Everything you know about substance abuse treatment is wrong

August 27, 2015
To: My Colleagues

Subject: Almost Everything You Thought You Knew About Substance Abuse is Wrong

Abstract: (This article is a compilation of scientific data gathering for over 15 years and with the recent article and personal communication with Ms. Glasser, I decided to publish this work.
This article exposes: The success of Alcoholic anonymous is not 75% as they report but somewhere between 5 and 33%. Almost all substance abuse residential centers in the U.S. require attendance of AA by its patients. Patients have a significantly better chance of recovery if they receive certain medications.

I am well aware of the negative reception to this article by those professionals engaged in the treatment of alcoholic individuals. It will be seen as an attack on their recovery and attachment to AA which has become spiritual to them. Please step back from this issue and believe there is a better, more scientific approach to sobriety as evidenced by a few places in this country and in Europe. Can we not learn from others? Are we not obligated to provide the very best treatment regardless of our personal bias? Ms. Glasser told me she received hundreds of hate mail from AA supporters after her article was published. I believe none of them was based on scientific data and all was based on their own bias and prejudice without knowledge.)

Introduction: Substance Abuse hits close to my family including two of my three children, my brother and father who are now deceased. Twenty-five years ago when my son became addicted I took him to the best treatment facilities in town, and trusted the staff was professional with advanced education and training in substance abuse; so I trusted them. I was wrong to do so because although the staff were nice, well-intended people they were not educated and trained in providing scientific principles
proven to work with addicts. They had only one faith based program called AA and 12 Steps. I was told this was the only and most successful for addiction.

This is scientifically wrong; in fact it is rated 38th out of 48 treatment programs.

My blind faith for the professionals to help the person I cared about most in the world was almost 100% wrong! The therapists, in general were Certified Alcohol Counselors I, II, III. The educational requirement to enter the CAC program is a GED or high school diploma and usually only the CAC III has a B.S. degree. The Director may be a person with a Master’s Degree.

Secondly, they only had one faith based treatment approach which is AA and 12 Steps. Nothing based on evidenced based treatment.

Thirdly, I was not told the truth about the effectiveness of their faith-based treatment.

I am a psychologist with a doctorate and knowledge of substance abuse and if I didn’t know better than to accept these “professionals”, how is a lay person expected to know this information? Medical doctors don’t know any better either. We are all victims of this myth forced on us by one large faith based program. You don’t believe it’s forced on us? Find one residential program for substance abuse in Colorado who does not insist on the AA program.
Today, Nationally 70% to 80% of residential treatment programs out of 13,000
require AA. I can’t find one in Colorado who doesn’t utilize AA, NA, CA, etc.

Dr. Chad Emrick of Denver conducted the first and only scientific study on the effectiveness of AA and found it to be about 33% of those people who go and continuing attending AA over a period of time. Of course doing the 12 steps is more predictive of success. Think about consulting a surgeon for life-threatening surgery who told you the success of this surgery was 33% or less and claimed this was the very best surgery in the world? Would you go for it? I would do research of other techniques and would find in the case several other therapies with a higher success rate.

May I now introduce a well-known writer and researcher on substance abuse: I will report in this paper some of her highlights. For the total article and her book you can contact Ms. Glaser or me. I will be adding commentary throughout the article.)

Her Best-Kept Secret: Why Women Drink
And How They Can Regain Control.

By Gabrielle Glaser
“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—abig 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 e faith-based approach of the 12 steps, five 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 one 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 years. What will happen when 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: “of testimonials from those who say AA saved their life that we take the program’s efficacy as an article of faith. The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

(Stop reading and think about this paragraph for a minute. The chances of an addicted person seeing a MD with a specialty in addiction; one out of 582 in the entire U.S.! I know of one in Denver and one in Colorado Springs in the State of Colorado. This does not include psychologists and other mental health workers. So if you had cancer, would you go to a support group or a doctor with this specialty? And what would you do if there were on 582 MD’s in the U.S. to choose from?)
To continue with Ms. Glasser’s article: “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. (Not scientific data)

“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 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 it. 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?

“…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 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. (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.)”

“…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.”

(At least one residential treatment program in Colorado takes people off all psychotropic medications upon arrival not recognizing the majority people come to them with mental health problems. Many AA members also reject the ideal that one needs medication for depression and other illnesses.)

“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.”

(Another AA truism is that the only difference between a sober member and a drunk is one drink! Is this not equally absurd. Yes there are a percentage of alcoholic (around15%) who can never drink again because of the severity to addiction; but this leaves 85% that can learn to moderate their drinking.)

“…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.”

(This applies to the little old lady that had two glasses of wine and couldn’t pass the roadside sobriety test; so she is put in handcuffs, spends the night in jail and is sentenced to probation and to attend AA meetings. Does this make sense to anybody?)

“…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 hard-core abusers and the more moderate over drinkers—need more-individualized treatment options.”

(We treat the 85% as if they were the 15% of those who are the severe end of the spectrum! Go to 90/90 AA meetings which means 90 meetings in 90 days. Get a sponsor and do the 12 steps. Take urine tests or an ankle monitor to insure your honesty; or get a device on your car that you blow into before you can drive which cost quite a bit a month. Does this make any sense to the 85% or my little old lady?)

“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?”

(Everybody agrees these people need professional help. But how long are we going to send them to a program with a 5-30% success rate? Yes, testimonials are wonderful and emotional; but they are not scientific data from which to base any conclusions. We have to do something different. Some great philosopher once said, “Doing something over and over again and expecting different results is the definition of insanity”. Are we as professionals and as a nation insane on this subject?)

What does work with alcoholics if traditional programs’ success rate is so poor?
One is the introduction of certain medications which has long been advocated by notable psychiatrists like John Fleming, MD of Colorado Springs, CO. He is quoted as saying “Not only is medication recommended for some alcoholics, I consider it malpractice to not prescribe it.” This statement was promptly rejected by a majority of the 400 attendees.)

Back to Glasser, “Subsequent studies 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.”

“…Patients on Naltrexone have to be motivated to keep taking the pill. But Sari Castrén, a psychologist at the Contral Clinic I visited in Helsinki, told me that when patients come in for treatment, they’re desperate to change the role alcohol has assumed in their lives. They’ve tried not drinking, and controlling their drinking, without success—their cravings are too strong. But with naltrexone or nalmefene, they’re able to drink less, and the benefits soon become apparent: They sleep better. They have more energy and less guilt. They feel proud. They’re able to read or watch movies or play with their children during the time they would have been drinking. In therapy sessions, Castrén asks patients to weigh the pleasure of drinking against their enjoyment of these new activities, helping them to see the value of change. Still, the combination of naltrexone and therapy doesn’t work for everyone.

“Some clients opt to take Antabuse, a medication that triggers nausea, dizziness, and other uncomfortable reactions when combined with drinking. And some patients are unable to learn how to drink without losing control. In those cases (about 10 percent of patients), Castrén recommends total abstinence from alcohol, but she leaves that choice to patients. “Sobriety is their decision, based on their own discovery,” she told me.”

“…In the United States, doctors generally prescribe naltrexone for daily use and tell patients to avoid alcohol, instead of instructing them to take the drug anytime they plan to drink, as Sinclair would advise. There is disagreement among experts about which approach is better.
“Sinclair is adamant that American doctors are missing the drug’s full potential—but both seem to work: naltrexone has been found to reduce drinking in more than a dozen clinical trials, including a large-scale one funded by the National Institute on Alcohol Abuse and Alcoholism that was published in JAMA in 2006.

The results have been largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking!”

“…. Today there are more than 13,000 rehab facilities in the United States, and 70 to 80 percent of them ascribe to the 12 steps, according to Anne M. Fletcher, the author of Inside Rehab, a 2013 book investigating the treatment industry.”

(How many of these 1300 rehab facilities know and inform their patients of the scientific success of their AA program? None? What do they cost? $5,000 to $30,000 for 28 days!)

(What type of “professionals dispense treatment at these expensive facilities? Medical doctors? No, Doctoral level psychologists and counselors? No. Master’s level counselors? A few, Bachelor levels? Quite a few, No degree? Most of “professionals” in the field are Certified Alcohol Counselors, Level I, II, III, with no advanced degree.)

“People addicted to alcohol can be secretive, self-centered, and filled with resentment. In response, Hazelden’s founders insisted that patients attend to the details of daily life, tell their stories, and listen to each other … This led to a heartening discovery, one that’s become a cornerstone of the Minnesota Model: Alcoholics and addicts can help each other.”

“That may be heartening, but it’s not science. As the rehab industry began expanding in the 1970s, its profit motives dovetailed nicely with AA’s view that counseling could be delivered by people who had themselves struggled with addiction, rather than by highly trained (and highly paid) doctors and mental-health professionals. No other area of medicine or counseling makes such allowances.”

“There is no mandatory national certification exam for addiction counselors. The 2012 Columbia University report on addiction medicine found that only six states required alcohol- and substance-abuse counselors to have at least a bachelor’s degree and that only one state, Vermont, required a master’s degree. Fourteen states had no license requirements whatsoever—not even a GED or an introductory training course was necessary—and yet counselors are often called on by the judicial system and medical boards to give expert opinions on their clients’ prospects for Sobriety.”

(Myth: Recovering counselors are better than non-recovering counselors.
Fact: Recovering counselors are not better.)

“Bill Wilson, AA’s founding father, was right when he insisted, 80 years ago, that alcohol dependence is an illness, not a moral failing. Why, then, do we so rarely treat it medically? It’s a question I’ve heard many times from researchers and clinicians. “Alcohol- and substance-use disorders are the realm of medicine,” McLellan says. “This is not the realm of priests.”

“The history—and current state—is really, really dismal,” Willenbring said.
Perhaps even worse is the pace of research on drugs to treat alcohol-use disorder. The FDA has approved just three: Antabuse, the drug that induces nausea and dizziness when taken with alcohol; acamprosate, which has been shown to be helpful in quelling cravings; and naltrexone. (There is also Vivitrol, the injectable form of naltrexone.)”

“Reid K. Hester, a psychologist and the director of research at Behavior Therapy Associates, an organization of psychologists in Albuquerque, says there has long been resistance in the United States to the idea that alcohol-use disorder can be treated with drugs. For a brief period, DuPont, which held the patent for naltrexone when the FDA approved it for alcohol-abuse treatment in 1994, paid Hester to speak about the drug at medical conferences. “The reaction was always ‘How can you be giving alcoholics drugs?’ ” he recalls.

“Hester says this attitude dates to the 1950s and ’60s, when psychiatrists regularly prescribed heavy drinkers Valium and other sedatives with great potential for abuse. Many patients wound up dependent on both booze and benzodiazepines. “They’d look at me like I was promoting Valley of the Dolls 2.0,” Hester says.”

“Hazelten was prescribing acamprosate to patients in 2003. But this makes Hazelden a pioneer among rehab centers. “Everyone has a bias,” Marvin Seppala, the chief medical officer, told me. “I honestly thought AA was the only way anyone could ever get sober, but I learned that I was wrong.”
“Stephanie O’Malley, a clinical researcher in psychiatry at Yale who has studied the use of naltrexone and other drugs for alcohol-use disorder for more than two decades, says naltrexone’s limited use is “baffling.”

“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.”

“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 50 years of research saying that, chances are, that’s not the way it’s going. We can change the course.”

“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.”
______________________________________________________________________
Gabrielle Glaser is the author of her book, Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control. This article was also published in The Atlantic, “The Irrationality of Alcoholics Anonymous. This article was read by 1.5 million readers.

 

(So is change possible? Only with the change of ideas and attitudes of the alcoholic treatment providers in the U.S. Unfortunately in the past, they have been negative and resistant to any new ideas that changes their belief system. If they are to remain relevant to the best treatment methods they must change.

The insurance industry as well as their clients are going to demand change. Continuing the old model will only insure more failure with fewer successes. So they can do nothing and not change and become antiques; or join the new modern scientific community of alcoholic treatments.)

Note: The comments in this article are those of Dr. Jack McInroy and not of Gabrielle Glaser.

Dr. Jack McInroy, Shrink1324@gmail.com