Posts Tagged ‘Alcoholism Treatment’


Alcoholics Anonymous: Cult or Cure? front coverby Chaz Bufe, author of Alcoholics Anonymous: Cult or Cure?

Chris Hedges’ series on RT, “On Contact with Chris Hedges,” has a new episode titled “The Fatal Addiction.” In it, Hedges does a fine job of presenting the human cost — the heartache, the deaths (50,000 last year in the U.S.) — caused by opioid addiction and overdoses.

While he succeeds at that, he doesn’t deal with the causes of addiction, nor with the failed, dominant approaches to curbing drug addiction, nor with better approaches. (Of course, it’s too much to expect any of this in a half-hour documentary, and one hope Hedges will deal with these matters in future episodes.)

Since “The Fatal Addiction” doesn’t tackle these issues, we will here. Please consider the following:

  • The dominant view of addiction in the U.S. is that it’s both a result of moral failings and is a “disease” or “illness.” (See AA’s “Big Book.”) This is  wrong on both counts, which can be easily seen when you look at historical addiction and overdose rates. They’re not steady, but vary dramatically over time.

Opioid overdose deaths have multiplied tenfold over the last two decades in the U.S.; reported rates of alcoholism have also fluctuated considerably over the years; the rate of tobacco addiction has plummeted in recent decades; and 95% of American soldiers who were addicted to heroin in Vietnam kicked it without treatment after they came home.

If addiction was caused by moral “shortcomings” (see AA’s 12 steps), one might ask whether former tobacco addicts became more moral over the years, whether morality skyrocketed among heroin-addicted Vietnam vets after they returned home, and whether the spiking opioid addiction rate has been caused by a mass outbreak of individual immorality.

If addiction is a “disease,” not a behavior, as we’re constantly told by 12-step treatment professionals, 12-stepping celebrities, and reporters who accept that absurd assertion at face value and who haven’t done their jobs (investigating, analyzing, raising awkward questions), one might ask the following: Why would the rates of addiction to different substances vary so radically from one substance to another in the same time periods, why would the rates of addiction to single substances vary so radically over time, and what does disease “theory” predict about rates of addiction in the years ahead?

Disease “theory” advocates have no answers to these questions, because disease “theory” is a “theory” only in the popular sense of the word (a conjecture or wild guess). In a word, it’s an assertion. It is in no way a scientific theory, and hence cannot provide answers; its adherents cannot use it to generate testable (falsifiable) predictions.

The dominant 12-step view of addiction (that it results from moral shortcomings and is a “disease”) is very, very wrong.

(As for the actual roots of addiction, one can look to psychological factors — stress and hopelessness, to oversimplify — and the environmental factors contributing to stress and hopelessness. I dealt with this in a separate post, “AA, the War on Drugs, and Disastrous Misconceptions,” so I’ll leave the matter here.)

  • As for AA and the treatment approaches derived from AA with its incorrect assertions about “moral” failings and “disease,” they’re every bit as ineffective as you’d expect.

Twelve-step groups such as AA and its clones (NA, CA, etc.) produce results no better than the rate of spontaneous remission, as shown by the best available studies: studies with control groups and random assignment of subjects, mass-participation longitudinal studies, and AA’s own triennial surveys. I summarized this evidence in “Alcoholics Anonymous Is Not Effective,” so again I’ll leave this matter here.

The formal (“professional”) 12-step treatment programs derived from AA are just as ineffective as AA itself. (I haven’t put up anything about this on the blog, but deal with the matter at length in Alcoholics Anonymous: Cult or Cure?)

One telling segment in Chris Hedges’ documentary is with an interviewee who mentions an addict who’s been in and out of rehab 17 times, which the interviewee says is typical. (The numerous 12-step references in the documentary [“meetings,” “sponsors,” “recovering addicts”] are equally typical.)

Clearly, the dominant American approaches to addiction aren’t working. Why, beyond faulty “moral failings” / “disease” premises?

  • For one thing, we’ve been stuck with the authoritarian, worse-than-useless “war on drugs” and the criminalization of addicts and recreational drug users for decades. This has resulted in untold suffering and incredible waste of tax money (easily $1 trillion over the years, and currently a good $50 to $70 billion per year).  Criminalization has ruined countless lives to no good effect, and it’s been utterly ineffective at reducing drug use and addiction. If you doubt this, consider the number of opioid overdose deaths over the years, that hard drugs are freely available to almost anyone who wants them (see Hedges’ “The Fatal Addiction“), and have become both cheaper and more powerful as the “war on drugs” has ground on.

So, what does work? What will reduce drug use, addiction rates, and deaths from overdoses?

  • On the purely personal level, the only treatment approaches with good evidence of efficacy are cognitive behavioral therapy approaches. (I deal with this in the final paragraphs of “Alcoholics Anonymous Is Not Effective.”)

I should note that methadone “treatment” merely substitutes a legal synthetic narcotic for illegal narcotics; this is substitution, not treatment — it keeps users dependent on an addictive substance.

  • On the societal level, it’s obvious that the “war on drugs” and criminalization of drug users and addicts must be abandoned.

Not only has criminalization of drug users and addicts failed to reduce the rates of drug use and drug addiction, it has taken an incredible human and economic toll. It’s done nothing to reduce the availability nor the price of drugs. And it’s a major component of “big government” intrusion into the lives of individuals.

Criminalization of drugs and drug users has been an utter disaster.

(Those who profit from the enslavement of “war on drugs” prisoners might disagree.)

Criminalization of drugs and their users is in large part directly responsible for the tens of thousands of overdose deaths every year in the U.S. Why? There is no quality control with illegal drugs. Those who buy them (especially opioids) are quite literally gambling with their lives, and multitudes lose that gamble every year.

So, is legalization (or at least decriminalization) a better approach?

Yes.

In Portugal, where drug use was decriminalized in 2001, the rate of death from overdoses has plummeted, as shown in a recent Washington Post article, “Why hardly anyone dies from a drug overdose in Portugal.” The rate of opioid addiction has fallen in half. Portuguese taxpayers aren’t paying ungodly amounts of money annually to lock up drug users and drug addicts. And Big Brother isn’t intruding (or at least intruding less) into one aspect of the lives of individuals.

  • Finally, here’s a question that almost no one asks, and even fewer try to answer: Why do millions of Americans feel so stressed, so hopeless that they drink themselves to death or play Russian Roulette with hard drugs?

The answer to that question has been available for decades.

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Alcoholics Anonymous: Cult or Cure? front coverby Chaz Bufe, author of Alcoholics Anonymous: Cult or Cure?

AA is arguably America’s most sacred cow, and has been almost since it first came to public notice prior to World War II. During the more than three-quarters of a century since then, while the country was inundated in pro-AA books and newspaper and magazine articles, entire decades went by without publication of a single book critical of AA, or a single critical article in a major periodical. This has changed a bit in recent years, but public criticism of AA is still relatively rare.

Why?

AA presents alcohol abuse as an entirely personal problem, and preaches that AA always “works if you work it.” If someone goes to AA and it doesn’t work for them, they tend not to talk about it, because of the stigma attached to alcohol abuse and because they probably do believe what they heard in AA–that their problems are entirely their fault. So, they don’t talk about AA.

And there are a lot of such people: well over a million Americans are either attracted to AA or are coerced into attendance annually, and then leave almost immediately. (According to its own figures, AA’s membership has been nearly static over the last two decades, with a growth rate considerably under 1% per year.)

But you don’t hear from those repelled by AA. Rather, you hear from and about the relatively few AA successes (roughly 5% according to AA’s triennial surveys). And because AA is a “program for life,” those few successes stick around to trumpet AA as “spiritual, not religious” (though it clearly is religious, as several federal courts of appeal have ruled), and as the only approach to alcohol abuse that works (though it clearly doesn’t work–its success rate is about that of spontaneous remission).

Those AA successes also tend to be the owners/operators of almost all alcohol abuse treatment facilities in the United States. They then use their position as “experts” to promote AA and its “program.” They also found “public health” 12-step front groups, notably the National Council on Alcoholism and Drug Dependence (NCADD), to lend a scientific sheen to their promotion of AA. (The NCADD is hostile to scientifically based treatment methods with good evidence of efficacy.)

Given all this, it’s not surprising that there’s so little critical examination of AA in the corporate media. Reporters are often overworked, and sometimes lazy, so they tend to take the easy way out and report as fact the claims of 12-stepping “experts,” while doing no investigation of those claims. Beyond that, there are many 12-steppers and relatives of 12-steppers in the media who openly promote AA and attack its critics while concealing their connections to AA. (One can’t “break anonymity,” of course.)

(Even some of those from whom you’d expect better fall into this category. About fifteen years ago Bill Moyers [who has a 12-stepping son] produced Close to Home: Moyers on Addiction about alcohol abuse and alcohol treatment. It was a love letter to AA and one of the most dishonest pieces of reporting I’ve ever seen.)

So, the next time you see a glowing article on AA, or an interview with a gushing “recovering” celebrity, don’t be surprised. Just be aware that the claims of AA’s promoters are just that–claims. AA is religious, not spiritual. And its success rate is no better than the rate of spontaneous recovery–that is, AA is utterly ineffective. Not that you’ll hear much about that in the media.

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Alcoholics Anonymous: Cult or Cure? front coverby Chaz Bufe, author of Alcoholics Anonymous: Cult or Cure?

AA’s supporters commonly trumpet AA as the best, if not the only, way  to deal with alcohol problems. To back their claims, they cite anecdotal evidence and uncontrolled studies; but they ignore the best scientific evidence–the only available controlled studies of AA’s effectiveness–as well as the results of AA’s own internal surveys of its membership.

There have been only two controlled studies (with no-treatment comparison groups) of AA’s effectiveness. Both of these studies indicated that AA attendance is no better than no treatment at all.

The first of these studies was conducted in San Diego in 1964 and 1965, and its subjects were 301 “chronic drunk offenders.”(1) These individuals were assigned as a condition of probation to attend AA, to treatment at a clinic (type of treatment not specified), or to a no-treatment control group. All of the subjects were followed for at least a year after conviction, and the primary outcome measure was the number of rearrests during the year following conviction. The results were that 69% of the group assigned to AA were rearrested within a year, 68% of the clinic-treatment group were rearrested, and 56% of the no-treatment control group were rearrested. Based on these results, the authors concluded: “No statistically significant differences between the three groups were discovered in recidivism rate, in number of subsequent rearrests, or in time elapsed prior to rearrest.”(2)

(As an aside, the results of this study were very close to being “statistically significant.” This normally means–as it did in this study–that there’s a 5% or less likelihood that random chance accounts for an outcome. In the case of this study,  there was a 6% or less  likelihood that the poor results of the AA group were the result of random chance. Hence, the authors classified the result as “no[t] statistically significant.”)

The second controlled study of AA’s effectiveness was carried out in Kentucky in the mid-1970s, and its subjects were 260 clients “representative of the ‘revolving door’ alcoholic court cases in our cities.”(3) These subjects were divided into five groups:  One was assigned to AA; a second was assigned to nonprofessionally led Rational Behavior Therapy; a third was assigned to professionally led Rational Behavior Therapy; a fourth was assigned to professionally led traditional insight (Freudian) therapy; and the fifth group was the no-treatment control group. The individuals in these groups were given an outcome assessment following completion of treatment, and were then reinterviewed three, six, nine, and twelve months later.

The results of this study were as follows: AA had by far the highest dropout rate of any of the treatment groups–68%;  the lay RBT group had a 40% dropout rate; the professionally led RBT group had a 42% dropout rate; and the professionally led insight group had a 46% dropout rate.

In terms of drinking behavior, 100% of the lay RBT group reported decreased drinking at the outcome assessment; 92% of the insight group reported decreased drinking; 80% of the professionally led RBT group reported decreased drinking;  67% of the AA attendees reported decreased drinking; and only 50% of the no-treatment controls reported decreased drinking.

But in regard to bingeing behavior, the group assigned to AA did far worse than any of the other groups, including the no-treatment control group. The study’s authors reported: “The mean number of binges was significantly greater (p = .004) (4) for the AA group (2.37 in the past 3 months) in contrast to both the control (0.56) and lay-RBT group (0.26). In this analysis, AA was [over four] times [more] likely to binge than the control [group] and nine times more likely than the lay-RBT group.(5)

It seems likely that the reason for this dismal outcome for the AA group was a direct result of AA’s “one drink, one drunk” dogma, which is drummed into the heads of members at virtually every AA meeting. It seems very likely that this belief all too often becomes a self-fulfilling prophecy, as it apparently did with the AA attendees in this study. Combine this with the million-plus people coerced into AA attendance annually in the U.S., and AA’s astronomically high dropout rate (95%, according to AA’s own triennial surveys), and it’s reasonable to speculate that AA contributes to binge drinking.

The third significant piece of evidence regarding AA’s effectiveness is that provided by AA’s triennial membership surveys. In 1990 or 1991 (there’s no publication date; I obtained the report in 1991), AA produced an analysis of its previous five triennial membership surveys, “Comments on AA’s Triennial Surveys.”(6) This document revealed that 95% of those coming to AA drop out during their first year of attendance. (7) Even if all those who remain in AA stay sober (which is not the case), this is still a poor success rate, even in comparison with the rate of spontaneous remission.

There have been many studies of spontaneous remission (sometimes called spontaneous recovery), and one meta-analysis of such studies indicates that between 3.7% and 7.4% of individuals with alcohol problems “spontaneously” recover in any given year.(8) In comparison with this, AA’s annuals 5% retention rate of new attendees is not impressive. And that 5% rate might be optimistic–it was derived from surveys conducted during the 1970s and 1980s, a period of very high growth in AA membership. In contrast, since the mid-1990s, AA’s U.S. membership has been almost flat. According to AA’s own figures, two decades ago it was roughly 1.2 million, and in January 2013 it was approximately 1.3 million.(8). This works out to a minuscule growth rate of under one-half of one percent annually. Even taking into account dropouts with “time” (in this “program for life”) and mortality, this means that AA’s current annual new-member retention rate could well be under 5%.

As for AA being the only way to beat an alcohol problem, it has been known for decades that alcoholism (alcohol dependence–as contrasted with mere alcohol abuse) disappears faster than can be explained by mortality after the age of 40.(9) Also a very large Census Bureau-conducted survey in the early 1990s found that over 70% of the formerly alcohol-dependent individuals surveyed (over 4,500 in all) had recovered without participating in AA or attending treatment of any kind, and that those who had not participated in AA or attended treatment had a higher rate of recovery than those who had.(10)

As well, in contrast to AA and treatment derived from it (the dominant mode of treatment in the U.S.), there are several types of treatment that are well supported by the best available scientific evidence (studies with random assignment of subjects and no-treatment control groups, and/or comparison groups using standard 12-step treatment). Among the best-supported therapies are those known as the community reinforcement approach, social skills training, motivational enhancement, and brief intervention.(11) All of these well-supported therapies are low-cost, cognitive-behavioral approaches in which alcohol abusers are reinforced in the belief that they have power over their own actions, and are responsible for them. (This is in direct contrast to the 12-step approach, which teaches alcohol abusers that they are “powerless.”) Unfortunately, none of these proven-effective, low-cost therapies is in common use in the United States, in which the ineffective 12-step approach dominates.

Finally, over the last third of a century, a number of “alternative” (non-12 step) recovery groups have arisen in the U.S., and many, many individuals have recovered through them. Abstinence-oriented groups include SMART Recovery, Secular Organizations for Sobriety, Lifering, and Women for Sobriety. Moderation-oriented groups include Moderation Management and Harm Reduction Network. Between them, they have hundreds of meetings across the country and all provide help via the Internet.

In sum, those who trumpet AA as the best (or only) way to deal with an alcohol problem do so only by ignoring well supported alternative therapies, the widespread “alternative” self-help groups, the best available scientific evidence, and the evidence generated by AA itself.

Endnotes

1. Ditman, K.S. et al. “A controlled experiment on the use of court probation for drunk arrests.” American Journal of Psychiatry, 124(2), pp. 64-67.

2. Ibid., p. 64.

3. Brandsma, J.M. et al.  Outpatient Treatment of Alcoholism: A review and comparative study. Baltimore: University Park Press, 1980.

4.  This means there was only a 1 in 250 chance that this was the result of random chance.

5. Op. cit., Brandsma et al., p. 105.

6.  “Comments on AA’s Triennial Surveys,” no author listed. New York: Alcoholics Anonymous World Services, n.d. (This document was intended for AA’s internal use only. It’s very crudely produced–mimeographed stapled sheets bound by a staple in one corner–and is not part of AA’s official “conference approved” literature. I first found mention of this document while digging through the reference shelves at AA’s San Francisco intergroup office in 1991, and I–and subsequently other researchers–obtained it by writing to AA’s General Service Office in New York and asking for it.)

7. Ibid., p. 12.

8. http://www.aa.org/en_pdfs/smf-53_en.pdf

9. Drew, R.D. “Alcoholism as a Self-Limiting Disease.” Quarterly Journal of Studies on Alcohol, 29, pp. 956-967.

10.  Dawson, Deborah. “Correlates of past-year status among treated and untreated persons with alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, Vol. 20, pp. 771-779.

11. See Handbook of Alcoholism Treatment Approaches (3rd Edition), by William Miller and Reid Hester. Pearson, 2002.

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