by Amy Stewart
“There was never any campaign for this medication that said, ‘Ask your doctor,’” she says. “There was never any attempt to reach consumers.” Few doctors accepted that it was possible to treat alcohol-use disorder with a pill. And now that naltrexone is available in an inexpensive generic form, pharmaceutical companies have little incentive to promote it.
In one recent study, O’Malley found naltrexone to be effective in limiting consumption among college-age drinkers. The drug helped subjects keep from going over the legal threshold for intoxication, a blood alcohol content of 0.08 percent. Naltrexone is not a silver bullet, though. We don’t yet know for whom it works best. Other drugs could help fill in the gaps. O’Malley and other researchers have found, for example, that the smoking-cessation medication varenicline has shown promise in reducing drinking. So, too, have topiramate, a seizure medication, and baclofen, a muscle relaxant. “Some of these drugs should be considered in primary-care offices,” O’Malley says. “And they’re just not.”
In late August I visited Alltyr, a clinic that Willenbring founded in St. Paul. It was here that J.G. finally found help.
After his stays in rehab, J.G. kept searching for alternatives to 12-step programs. He read about baclofen and how it might ease both anxiety and cravings for alcohol, but his doctor wouldn’t prescribe it. In his desperation, J.G. turned to a Chicago psychiatrist who wrote him a prescription for baclofen without ever meeting him in person and eventually had his license suspended. Then, in late 2013, J.G.’s wife came across Alltyr’s website and discovered, 20 minutes from his law office, a nationally known expert in treating alcohol- and substance-use disorders.
J.G. now sees Willenbring once every 12 weeks. During those sessions, Willenbring checks on J.G.’s sleep patterns and refills his prescription for baclofen (Willenbring was familiar with the studies on baclofen and alcohol, and agreed it was a viable treatment option), and occasionally prescribes Valium for his anxiety. J.G. doesn’t drink at all these days, though he doesn’t rule out the possibility of having a beer every now and then in the future.
I also talked with another Alltyr patient, Jean, a Minnesota floral designer in her late 50s who at the time was seeing Willenbring three or four times a month but has since cut back to once every few months. “I actually look forward to going,” she told me. At age 50, Jean (who asked to be identified by her middle name) went through a difficult move and a career change, and she began soothing her regrets with a bottle of red wine a day. When Jean confessed her habit to her doctor last year, she was referred to an addiction counselor. At the end of the first session, the counselor gave Jean a diagnosis: “You’re a drunk,” he told her, and suggested she attend AA.
The whole idea made Jean uncomfortable. How did people get better by recounting the worst moments of their lives to strangers? Still, she went. Each member’s story seemed worse than the last: One man had crashed his car into a telephone pole. Another described his abusive blackouts. One woman carried the guilt of having a child with fetal alcohol syndrome. “Everybody talked about their ‘alcoholic brain’ and how their ‘disease’ made them act,” Jean told me. She couldn’t relate. She didn’t believe her affection for pinot noir was a disease, and she bristled at the lines people read from the Big Book: “We thought we could find a softer, easier way,” they recited. “But we could not.”
Surely, Jean thought, modern medicine had to offer a more current form of help.
Then she found Willenbring. During her sessions with him, she talks about troubling memories that she believes helped ratchet up her drinking. She has occasionally had a drink; Willenbring calls this “research,” not “a relapse.” “There’s no belittling, no labels, no judgment, no book to carry around, no taking away your ‘medal,’” Jean says, a reference to the chips that AA members earn when they reach certain sobriety milestones.
In his treatment, Willenbring uses a mix of behavioral approaches and medication. Moderate drinking is not a possibility for every patient, and he weighs many factors when deciding whether to recommend lifelong abstinence. He is unlikely to consider moderation as a goal for patients with severe alcohol-use disorder. (According to the DSM-5, patients in the severe range have six or more symptoms of the disorder, such as frequently drinking more than intended, increased tolerance, unsuccessful attempts to cut back, cravings, missing obligations due to drinking, and continuing to drink despite negative personal or social consequences.) Nor is he apt to suggest moderation for patients who have mood, anxiety, or personality disorders; chronic pain; or a lack of social support. “We can provide treatment based on the stage where patients are,” Willenbring said. It’s a radical departure from issuing the same prescription to everyone.
The difficulty of determining which patients are good candidates for moderation is an important cautionary note. But promoting abstinence as the only valid goal of treatment likely deters people with mild or moderate alcohol-use disorder from seeking help. The prospect of never taking another sip is daunting, to say the least. It comes with social costs and may even be worse for one’s health than moderate drinking: research has found that having a drink or two a day could reduce the risk of heart disease, dementia, and diabetes.
No one knows that better than Mark and Linda Sobell, who are both psychologists. In the 1970s the couple conducted a study with a group of 20 patients in Southern California who had been diagnosed with alcohol dependence. Over the course of 17 sessions, they taught the patients how to identify their triggers, how to refuse drinks, and other strategies to help them drink safely. In a follow-up study two years later, the patients had fewer days of heavy drinking, and more days of no drinking, than did a group of 20 alcohol-dependent patients who were told to abstain from drinking entirely. (Both groups were given a standard hospital treatment, which included group therapy, AA meetings, and medications.) The Sobells published their findings in peer-reviewed journals.
In 1980 the University of Toronto recruited the couple to conduct research at its prestigious Addiction Research Foundation. “We didn’t set out to challenge tradition,” Mark Sobell told me. “We just set out to do good research.” Not everyone saw it that way. In 1982 abstinence-only proponents attacked the Sobells in the journal Science; one of the writers, a UCLA psychologist named Irving Maltzman, later accused them of faking their results. The Science article received widespread attention, including a story in the New York Times and a segment on 60 Minutes.
Over the next several years, four panels of investigators in the United States and Canada cleared the couple of the accusations. Their studies were accurate. But the exonerations had scant impact, Mark Sobell said: “Maybe a paragraph on page fourteen” of the newspaper.
The late G. Alan Marlatt, a respected addiction researcher at the University of Washington, commented on the controversy in a 1983 article in American Psychologist. “Despite the fact that the basic tenets of [AA’s] disease model have yet to be verified scientifically,” Marlatt wrote, “advocates of the disease model continue to insist that alcoholism is a unitary disorder, a progressive disease that can only be arrested temporarily by total abstention.”
What’s stunning, 32 years later, is how little has changed.
The Sobells returned to the United States in the mid-1990s to teach and conduct research at Nova Southeastern University, in Fort Lauderdale, Florida. They also run a clinic. Like Willenbring in Minnesota, they are among a small number of researchers and clinicians, mostly in large cities, who help some patients learn to drink in moderation.
“We cling to this one-size-fits-all theory even when a person has a small problem,” Mark Sobell told me. “The idea is ‘Well, this may be the person you are now, but this is where this is going, and there’s only one way to fix it.’” Sobell paused. “But we have fifty years of research saying that, chances are, that’s not the way it’s going. We can change the course.”
During my visit to Finland, I interviewed P., a former Contral Clinic patient who asked me to use
only his last initial in order to protect his privacy. He told me that for years he had drunk to excess, sometimes having as many as 20 drinks at a time. A 38-year-old doctor and university researcher, he describes himself as mild-mannered while sober. When drunk, though, “it was as if some primitive human took over.”
His wife found a Contral Clinic online, and P. agreed to go. From his first dose of naltrexone, he felt different—in control of his consumption for the first time. P. plans to use naltrexone for the rest of his life. He drinks two, maybe three, times a month. By American standards, these episodes count as binges, since he sometimes downs more than 5 drinks in one sitting. But that’s a steep decline from the 80 drinks a month he consumed before he began the treatment—and in Finnish eyes, it’s a success.
Sari Castrén, the psychologist I met at Contral, says such trajectories are the rule among her patients. “Helping them find this path is so rewarding,” she says. “This is a softer way to look at addiction. It doesn’t have to be so black-and-white.”
J.G. agrees. He feels much more confident and stable, he says, than he did when he was drinking. He has successfully drunk in moderation on occasion, without any loss of control or desire to consume more the next day. But for the time being, he’s content not drinking. “It feels like a big risk,” he says. And he has more at stake now—his daughter was born in June 2013, about six months before he found Willenbring.
Could the Affordable Care Act’s expansion of coverage prompt us to rethink how we treat alcohol-use disorder? That remains to be seen. The Department of Health and Human Services, the primary administrator of the act, is currently evaluating treatments. But the legislation does not specify a process for deciding which methods should be approved, so states and insurance companies are setting their own rules. How they’ll make those decisions is a matter of ongoing discussion.
Still, many leaders in the field are hopeful—including Tom McLellan, the University of Pennsylvania psychologist. His optimism is particularly poignant: in 2008 he lost a son to a drug overdose. “If I didn’t know what to do for my kid, when I know this stuff and am surrounded by experts, how the hell is a schoolteacher or a construction worker going to know?” he asks. Americans need to demand better, McLellan says, just as they did with breast cancer, HIV, and mental illness. “This is going to be a mandated benefit, and insurance companies are going to want to pay for things that work,” he says. “Change is within reach.”
ANTONIA JUHASZ
Thirty Million Gallons Under the Sea
FROM Harper’s Magazine
ONE MORNING IN MARCH of last year, I set out from Gulfport, Mississippi, on a three-week mission aboard the U.S. Navy research vessel Atlantis. The 274-foot ship, painted a crisp white and blue, stood tall in the bright sunlight. On its decks were winches, cranes, seafloor-mapping sonar, a machine shop, and five laboratories. Stowed in an alcove astern was Alvin, the federal government’s only manned research submarine. “Research vessel Atlantis outbound,” A. D. Colburn, the ship’s captain, reported into the ship radio.
The water was calm and the bridge crew quiet as they steered us into open water. For the next 14 hours, we would sail toward the site of BP’s Macondo well, where in April 2010 a blowout caused the largest offshore-drilling oil spill in history. Once there, Atlantis’s crew would launch Alvin and guide it to the bottom of the ocean, reaching depths as great as 7,200 feet below the surface. Over the next 22 days they would send the submersible down 17 times, to gather animal, plant, water, and sediment samples. Their goal was to determine how BP’s spill had affected the ocean’s ecosystem from the seabed up. I would get the chance to join them in the submarine as they went closer to the Macondo wellhead than anyone had gone since the blowout.
Data gathered by the Atlantis would likely be used in the federal legal proceedings against BP, which began in December 2010. A few months after our mission, U.S. district judge Carl Barbier found the company guilty of gross negligence and willful misconduct. In January 2015 he ruled that the amount of oil the company was responsible for releasing into the Gulf totaled some 134 million gallons, a decision both sides have appealed. By the time this article went to press, Barbier had yet to make his third and final ruling, which will determine how much BP owes in penalties under the Clean Water Act. (If his judgment about the size of the spill is not overturned, the company will face a $13.7 billion fine.) Meanwhile, the Environmental Protection Agency, the National Oceanic and Atmospheric Administration, the Department of Agriculture, and the Department of the Interior are concluding an ecological-damages assessment to determine how much BP must pay to restore the Gulf Coast. The trial and the assessment are likely to result in the largest penalty ever leveled against an oil company.*
Dr. Samantha Joye, a biogeochemist at the University of Georgia and the lead scientist on the mission, estimated that 30 million gallons of oil from the BP spill remain in the Gulf—the equivalent of nearly three Exxon Valdez spills—and that about half of this amount has settled on the ocean floor, where its ecological effects could be devastating. A BP spokesman told me that most of the spilled oil had been removed, consumed, or degraded, and that there had been “very limited impact from the oil spill on the seafloor.” But Joye’s research indicates that any damage the oil has done to creatures inhabiting the deep-sea waters—from tubeworms to sperm whales—threatens the ecosystem, harming organisms that rely on those species. Among those at risk are phytoplankton, the sea vegetation that produces about half of the planet’s oxygen. “If you short-circuit the bottom, you threaten the entire cycle,” Joye told me. “Without a healthy ocean, we’ll all be dead.”
The Gulf of Mexico is one of the world’s most ecologically diverse bodies of water, home to more than 15,000 marine species. Its coastal areas contain half of the wetlands in the United States—some 5 million acres—which provide habitat for a variety of birds and fish. Mangrove forests line the Gulf shore, and its shallow waters are filled with seagrass. Before the oil spill, more than 60 percent of all oysters harvested in U.S. waters were caught in the Gulf. Today that share has dropped to about 40 percent. Many threatened and endangered species also live in the Gulf: sea turtles, Florida manatees, whooping cranes, and bald eagles. Dolphins are a frequent sight. Giant squid, jellyfish, and octopuses swimming through the Gulf’s waters pass some of America’s lushest and most imperiled coral reefs.
As Atlantis carried us farther from shore, the fishing boats dropped away and we gradually entered clear, open ocean. Mississippi and Florida are the only Gulf states that do not allow offshore drilling in their coastal waters, which extend several miles out from shore. But as soon as we entered federal waters, oil rigs and drilling platforms began to appear. We sailed through the rigs for 12 hours and, near 11:00 at night, arrived at our destination, Mississippi Canyon Block 252 (MC252). This was the roughly 5,760-acre lease area that contained the Macondo oil well.
Much of the western and central Gulf of Mexico has been parceled into a patchwork of oil and natural-gas lease blocks. A web of underwater pipelines carries the fuel to shore. MC252 sits in an industrial corridor that is occupied by the world’s largest oil companies—including ExxonMobil, Chevron, Shell, Eni, Noble Energy, Hess, and BP. Some 17 percent of U.S. oil comes from the Gulf, nearly 80 percent of that from depths of 1,000 feet or more below the ocean’s surface. In 2008 BP leased MC252 from the Department of the Interior, paying $34 million for 10 years. The company then leased the Deepwater Horizon, a semisubmersible oil rig, from Transocean, which also ran the rig’s daily operations. On February 15, 2010, the crew of the Deepwater Horizon started drilling at the Macondo site, some 5,000 feet below the ocean’s surface. Eventually they dug through more than two miles of rock and sediment, to a depth of 18,360 feet.
The Gulf of Mexico’s high concentrations of methane, along with other natural features, make it an especially dangerous place to drill. Natural gas, which is lighter than oil, can get into oil pipes and overwhelm a well’s pressure-control
systems, leading to a blowout. At 9:45 on the night of April 20, 2010, as the crew worked to prepare the well, methane escaped from the Macondo and shot up the steel pipe that connected it to the Deepwater Horizon. Inside the rig, sparks from machinery ignited the gas, setting off a series of explosions. The two men who were working near the pipe, in the rig’s mudroom, were quickly incinerated. They were the first of 11 crew members to die. At 10:21 a.m. on April 22, the Deepwater Horizon collapsed into the ocean. Its wreckage remains strewn around the well to this day.
When the Macondo well blew, none of the oil companies operating in the deep waters of the Gulf were prepared, even though the largest among them—ExxonMobil, Chevron, Shell, and BP—had claimed to the Department of the Interior that they could handle a far-worse deepwater blowout. So BP applied methods designed for smaller, shallow-water spills. In May, employing what were known as the “top kill” and “junk shot” approaches, BP dumped drilling mud, golf balls, and tire rubber onto the well. Nothing worked. In the 87 days it took to secure the well with a temporary cap, more than a hundred million gallons of oil and half a million tons of natural gas—most of which was methane—escaped into the Gulf. Eventually, BP performed the one operation that, however risky and time-consuming, it knew how to do: it drilled another well. One hundred and fifty-two days after the blowout, BP’s relief well intersected the Macondo borehole, allowing the company to pump in mud and cement. This remains the only proven method for permanently sealing a blown-out well in deep water.
By May 2011 BP’s oil had sickened or killed more than 100,000 Gulf animals: 28,500 sea turtles, 82,000 birds, and more than 26,000 marine mammals, including several sperm whales. Too small or too numerous to count were the vast numbers of dead fish, crustaceans, insects, and plants that washed up onshore. Most of the other organisms initially killed by the spill died at sea and were never seen.
