In the US, we frequently believe that there’s only one solution for people who develop a serious drinking problem: They have to quit, cold-turkey, start going to Alcoholics Anonymous meetings, and at that point, one drink is too many.
But that might not be the only way — and in fact, the 80-year-old AA approach to substance abuse treatment might be a pretty poor way to treat addiction compared to more modern methods, according to Gabrielle Glaser, author of “Her Best-Kept Secret: Why Women Drink — And How They Can Regain Control,” writing in The Atlantic.
Other strategies like interventions by a doctor, therapy that helps people understand why making a change is essential, and drugs that can ease cravings may work far better than AA according to a book Glaser cites, “The Handbook of Alcoholism Treatment Approaches,” which ranks AA 38th out of 48 possible treatments for alcohol-use disorders (the term “alcohol-use disorder” has replaced “alcohol abuse” and “alcoholism” according to the American Psychiatric Association’s book listing psychiatric disorders, the DSM-5).
It’s worth pointing out that some disagree strongly with the assertion that AA doesn’t work well, like Jesse Singal at New York Magazine, who says there’s much better scientific evidence that AA works than Glaser thinks.
Still, pointing out that there are other ways to treat problem drinking is helpful too, especially since not all drinking disorders are the same and some people may have different needs or respond better to one type of treatment than another. Singal agrees that these other options “may not always get the attention they deserve.”
A pill for people with drinking problems?
One of those options is naltrexone, a drug prescribed to help people reduce their drinking to moderate levels in Europe. It’s occasionally prescribed in the US too, but only to help people stop drinking altogether.
Glaser says that less than 1% of people who receive treatment for alcohol disorders in the US are prescribed any of the drugs known to help people cut back, even though we spend $US35 billion a year treating substance abuse — some estimates of substance abuse cost (including drugs) put those costs far higher.
The idea that a pill could treat what many think of as a behavioural problem that can only be helped by quitting drinking altogether sounds crazy, like a too-good-to-be-true solution for people who want a drug to solve their problems instead of really dealing with them.
But if you think of a compulsion to drink too much as something affected by brain chemistry and then you do something to modulate that brain chemistry, it makes much more sense.
As Glaser explains, research has shown that alcohol makes people’s brains start producing certain chemicals (and inhibiting others) that help make the brain feel good. As people become heavy drinkers however, their brains sometimes start to counteract that by producing more of the chemicals that make people feel anxious in general, at which point “instead of drinking to feel good, the person ends up drinking to avoid feeling bad.”
This cycle of tolerance and dependence — needing more to feel the same — is how addiction functions in general, though alcohol has its own unique effects on the brain and other factors (genetic and environmental) are involved as well.
Drugs like the opioid antagonist naltrexone regulate those feel-good effects that alcohol can have, making it easier to stick to one or two drinks instead of ten. People in Finland and Spain that are prescribed the drug take one about an hour before drinking to help them have a moderate evening, Glaser explains. Why rush to have more if it doesn’t make you feel particularly good?
Cold turkey isn’t the only option
It helps to remember that even though some people might need to cut themselves off from alcohol completely, not everyone does. The vast majority of people who drink too much aren’t alcoholics, according to the CDC.
Clinicians look at seven indicators of problem drinking: tolerance, withdrawal, impaired control (the inability to stop drinking once you start), unsuccessful attempts to cut down or stop drinking, continued use despite problems, neglect of activities, and time spent in alcohol related activity (having a large portion of your life revolve around drinking).
Three or more of those indicators constitute a disorder, six or seven a severe disorder.
People with particularly severe disorders may not be able to opt for a “moderation” approach and may need something like AA that provides an abstinence support nextwork.
But the vast majority of people who drink too much might have other options to help control their drinking, options which Glaser argues are underused in the US.
Aside from naltrexone, she mentions the similar drug nalmefene and also mentions acamprosate, which helps moderate cravings, and Antabuse, which makes people feel sick if they drink alcohol, helping those who want to abstain completely. Some things work for some people but not all, as is true for all medication. Behavioural therapies are options too, including some that are referred to as “moderation management.”
So why take medication that makes drinking less pleasurable in the first place instead of just quitting overall?
For one thing, it works. One Finnish group of clinics, Contral Clinics, that Glaser visited says they have helped 75% of their 5,000 visitors cut down to safe drinking levels over the past 18 years — a much better response rate than most abstinence-only programs can boast. While it’s hard to verify the clinic’s claims specifically, there are a number of studies confirming the effectiveness of pharmaceutical treatments that help people reduce drinking, including many conducted along with the clinic.
And for that great number of people who aren’t severely dependent but still drink too much — affecting their health, family lives, and jobs to some degree or another — an approach that makes moderation possible could be hugely beneficial for society.
As Glaser writes:
[P]romoting 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.
As a psychologist who runs a moderation management clinic in Florida told Glaser, “We cling to this one-size-fits-all theory even when a person has a small problem,” thinking that they are going down a dangerous road they must turn away from. “But we have 50 years of research saying that, chances are, that’s not the way it’s going. We can change the course.”
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