Therapies for Addiction

Alcoholism is labeled AUD (alcohol use disorder) in the DSM manual. In the U.S., about 14% of the population suffers from AUD in a one-year period, and 30% suffer from AUD at least once in their lives (Grant et al., 2015). Men are a third more likely to have AUD compared to women.

About 15% of those with alcohol-use disorder (AUD) are "at the severe end of the spectrum" showing classic debilitating effects of alcoholism. That implies about 2% of people in the U.S. had severe alcoholism in a given year, and many more had lesser degrees of AUD.

What is AUD and how common is it?

Addiction and related problems are involved in a majority of the problems dealt with in mental health clinics. Yet clinicians have a hard time dealing with any of the addictions.

People may improve for a time after counseling, but often they slide back into their old ways. Recidivism (backsliding) is very common when people try to quit addictive behaviors.

Recidivism occurs with approximately equal frequency in all addictions. The same percentage of people (about 75%) fail to quit the first time they try, whether they are quitting heroin or cigarettes (Squires, 1982).

How common is recidivism when people try to quit an addiction?

Treatment of alcoholism usually centers on total abstinence from the drug, especially in the United States. Alcoholics Anonymous (AA) provides group support and a comprehensive program to help addicts stay off alcohol.

AA works by encouraging a "total personality change," not just abstinence. Spiritual elements are strong in the AA program. Addicts are encouraged to admit personal weakness and submit their lives to God.

That basic approach has been used to treat all the other addictions, too. Over 1,000 different 12-step programs exist.

While inspired by the Alanon (Alcoholics Anonymous) program, most 12-step programs modify the procedures slightly for different addictions. Gamanon (Gambler's Anonymous) has over 10,000 members and uses 12 Steps to Recovery modeled after the almost identical 12 steps used by Alcoholics Anonymous.

1. We admitted we were powerless over gambling, that our lives had become unmanageable.

2. We came to believe a Power greater than ourselves could restore us to a normal way of thinking and living.

3. We made the decision to turn our will and our lives over to the care of this Power, of our own understanding.

4. We made a searching and fearless moral and financial inventory of ourselves.

5. We admitted to ourselves and to another human being the exact nature of our wrongs.

6. We're emotionally ready to have these defects of character removed.

7. We humbly ask God of our understanding to remove our shortcomings.

8. We made a list of all persons we have harmed and became willing to make amends to them all.

9. We made direct amends to such people wherever possible except when to do so would injure them or others.

10. We continued to take personal inventory and when we were wrong, promptly admitted it.

11. We felt through prayer and meditation to improve our conscious contact with God as we understand Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having made an effort to practice these principles in all our affairs, we try to carry this message to other compulsive gamblers.

Details of the 12-step program vary somewhat, with more or less emphasis on conventional religion. During the 1980s, the AA program was adapted for use in Russia, then the Soviet Union, and all references to God were deleted.

What element of the 12-step approach is often modified?

In 2002 an American student told me, "I belong to a group which uses a 12-step program, and we specifically mention a Higher Power without mentioning God, to avoid alienating people who are not religious." With modifications, the basic 12-step approach has been tried with addictions in all countries.

Other therapies for addiction are available. "At least 4 types of one-on-one behavioral treatments for AUD are effective: cognitive behavioral therapy, motivational enhancement therapy, behavioral couples therapy, and 12-step facilitation. Moreover, no single behavioral treatment is superior to all others." (Bradley and Kivlahan, 2014)

What are other approaches to treatment, besides AA?

Fiorentine and Hillhouse (2000) reviewed abstinence data (i.e. how many people stayed away from alcohol) and found 12-step and other therapies had an "additive effect." People who combined two approaches did better than people who selected only one.

Critics of 12-step programs abound. The programs are so common they have made many enemies as well as friends. As to whether 12-step programs are the most effective approach to quitting addictions, data is ambiguous. Glaser (2015) said that her review of the literature showed little support for the effectiveness of 12-step programs.

Alcoholics Anonymous is famously difficult to study. By necessity, it keeps no records of who attends meetings; members come and go and are anonymous, of course.

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."

Glaser (201) pointed out that Lance Dodes, a retired psychiatry professor from Harvard Medical School, put AA's actual success rate between 5 and 8 percent. This was in a book titled, The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. "That is just a rough estimate, but it's the most precise one I've been able to find," wrote Glaser (2015).

Glaser encountered disbelief when she informed doctors and psychiatrists that AA success rates were in the single digits. When she published her book, Her Best-Kept Secret: Why Women Drink–And How They Can Regain Control, she was confronted with hostile criticisms from AA members who said her advocacy of controlled drinking would be responsible for people dying from their alcohol addictions.

What did Glaser conclude about AA, and what reactions did she encounter?

But Glaser also heard from many people frustrated with AA and the absence of alternatives. Glaser stuck to her guns about the cure rate of AA:

A meticulous analysis of treatments, published more than a decade ago in The 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.

For those who do not opt for the 12-step approach, pharmaceutical interventions are available. Several effective anti-alcohol drugs are opiate antagonists. The effects of alcohol share some of the same chemical pathways as opiates, so drugs like naltrexone and nalmefene, opiate blockers, can reduce cravings for alcohol.

Naltrexone is most commonly used with opioid addicts. It prevents them from getting any high from drugs like heroin. In 1994 naltrexone was approved by the FDA (Food and Drug Administration) in the U.S. to treat alcohol dependence. Another opiate antagonist, nalmefene, was approved for experimental use.

A review and meta-analysis of AUD treatment with naltrexone and nalmefene found that both reduced rates of drinking, There was no evidence that one was superior to the other (Jonas et al., 2014). Naltrexone was somewhat more convenient, requiring only one pill per day, while Nalmefene had to be taken three times per day.

A third drug, acamprosate, marketed as Campral, has been used in France since 1989 to treat more than a million alcohol-dependent people. It produced better results than placebos as measured by continued abstinence and fewer episodes of heavy drinking. Acamprosate became the most widely prescribed drug for alcoholism in the United States (Mason and Heyser, 2010).

What drug treatments for AUD are available?

Unlike naltrexone and nalmefene, which are opiate blockers, acamprosate targets the neurotransmitter GABA. There have been no direct comparisons of acamprosate with the other two, but success rates are very similar. A 1997 study found that 51% of clients showed improvement with acamprosate, while a 1995 study showed 54% improved with naltrexone.

Another drug used historically for AUD treatment, disulfiram (antabuse) makes a person feel sick if they drink alcohol. The Jonas et al. (2014) meta-analysis did not find it to be effective. However, the researchers noted that studies of disulfiram failed to supervise drug administration, so people may have stopped taking it because of its unpleasant effects.

In one Finnish study, naltrexone produced a 78% success rate either helping patients reduce drinking to 10 drinks a week or less or stopping entirely. Glaser, the AA critic quoted above, found that result impressive, so she experimented with naltrexone to see what it was like.

"I sipped a glass of wine and felt almost nothing–no calming effect, none of the warm contentment that usually signals the end of my workday and the beginning of a relaxing evening. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it."

For a treatment like this to work, a person must voluntarily take a pill that eliminates their enjoyment of their addictive drug. Therefore, for pill-based treatments to work, a person with AUD must be motivated to change.

What was a powerful predictor of successful abstinence?

Gaume, Bertholet, and Daeppen (2017) confirmed that readiness to change was a powerful predictor of successful abstinence or reduced drinking, in a 12-month followup to outpatient treatment for AUD. By contrast, merely knowing the importance of change had no effect.

One complication for interpreting research results is that studies in the U.S. tend to aim for abstinence, following the assumptions of AA that abstinence is crucially important. Studies in Europe are more likely to aim for reduced harm, defined as reduced levels of alcohol consumption. Naltrexone seems to work particularly well for lowering alcohol consumption without stopping it.

In Finland, where opiate antagonists are widely employed in AUD treatment, clients are encouraged to take a dose of an opiate-antagonist an hour before drinking, and that usually helps them stop after one drink. The drugs are usually combined with therapies in which clients are encouraged to enjoy activities made possible by less drinking.

How do typical AUD treatments differ in Finland and the U.S.?

In the U.S., clients are urged to quit alcohol completely. Most with serious AUD cannot live up to that request. By contrast, in Finland, Dr. David Sinclair claims an 80% cure rate using naltrexone, where cure is defined as drinking moderately or being abstinent from alcohol.

In one study, Sinclair compared the effect of giving naltrexone and requiring abstinence vs. taking a naltrexone pill an hour before drinking. Only the group combining naltrexone with drinking remained abstinent or controlled. The conclusion was clear in one reporter's opinion:

"Giving alcoholics naltrexone daily and telling them to abstain from drinking is not effective. Giving alcoholics naltrexone and telling them to take it only before drinking alcohol is highly effective and cures Alcohol Dependence." (Anderson, 2013)

If this approach is so effective, why is it not used more often in the U.S.? The answer is apparently related to the dominating influence of the Alcoholics Anonymous approach.

Why are doctors in the U.S. reluctant to use the Finnish approach?

The 12-step philosophy is used by about three-quarters of treatment centers in the U.S., and it strongly emphasizes that the only cure for alcoholism is abstinence. Therefore doctors are reluctant to combine a pharmaceutical treatment like naltrexone with advice to keep drinking in a controlled manner.

Self-Cure of Addiction

Daniel Schachter created a mini-controversy in the 1980s by arguing that psychologists underestimated the number of successful self-cures for addictive behavior such as cigarette smoking. A self-cure occurs when somebody "kicks a habit" through his or her own efforts without seeing a therapist or joining a group. (Schachter, 1982)

Schachter found there was a large population of ex-addicted people who had never seen a therapist or joined a group. Some had overcome a weight problem, which Schachter defined as losing ten or more pounds and keeping it off.

Some had ended a cigarette addiction without professional help. Most had failed a few times before they finally succeeded. This led Schachter to suggest that the key to quitting was persistence.

Schachter recommended that a person seeking to quit an addiction simply keep trying, not getting discouraged by failures. Eventually something works and permanent change is achieved.

What was Schachter's recommendation, to encourage self-cure of addiction?

Arkowitz and Lilienfeld (2008) looked back on Schachter's claims twenty years afterward. They noted:

A particularly controversial finding was that the success rates of his so-called self-changers were actually greater than those of patients who underwent professional treatment. Schachter discussed two possible explanations. First, treatment seekers may be more severely addicted than self-changers. Second, studies typically examine only one change endeavor, whereas his interviews covered a lifetime of efforts. Perhaps it takes many tries before a person gets it right... (Arkowitz and Lilienfeld, 2008)

Reginald Smart of the Center for Addiction and Mental Health in Toronto surveyed research to determine if Schachter's point applied to alcohol abuse as it did to other addictions. Smart reported these results:

Most of those who change their problem drinking do so without treatment of any kind, including self-help groups.
A significant percentage of self-changers maintain their recovery with follow-up periods of more than eight years.
Many problem drinkers can maintain a pattern of non-problematic moderate use of alcohol without becoming re-addicted.
Those who do seek treatment have more severe alcohol and related problems than those who do not. (Arkowitz and Lilienfeld, 2008)

How did Smart confirm some of Schachter's points with AUD?

For those enter treatment with the goal of abstinence, immediate compliance with the requests to be abstinent was a powerful predictor of eventual success (Dunn et al, 2017). Those who did not abstain at the beginning of treatment were far less likely to be abstinent later.

These findings, and many others, suggest that not all problem drinkers are alike. For those with the worst addictions, abstinence is often the best option.

Although physicians may not offer this option without an explicit request in the U.S., some people can use prescriptions to encourage lower, non-harmful levels of drinking. Others, perhaps those starting with less severe problems, can moderate themselves without formal treatment.

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References:

Anderson, K. (2013, July 28) Drink your way sober with naltrexone. Psychology Today. Retrieved from: https://www.psychologytoday.com/blog/overcoming-addiction/201307/drink-your-way-sober-naltrexone

Arkowitz, H. & Lilienfeld, S. O. (2008, August) Scientific American. Retrieved from: https://www.scientificamerican.com/article/do-it-yourself-addiction-cures/

Bradley, K. A. & Kivlahan, D. R. (2014) Bringing patient-centered care to patients with alcohol use disorders. JAMA, 311, 1861-1862. doi:10.1001/jama.2014.3629

Dunn, K. E., Harrison, J. A., Leoutsakos, J-M., Han, D., & Strain, E. C. (2017) Continuous Abstinence During Early Alcohol Treatment is Significantly Associated with Positive Treatment Outcomes, Independent of Duration of Abstinence. Alcohol and Alcoholism, 52, 72-79. doi:10.1093/alcalc/agw059

Fiorentine, R. & Hillhouse, M. P. (2000) Drug treatment and 12-step program participation. Journal of Substance Abuse Treatment, 18, 65-74. https://dx.doi.org/10.1016/S0740-5472(99)00020-3

Gaume, J., Bertholet, N., & Daeppen, J-B. (2017) Readiness to Change Predicts Drinking: Findings from 12-Month Follow-Up of Alcohol Use Disorder Outpatients. Alcohol and Alcoholism, 52, 65-71. doi:10.1093/alcalc/agw047

Glaser, G. (2015, April) The irrationality of Alcoholics Anonymous. The Atlantic. Retrieved from: https://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/

Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., Pickering, R. P., Ruan, W. J., Smith, S. M., Huang, B., & Hasin, D. S. (2015). Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72,,757-766. doi:10.1001/jamapsychiatry.2015.0584

Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., Kim, M. M., Shanahan, E., Gass, C. E., Rowe, C. J., & Garbutt, J. C. (2014) Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient Settings: A Systematic Review and Meta-analysis. JAMA, 311, 1889-1900. doi:10.1001/jama.2014.3628

Mason, B. J., & Heyser, C. J. (2010). Acamprosate: A prototypic neuromodulator in the treatment of alcohol dependence. CNS and Neurological Disorders Drug Targets, 9,, 23-32.

Squires, S (1982, October 3). Alcohol, cigarettes could be as addicting as heroin. Atlanta Constitution. P.28-A.

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