others of the idea that members may need therapy and/or medication in addition to the group’s help.
AA truisms have so infiltrated our culture that many people believe heavy drinkers cannot recover before they “hit bottom.” Researchers I’ve talked with say that’s akin to offering antidepressants only to those who have attempted suicide, or prescribing insulin only after a patient has lapsed into a diabetic coma. “You might as well tell a guy who weighs 250 pounds and has untreated hypertension and cholesterol of 300, ‘Don’t exercise, keep eating fast food, and we’ll give you a triple bypass when you have a heart attack,’” Mark Willenbring, a psychiatrist in St. Paul and a former director of treatment and recovery research at the National Institute on Alcohol Abuse and Alcoholism, told me. He threw up his hands. “Absurd.”
Part of the problem is our one-size-fits-all approach. Alcoholics Anonymous was originally intended for chronic, severe drinkers—those who may, indeed, be powerless over alcohol—but its program has since been applied much more broadly. Today, for instance, judges routinely require people to attend meetings after a DUI arrest; fully 12 percent of AA members are there by court order.
Whereas AA teaches that alcoholism is a progressive disease that follows an inevitable trajectory, data from a federally funded survey called the National Epidemiological Survey on Alcohol and Related Conditions show that nearly one-fifth of those who have had alcohol dependence go on to drink at low-risk levels with no symptoms of abuse. And a recent survey of nearly 140,000 adults by the Centers for Disease Control and Prevention found that 9 out of 10 heavy drinkers are not dependent on alcohol and, with the help of a medical professional’s brief intervention, can change unhealthy habits.
We once thought about drinking problems in binary terms—you either had control or you didn’t; you were an alcoholic or you weren’t—but experts now describe a spectrum. An estimated 18 million Americans suffer from alcohol-use disorder, as the DSM-5, the latest edition of the American Psychiatric Association’s diagnostic manual, calls it. (The new term replaces the older “alcohol abuse” and the much more dated “alcoholism,” which has been out of favor with researchers for decades.) Only about 15 percent of those with alcohol-use disorder are at the severe end of the spectrum. The rest fall somewhere in the mild-to-moderate range, but they have been largely ignored by researchers and clinicians. Both groups—the hardcore abusers and the more moderate overdrinkers—need more-individualized treatment options.
The United States already spends about $35 billion a year on alcohol- and substance-abuse treatment, yet heavy drinking causes 88,000 deaths a year—including deaths from car accidents and diseases linked to alcohol. It also costs the country hundreds of billions of dollars in expenses related to health care, criminal justice, motor-vehicle crashes, and lost workplace productivity, according to the CDC. With the Affordable Care Act’s expansion of coverage, it’s time to ask some important questions: Which treatments should we be willing to pay for? Have they been proved effective? And for whom? Only those at the extreme end of the spectrum? Or also those in the vast, long-overlooked middle?
For a glimpse of how treatment works elsewhere, I traveled to Finland, a country that shares with the United States a history of prohibition (inspired by the American temperance movement, the Finns outlawed alcohol from 1919 to 1932) and a culture of heavy drinking.
Finland’s treatment model is based in large part on the work of an American neuroscientist named John David Sinclair. I met with Sinclair in Helsinki in early July. He was battling late-stage prostate cancer, and his thick white hair was cropped short in preparation for chemotherapy. Sinclair has researched alcohol’s effects on the brain since his days as an undergraduate at the University of Cincinnati, where he experimented with rats that had been given alcohol for an extended period. Sinclair expected that after several weeks without booze, the rats would lose their desire for it. Instead, when he gave them alcohol again, they went on weeklong benders, drinking far more than they ever had before—more, he says, than any rat had ever been shown to drink.
Sinclair called this the alcohol-deprivation effect, and his laboratory results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment: going cold turkey only intensifies cravings. This discovery helped explain why relapses are common. Sinclair published his findings in a handful of journals and in the early 1970s moved to Finland, drawn by the chance to work in what he considered the best alcohol-research lab in the world, complete with special rats that had been bred to prefer alcohol to water. He spent the next decade researching alcohol and the brain.
Sinclair came to believe that people develop drinking problems through a chemical process: each time they drink, the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol—until almost anything can trigger a thirst for booze, and drinking becomes compulsive.
Sinclair theorized that if you could stop the endorphins from reaching their target, the brain’s opiate receptors, you could gradually weaken the synapses, and the cravings would subside. To test this hypothesis, he administered opioid antagonists—drugs that block opiate receptors—to the specially bred alcohol-loving rats. He found that if the rats took the medication each time they were given alcohol, they gradually drank less and less. He published his findings in peer-reviewed journals beginning in the 1980s.
Subsequent stu
dies found that an opioid antagonist called naltrexone was safe and effective for humans, and Sinclair began working with clinicians in Finland. He suggested prescribing naltrexone for patients to take an hour before drinking. As their cravings subsided, they could then learn to control their consumption. Numerous clinical trials have confirmed that the method is effective, and in 2001 Sinclair published a paper in the journal Alcohol and Alcoholism reporting a 78 percent success rate in helping patients reduce their drinking to about 10 drinks a week. Some stopped drinking entirely.
I visited one of three private treatment centers, called the Contral Clinics, that Sinclair cofounded in Finland. (There’s an additional one in Spain.) In the past 18 years, more than 5,000 Finns have gone to the Contral Clinics for help with a drinking problem. Seventy-five percent of them have had success reducing their consumption to a safe level.
The Finns are famously private, so I had to go early in the morning, before any patients arrived, to meet Jukka Keski-Pukkila, the CEO. He poured coffee and showed me around the clinic, in downtown Helsinki. The most common course of treatment involves six months of cognitive-behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment typically also includes a physical exam, blood work, and a prescription for naltrexone or nalmefene, a newer opioid antagonist approved in more than two dozen countries. When I asked how much all of this cost, Keski-Pukkila looked uneasy. “Well,” he told me, “it’s 2,000 euros.” That’s about $2,500—a fraction of the cost of inpatient rehab in the United States, which routinely runs in the tens of thousands of dollars for a 28-day stay.
When I told Keski-Pukkila this, his eyes grew wide. “What are they doing for that money?” he asked. I listed some of the treatments offered at top-of-the-line rehab centers: equine therapy, art therapy, mindfulness mazes in the desert. “That doesn’t sound scientific,” he said, perplexed. I didn’t mention that some bare-bones facilities charge as much as $40,000 a month and offer no treatment beyond AA sessions led by minimally qualified counselors.
