Substance Abuse Treatment Begins With Research


Foreword by Chris G:

This article describes Dr. Willenbring’s history of research, and the clinic he has set up to provide treatment based on the best scientific evidence available – something typically ignored by existing treatment facilities. Dr. Willenbring points out that after years of chemical use & abuse, an addict may need long-term, perhaps even permanent, chemical help if he has indeed permanently damaged his brain’s chemistry.

The 12-step path relies on the addict being able to repair his brain through re-wiring it with his “spiritual experience”. Well, some can, and some can’t, it seems. Those who can’t are the “12-Step failures”: lacking “honesty”, or “born that way”, or “suffering from grave emotional and mental disorders” – and there are likely many more of these people than successful AA members. If they need chemical help, long-term, to balance that neurochemistry, and treatment for other problems, why not give it to them? But which medicine(s) and treatment(s), for how long? That may be the new major argument. And it is certainly amenable to scientific study.

This article explores just one evidence-based rehab plan; there are many more. Some focus more on chemical intervention, others psychological or psychiatric methods; some may actually be pretty well balanced.

While Willenbring’s Alltyr facility is heavy into chemical treatment, it is thin when it comes to including elements that are the essence of AA: the fellowship, the camaraderie, the unselfish helping hands, and the pride of tribal membership. For many in recovery this kind of support is essential. An evidence-based treatment that included this aspect of AA would really have something.

We would like to have a section in The Practical Book on scientific treatment based upon modern day research into alcoholism. Have any of you had experience with evidence-based treatment? Some essays based on experience in this area would be most welcome.

And now, here’s the article, recently published in the New York Times:

By Gabrielle Glaser
Published  in The New York Times on  February 22, 2016

On the rainy fall morning of their first appointment, Dr. Mark Willenbring, a psychiatrist, welcomed a young web designer into his spacious office with a firm handshake and motioned for him to sit. The slender 29-year-old patient, dressed in a plaid shirt, jeans and a baseball cap, slouched into his chair and began pouring out a story of woe stretching back a dozen years.

Addicted to heroin, he had tried more than 20 traditional faith- and abstinence-based rehabilitation programs. In 2009, a brother died of an OxyContin overdose. Last summer, he attempted suicide by swallowing a fistful of Xanax. When he woke up to find he was still alive, he overdosed on heroin.

At a boot camp for troubled teenagers, he said, staffers beat him and withheld food. After he refused to climb a mountain in a team-building exercise, they strapped him to a gurney and dragged him up themselves.

The young man in the psychiatrist’s office paused, tears sliding down his cheeks.

“Sounds like a prison camp,” Dr. Willenbring said softly, leaning forward in his chair to pass a box of tissues.

He began explaining the neuroscience of alcohol and drug dependence, 60 percent of which, he said, is attributable to a person’s genetic makeup. Listening intently, the young patient seemed relieved at the idea that his previous failures in rehab might reflect more than a lack of will.

Dr. Willenbring, 66, has repeated this talk hundreds of times. But while scientifically unassailable, it is not what patients usually hear at addiction treatment centers.

Rehabilitation programs largely adhere to the 12-step principles of the 80-year-old Alcoholics Anonymous and its offshoot, Narcotics Anonymous. Addicts have a moral and spiritual defect, they are told; they must abstain from alcohol and drugs and surrender to a higher power to escape substance abuse.

This treatment is typically delivered through group therapy led by counselors whose main qualification is their own completion of the program. In some states, drug counselors with only a high school degree may treat patients, according to a 2012 study by the National Center on Addiction and Substance Abuse at Columbia University.

Dr. Willenbring says he believes this approach ignores the most recent research on the subject, a judgment he is well qualified to make. From 2004 to 2009, he was the director of treatment research at the National Institute for Alcohol Abuse and Alcoholism, and he oversaw dozens of studies proving the efficacy of medications and new behavioral therapies to treat drinking problems.

But he grew frustrated at the failure of most traditional rehabilitation facilities to take advantage of the findings.

“The taxpayers had paid for them,” he said of the studies, “but nobody was paying attention.”

When the National Heart, Lung, and Blood Institute, another federal research facility, publishes a major study on blood pressure, he said, cardiologists and other physicians in the field often move quickly to integrate the new drug or behavioral approach into their practices.

But the $35-billion-a-year treatment industry has proved far more resistant.

“When the facts change — and they’ve changed a lot — the minds have not,” Dr. Willenbring said.

“When we publish studies in our field, nobody who is running these centers reads them. If it counters what they already know, they discount them,” he continued. “In the addiction world, the knee-jerk response is typically, ‘We know what to do.’ And when that doesn’t work, we blame patients if they fail.”

And so in 2009, after five years in Washington, D.C., Dr. Willenbring returned to his home state, Minnesota, the birthplace of traditional inpatient rehab, to open a private clinic called Alltyr that treats people with alcohol and drug problems on an outpatient basis.

Unlike many rehabilitation concepts, in which treatment may be limited to a few weeks or months, Dr. Willenbring’s clinic, whose name was inspired by a stone with healing properties in Russian folklore, treats addiction as a chronic medical condition. After he makes an initial evaluation, his diagnoses may include a wide range of substance and psychological disorders.

His treatment plans can involve antidepressants; medication for anxiety, A.D.H.D. and chronic pain; anti-relapse medications; psychotherapy; and family training. Patients may come for a single consultation, or be treated for years.

The question of effective treatment for alcohol and substance-use disorders is more pressing than ever. According to a recent article in The New England Journal of Medicine, the number of Americans admitted to treatment programs for prescription opioids more than quadrupled from 2002 to 2012. Deaths from heroin overdoses nearly quadrupled from 2002 to 2013, the Centers for Disease Control and Prevention reported.

In addition, an estimated 18 million Americans have alcohol use disorder, according to the N.I.A.A.A., and a study published in JAMA last year found that the number of Americans who drank to excess was rising.

Last month, President Obama proposed $1.1 billion in new federal spending to fight the growing epidemic of heroin and prescription opioid addiction. His 2017 proposed budget designates $920 million for states to expand access to drug-assisted treatment over the next two years. It also calls for more prescription-drug monitoring programs and increasing the use of the opioid-reversal treatment naloxone.

Only 10 percent of those with alcohol and substance-use disorders ever seek treatment, said Brad Stone, a spokesman for the Substance Abuse and Mental Health Services Administration. The Affordable Care Act covers treatment for alcohol- and substance-abuse disorders, but many who need it fear they will be stigmatized if they ask for help.

A Range of Therapies

Many people in need of treatment believe that the only way to recover is to spend time at a rehab facility, which can cost as much as $50,000 a month. Yet there is no reliable evidence that intensive inpatient treatment is more effective than continual outpatient care, Anne M. Fletcher, the author of the 2013 exposé of the treatment system, “Inside Rehab,” said in an interview.

Dr. Willenbring founded his outpatient center, Alltyr, in St. Paul in 2012. Instead of spiritual confession, he relies on a range of behavioral therapies to help patients identify the triggers that lead to risky behaviors. They include motivational interviewing, in which therapists ask a series of questions intended to help clients understand why they drink or use drugs, and cognitive behavioral therapy, short-term counseling that helps patients recognize and avoid high-risk situations.

Dr. Willenbring also treats patients for depression, anxiety and post-traumatic stress disorder, which can make recovery from addiction difficult. He prescribes medications to reduce alcohol cravings, along with Suboxone to eliminate opioid cravings and block their highs. And he trains relatives to support their loved ones with kindness and compassion, not ultimatums.

The first year of treatment costs roughly $2,600; it decreases afterward.

A gentle man with a trim beard, graying buzz cut and green-framed glasses, Dr. Willenbring was raised in the rugged Iron Range of northern Minnesota. An avid skier and cyclist, he has been married to Kate Meyers, an artist and his business partner, for 37 years, and they have two sons. He has an eclectic style: He pairs John Varvatos suits with cowboy boots, and his office speakers pipe in blues and hip-hop.

Most of Alltyr’s 500 patients have mild to moderate alcohol-use disorder and want to try to curb their habits before they are out of control. But some have been on a long, tangled journey to multiple treatment programs.

“I don’t want anybody to have to go through the crap I had to,” said Joe Karkoska, 32, an elder care worker. Mr. Karkoska said he had tried 10 rehab clinics before he found Alltyr. Dr. Willenbring prescribed Suboxone, the drug Mr. Karkoska credits for his not having taken opioids for three years.

Dr. Willenbring’s embrace of medications for those who struggle with addictions is anathema to many involved in traditional recovery programs. Only about 2 percent of Americans with alcohol-use disorder are ever prescribed anti-craving medications, according to John Bowersox, a National Institute for Alcohol Abuse and Alcoholism spokesman.

The majority of those addicted to heroin or prescription painkillers do not receive methadone or Suboxone, Dr. Willenbring and other experts said, despite evidence of their effectiveness.

Dr. Willenbring is adamant that for many, such drugs are crucial for a safe recovery. Long-term use of opioids can halt the brain’s mechanism for producing its own painkilling chemicals, he said; without replacement drugs, many users remain in continuous discomfort.

In abstinence-based rehab, users are detoxed and lose their tolerance for drugs, he said — but they do not lose the cravings. “So what do they do when they get out?” he said. “They use the same amount as they did before and die of an overdose.”

Dr. Willenbring supports open-ended, long-term drug-replacement therapy for his patients with opioid-use disorder. That raises eyebrows among those who favor abstinence. John Johnston, a counselor at Serenity Lane, a treatment center in Eugene, Ore., said that although the drugs could help prevent overdoses, they did not address the core cause of addiction.

“Substituting one drug for another is an external solution for an internal problem,” Mr. Johnston said. Dr. Willenbring’s approach deprives “his patients of the opportunity to have a full range of emotional experiences, a change of spiritual perspective and a return to an improved quality of life.”

But for many of Dr. Willenbring’s patients, Suboxone has been instrumental in helping to find just that. Most, like Kyle Larsen, a 23-year-old nursing student from Albert Lea, Minn., began misusing opioids after they were prescribed for sporting injuries or operations.

He found Alltyr after a stint at Hazelden Betty Ford and another in a so-called sober-living facility. “It was one-size-fits all, except that it didn’t fit,” Mr. Larsen said.

Suboxone, he said, has eliminated his cravings, allowed him to regain the equilibrium he needed to return to school and to restore his family’s trust. Like many of Dr. Willenbring’s patients, Mr. Larsen attends a regular Suboxone group, which costs $100 a session and is offered to those who have been on a sustained, stable dose for many months. (They must submit urine samples to check for recreational drug use.)

The meeting offers a forum for patients to discuss struggles and successful coping strategies, as well as the camaraderie some studies have found to be supportive in drug- and alcohol-use recovery.

Despite being in addiction programs for years, many patients have never been treated effectively for depression, anxiety or other emotional disorders.

Mr. Karkoska, for example, began having severe social anxiety when he was in elementary school. He discovered opiates as a young adult, and they helped blunt his fears. Yet the repeated instructions he received in rehab — to “do the steps” and call his sponsor when he had cravings — did little to ease the panic that returned whenever he stopped shooting heroin.

Some years ago, one doctor prescribed high doses of the anti-anxiety medication clonazepam, which helped a little. “But I really didn’t have any idea how to calm myself down otherwise,” Mr. Karkoska said.

Since he began taking Suboxone, he has worked with Ian McLoone, an Alltyr therapist, to learn breathing exercises and cognitive behavioral techniques that help identify and change unhelpful, irrational beliefs. They have helped him cut down on clonazepam, overcome his fear of groups and work.

“I’ve got people depending on me now,” he said. “I’m a part of my community.”

The group’s conversation does not steer away from somber topics: friends who have overdosed; sad breakups, suicidal thoughts and job disappointments. But members encourage one another, and there are moments of levity, too.

Dan Bolmgren, an aspiring Minneapolis filmmaker who tried 12 rehab programs from Antigua to Utah, mentioned that he had smoked a lot of marijuana the past week. Dr. Willenbring made a theatrical gasp: “Oh no, not weed!”

This is a critical, and controversial, aspect of Dr. Willenbring’s approach to opiate addiction: He tolerates the casual use of drugs such as marijuana and alcohol. Overdoses, he argues, are the biggest threat.

“In here, we focus on the drugs that can kill you,” he told Mr. Bolmgren, 30. “The only way weed is going to do that is if a bale of it falls on your head.”

Some specialists questioned Dr. Willenbring’s tolerance for marijuana and alcohol use among patients who have misused opioids. Dr. Willenbring describes the notion of “cross-addiction” — the chance that a person with alcohol-use disorder will develop, say, an opioid problem — as overblown, and points to a large 2014 JAMA study that found it unlikely.

But Dr. David Sack, an addictions psychiatrist who is the president and chief executive of Elements, a California-based chain of treatment centers, disagrees, cautioning that cannabis or alcohol use could undermine the efficacy of Suboxone treatment.

“Alcohol and marijuana are real drugs,” he said. “People enjoy their lives most fully when they use the fewest amount of substances. Why wouldn’t we want to maximize that potential?”

Dr. Sack said that he supports the use of Suboxone and methadone, but added that their success rates, which are difficult to track, are oversold.

Still, their use is becoming more mainstream. The Hazelden Betty Ford Foundation, long a bastion of 12-step care, has been offering patients Suboxone and extended-release naltrexone, another drug that blocks the high of opioids, since 2013.

Deciding to Fill a Void

Dr. Willenbring did not set out to be an addictions psychiatrist. During his residency at the University of California, Davis, in the late 1970s, fellow residents were clamoring for grant money to study psychotherapy. His mentor directed him to an even larger set of National Institutes of Health funds to study effective treatments for complex patients, including medically ill veterans who were also alcohol dependent.

Quickly, he became an expert in a field that had attracted relatively few researchers and was neglected by general practitioners, who often have biases against patients with alcohol- and substance-use disorders.

Indeed, few medical school students ever learn about addiction, and only a small percentage of physicians are specifically trained to treat them, said Kathryn Cates-Wessel, the executive director of the American Academy of Addiction Psychiatry.

By the early 1980s, Dr. Willenbring was treating patients with severe drinking problems at the Department of Veterans Affairs hospital in Minneapolis. Most had dire living circumstances but aspired to conventional lives: a wife, children, two cars in the driveway.

“They were in the deep, deep hole of addiction,” Dr. Willenbring said. “And the traditional approach to treatment — just work this program and you’ll dig yourself out — wasn’t working.”

One night while walking his dog in a snowstorm, Dr. Willenbring wondered why so few of his patients were able to abstain from drugs and alcohol. Most people with alcohol and substance use disorders need months or years to achieve stable recovery.

But they were seldom treated as if they had a chronic illness. “If you went to a doctor during your first bout with asthma, would you expect to be cured after just one inhaler?” he said. “Of course not. Why not approach addiction the same way?”

These days, Alltyr is expanding, recently adding a second psychiatrist to its staff of three therapists and a nurse. Dr. Willenbring said he saw treatment of addictions moving toward the mainstream of evidence-based medicine.

“Before Prozac,” he said, “nobody thought a depressed person could get well outside a mental hospital. But that’s not true anymore, either.”

32 Responses

  1. Rajiv B. says:

    Thanks AA Agnostica for highlighting the need for correcting the brain biochemistry of addicts/alcoholic. But this NY Times article does not give us the real facts. It says:

    The majority of those addicted to heroin or prescription painkillers do not receive methadone or Suboxone, Dr. Willenbring and other experts said, despite evidence of their effectiveness.

    But the fact is that suboxone and methadone are both opiods like heroin and are much more dangerous than heroin, and also lethal. The January 2012 Grand Rounds report of the Centers for Disease Control and Prevention (CDC) announced that, “Since 2003, more overdose deaths have involved opioid analgesics (prescription painkillers) than heroin and cocaine combined.” (Prescription Drug Overdoses — a U.S. Epidemic) And in July 2012, CDC announced that Methadone contributed to nearly 1 in 3 prescription painkiller deaths. (Use and Abuse of Methadone as a Painkiller) But the worst of it was that in 2012 the United Nation Offices of Drugs and Crime (UNODC) got the biggest government hospitals in India to begin prescribing methadone. It’s a pathetic situation for the poor addicts here. I’ve served as the NA India Region’s Regional Delegate (RD) and have even started H&I for NA in India and so I get to see how badly it’s affecting the hospital addicts.

    Also all psychiatric drugs are psychoactive substances and the standard McGraw Hill textbook Vander’s Human Physiology says:

    Virtually all the psychoactive substances exert their actions either directly or indirectly by altering neurotransmitter-receptor interactions in the biogenic amine—particularly dopamine—pathways. For example, the primary effect of cocaine comes from its ability to block the reuptake of dopamine into the presynaptic axon terminal. Psychoactive substances are often chemically similar to neurotransmitters such as dopamine, serotonin, and norepinephrine, and they interact with the receptors activated by these transmitters.

    And once any psychoactive substance – both street drugs and prescription psychoactive drugs – makes alterations in a person’s neural pathways in the brain, the person cannot feel normal unless he or she continues taking the substance. This is why these people continue taking the drugs and alcohol and become addicts.

    Our biochemistry can be corrected only by nutrition and vitamin supplementation, and not by psychiatric drugs. Bill W in his final years had written three papers on The Vitamin B-3 Therapy for Doctors in AA. And I’ll write more about it in another article or a small book later on.

    I’m so glad that I’ve finally found your site, where I can openly share all this. Thank you.

    • Brent P. says:

      How Is Suboxone Treatment Different than Drug Abuse?

      Buprenorphine / Subutex / Suboxone

      In 2002, the FDA approved the use of the unique opioid buprenorphine (Subutex, Suboxone) for the treatment of opioid addiction in the U.S. Buprenorphine has numerous advantages over methadone and naltrexone. As a medication-assisted treatment, it suppresses withdrawal symptoms and cravings for opioids, does not cause euphoria in the opioid-dependent patient, and it blocks the effects of the other (problem) opioids for at least 24 hours. Success rates, as measured by retention in treatment and one-year sobriety, have been reported as high as 40 to 60 percent in some studies. Treatment does not require participation in a highly-regulated federal program such as a methadone clinic. Since buprenorphine does not cause euphoria in patients with opioid addiction, its abuse potential is substantially lower than methadone.

      What Is Medication-Assisted Treatment?

      Medication-assisted treatment for opioid dependence can include the use of buprenorphine (Suboxone) to complement the education, counseling and other support measures that focus on the behavioral aspects of opioid addiction. This medication can allow one to regain a normal state of mind – free of withdrawal, cravings and the drug-induced highs and lows of addiction. Medication-assisted treatment for opioid addiction and dependence is much like using medication to treat other chronic illnesses such as heart disease, asthma or diabetes. Taking medication for opioid addiction is not the same as substituting one addictive drug for another.

      What Is Suboxone and How Does it Work?

      There are two medications combined in each dose of Suboxone. The most important ingredient is buprenorphine, which is classified as a ‘partial opioid agonist,’ and the second is naloxone which is an ‘opioid antagonist’ or an opioid blocker.

      What Is a ‘Partial Opioid Agonist’?

      A ‘partial opioid agonist’ such as buprenorphine is an opioid that produces less of an effect than a full opioid when it attaches to an opioid receptor in the brain. Oxycodone, hydrocodone, morphine, heroin and methadone are examples of ‘full opioid agonists.’ For the sake of simplicity from this point on we will refer to buprenorphine (Suboxone) as a ‘partial opioid’ and all the problem opioids like oxycodone and heroin as ‘full opioids.’

      When a ‘partial opioid’ like Suboxone is taken, the person may feel a very slight pleasurable sensation, but most people report that they just feel “normal” or “more energized” during medication-assisted treatment. If they are having pain they will notice some partial pain relief.

      People who are opioid dependent do not get a euphoric effect or feel high when they take buprenorphine properly. Buprenorphine tricks the brain into thinking that a full opioid like oxycodone or heroin is in the lock, and this suppresses the withdrawal symptoms and cravings associated with that problem opioid.

      Buprenorphine is a long-acting form of medicated-assisted treatment, meaning that it gets ‘stuck’ in the brain’s opiate receptors for about 24 hours. When buprenorphine is stuck in the receptor, the problem ‘full opioids’ can’t get in. This gives the person with opioid addiction a 24-hour reprieve each time a dose of Suboxone is taken. If a full opioid is taken within 24 hours of Suboxone, then the patient will quickly discover that the full opioid is not working – they will not get high and will not get pain relief (if pain was the reason it was taken). This 24-hour reprieve gives the patient time to reconsider the wisdom of relapsing with a problem opioid while undergoing medication-assisted treatment.

      Another benefit of buprenorphine in treating opioid addiction is something called the ‘ceiling effect.’ This means that taking more Suboxone than prescribed does not result in a full opioid effect. Taking extra Suboxone will not get the patient high. This is a distinct advantage over methadone. Patients can get high on methadone because it is a full opioid. The ceiling effect also helps if buprenorphine is taken in an overdose – there is less suppression of breathing than that resulting from a full opioid.

      • Rajiv B. says:


        Emergency departments reported a significant rise in the number of visits related to the opioid addiction medication buprenorphine between 2005 and 2010, according to a new government report. The number of buprenorphine-related visits rose from 3,161 in 2005, to 30,135 in 2010.

        The scary news for us in AA is that Alcoholic Foundation, which is now called AA’s General Service Board, was founded by Willard Richardson, who was in charge of all of Rockefeller Church Charities, and Frank Amos, who was Rockefeller’s marketing and advertising genius (Pass it On, p. 188), Rockefeller Medical Institute being the Institute that got the Methadone therapy approved by the FDA.

    • life-j says:

      Just my personal feeling, one man’s vote, that while I don’t share the more fundamentalist oldtimers’ refusal to talk about drugs at all, I do get a bit concerned when the discussion turns to be all about drugs…

  2. John R says:

    “Addicts have a moral and spiritual defect, they are told; they must abstain from alcohol and drugs and surrender to a higher power to escape substance abuse.”

    The above statement does not reflect anything I was told when I got sober, nor does it accurately state the case I still make today. I use the steps primarily to find peace and serenity of mind … to let go of my own preconceived ideas, reactions, and implicit memory laden knee-jerk attitudes. The steps don’t get me sober, and they don’t keep me sober – no moral rearmament would. As for suboxone, I have heard a lot of horror stories about it from those who’ve had a hard time getting off of it, and I haven’t seen any good longitudinal studies regarding its efficacy. U.S. pharma and psychiatry has a long history of using clients as guinea pigs. User beware.

    • Brent P. says:

      You are falling prey to a couple of popular myths. While I can’t say a thing about psychiatrists and pharmaceutical companies (so maybe that’s not a myth) I can speak to suboxone and addiction doctors. The doctor/former addict I see practices at the largest institution dedicated to treating addiction and mental health. It is a research facility and it is massive. My doctor (M.D.) provided me with suboxone that I was nervous about starting so she showed me studies plus anecdotal testimonies from other doctors and how their patients reacted. I started at 12 milligrams 3 years ago and am down to 8 now, making reductions of 2 milligrams at a time. Since there is no hurry she simply asks if I’m feeling like taking it down another notch. I’ve never said no and I’ve never had any discomfort doing so. While methadone can get a heroin addict high, suboxone has no psychotropic properties. It just means if you were to take something while on it you’d get none of the benefits. Your comment and cleverly disguised passive aggression (here here), didn’t address the issue at hand nor did it really provide any insight at all. It appears that it’s just your opinion based on hearsay. You came tilting at windmills.

      • John R says:

        Passive aggressive? Hardly. I simply stated my reservation regarding the medication. I appreciate more information, not flaming.

        That you can’t “hear” the idea that the article misrepresents AA as I understand it doesn’t necessarily mean that my comments don’t address an issue; simply that you seemingly may not want to see the issue i was primarily addressing.

        AA bashing seems to be De Rigueur by certain factions of the professional recovery reportage, but I think accuracy is important. ymmv.

        Glad you’re experiencing sobriety and recovery and wish you all the best.

      • John R says:

        FYI re: suboxone as problematic: Addiction Treatment With a Dark Side, NY Times 2013.

  3. Laurie says:

    When I edited “Share”, AA’s magazine in England and Wales, I put what I thought was a snappy headline on a letter “Meditation – not medication”. I was humbled by the angry reply from a reader who said he took anti-depressants to keep him alive and he did not have the emotional or mental resources to meditate. Meditation ain’t much use if you’ve got diarrhoea. [Apropos the United Kingdom: the fellowship this side of the pond is AA Great Britain. Britain comprises England, Wales and Scotland (which has its own magazine, “Roundabout”).

    “AA’s great failing is its refusal to even look at what modern day research is teaching us about alcoholism…” An unfair sweeping criticism. GSB trustees over the years and today (certainly in Britain) have included non-alcoholic psychiatrists and other clinicians. The current AA literature list still includes Bill W’s Grapevine article, “Let’s Be Friendly With Our Friends”, including those in the medical and academic fields. Bill notes, “The vast majority of us welcome any new light that can be thrown on the alcoholic’s mysterious and baffling malady, whether it be from a test tube, a psychiatrist’s couch or social studies.” If that has changed, why hasn’t the pamphlet been withdrawn? Another pamphlet, “How Members Co-operate With Professionals” records that a 1992 survey found a third of those questioned credited outside assistance with their recovery. Question 15 – “Does co-operating with professionals do any good?” answers in the affirmative (look it up).
    I recall that in the 80s “Grapevine” used to carry a regular page giving information about the latest developments in the treatment of alcoholism. I don’t know why it was discontinued, possibly because these were considered outside issues deflecting our attention, resources and energy from our primary purpose?

    As to AA’s declining or flat-lining membership, there may be many causes and without a rigorous research program one member’s anecdotal opinion is as worthless or valuable as anyone else. In any case a tree doesn’t reach the sky, maybe we’ve reached a natural plateau, but who knows?

    • Brent P. says:

      A lonely pamphlet on a threadbare library table and a statement in a decades old Grapevine – does anybody know when the next one’s coming out, I just can’t wait for the robust insights that magazine is jammed full of – do not constitute a longstanding policy of helping people get outside help. In fact if that’s all there is to point to when someone wants to know AA’s advice on medication, doctors who prescribe such and who those doctor’s might be, they don’t do the job. If anything it suggests a reluctant concession that, yes, some people do have other problems and may actually NEED outside help. It’s clear AA is not about keeping its members up to date on the newest developments in treatment or that would be a part of every meeting. In fact maybe it could replace the “slogan interpretations”.

      I say, in presenting this article AA Agnostica is making the next logical move for becoming a rational, relevant and vital resource for those suffering from things that clearly remain after the booze and drugs have been removed. The things that will drive a person back to drugs and drink.

      As there’s a spirit of the law there needs to be a spirit to AA and its stated purpose. People go there to stop drinking often without realizing that many afflicted by addiction have several possible, acute mental/emotional disorders that require attention if any real progress is to be made. If AA is actually there to help the suffering alcoholic, then it has a responsibility to be fully aware of all the ways alcoholics do suffer then recognize that AA is limited in what it provides.

      My suggestion to AA would be, keep it simple, keep AA a place where people with common problems made evident by alcohol abuse, gather with one another to trade stories, socialize and so on. But make it clear, it doesn’t treat alcoholism, rather it’s a supportive community that will happily accept others struggling from alcoholism to join them. And that it has on its library tables summaries of the most up to date treatment practices that will help the person recognize the holistic nature of their problem and what they might do to address the entire disorder.

      • brien says:

        Brent, your last two paragraphs are brilliant. If AA followed the last paragraph I believe so many more people could be saved from alcoholism.

    • Chris G. says:

      You have some really excellent points here, Laurie. From comments here, and contacts over the past few years, I get the impression that GB has a generally more secular and less ingrown AA than North America… although the variation by location in North America is certainly huge.

      My own single person anecdotal feelings about AA (shared by quite a few on this forum) undoubtedly come from so many local meetings of the heavily religious and BB-as-a-Bible type. In so many areas, this really is the face of AA that the public, and the newcomer, sees.

      Good point about dealing with professionals, too. Unfortunately, again my experience, most professionals, up until now, haven’t a clue when faced with an addict (alcohol or otherwise). Over the past 30-odd years I’ve dealt with over a dozen of them, and only two, both recovered from something themselves, knew what was going on and were helpful.

      I hope all this current conversation, here and elsewhere, will provide a leaven to get new information rising in the general AA consciousness.

  4. Kal B says:

    There is a free online course, designed to last for six weeks, which, amongst other things, showcases the current scientific research done at the UK’s National Addiction Centre which is based at King’s College, London. This may help people to understand what is going on in the global research effort. I commend it to the attention of anyone interested in this topic. It starts March 7 (Monday) and you can enrol here: Understanding Drugs and Addiction.

    Understanding Drugs and Addiction

  5. Skip D. says:

    “Some specialists questioned Dr. Willenbring’s tolerance for marijuana and alcohol use among patients who have misused opioids.” No shit! Anyone who can make a statement like “In here, we focus on the drugs that can kill you”, and not include alcohol as one of those drugs, doesn’t know much about alcoholism and alcohol abuse. I’d like to get a reference for that 2014 JAMA study he cited.

    It seems to me Dr. Willenbring is falling for the same denial-lies that many opioid addicts tell themselves and others… alcohol is not their problem – they can take a drink or leave it. As long as there are opiates available, maybe, but I have yet to meet a recovering heroin addict who drinks normally. Not that there are aren’t any, but that I’d bet they are very rare. Again, I’d like to read that 2014 JAMA study.

    • Jim says:

      I do know a couple of recovered heroin addicts who can take or leave alcohol. When they drink, which is rarely, the drink moderately. I have also spoken with folks who use marijuana to relieve anxiety and to stay off of booze. Yet they are derided in AA for using “the marijuana maintenance program.” I’m of the mind that if it improves the quality of life by the sufferer’s definition then I’m all for it.

      It seems that you are solidly immersed in 12 step based abstinence philosophy.

  6. Ron H says:

    Medication, not self medication, is very helpful. Antidepressants and antipsychotics. I have been helped by them. Not needed anymore but my brain needed them to relieve my symptoms so I could work on myself. I don’t need antipsychotics anymore because my meditation, thought management, and my understanding of the cause of my fear.

  7. Alma P. says:

    Hi. To each their own. I finds the identification, sense of belonging, a clean and well lit place to take myself to whether feeling bad, good, or indifferent and laying off all mood altering substances for 29 years works for me wonderfully.

    I will say I took an antidepressant and a tranquilizer twice in my recovery – once when suffering severe PTSD after Hurticane Katrina for 3 months and for 4 months when taking Hepatitis C treatment that made me crazy. But I stopped the meds when the episodes resolved then got back on my feet physically and mentally using the program. It works despite all the religious stuff in it where I live. I have a glorious life and I got it using the program. The program is my chronic treatment.

    Subixone contains a narcotic and of course is addictive. My sponsee just got off of it after a year. She is doing great and going to meetings. Unlike an old friend who shot and killed himself because he thought he could not detox off of suboxone. His thinking was distorted by the drug. I wish all persons well in their lives and hope all will find sobriety and happiness. For me total abstinence is the path that gave me a wonderful existence.

    I found the article personally disturbing because it reminded me of when I was using and trapped in a quagmire I felt there was no way out of but to be medicated. That proved to be quite untrue and I’m lucky I got around clean people in early recovery who showed me a different way to live.

    Thanks everyone for sharing. I need you all.

  8. Steve K says:

    While I agree that AA needs to modernise and evolve, some of the above criticisms are unjust in my opinion. I’ve been attending meetings for 25 yrs in the UK, and have generally always heard it suggested that members seek outside help for co-occurring illnesses etc. Every other person in AA is on some sort of prescribed medication, and seeking medical/psychiatric help is officially suggested by GSO in a leaflet they produce; in this country anyway. There’s nothing stopping members from taking antagonists or agonists either, and attending AA.

    In the UK it’s common for AA members to have an alcohol/drugs worker (NHS) who is not connected to the 12 Step approach. The NHS alcohol and drugs service in this country has always been outside of 12 Step philosophy; and until recently pretty much against it in the main; favouring behavioural theory and CBT/psychotherapeutic/medical interventions. Drugs like methadone, subutex and naltrexone have been prescribed in these services for many years, and are often misused by addicts. There are addicts in this country who have been stuck on methadone since the 1980’s and I personally know some of them from my drug using days.

    If alcoholics/addicts genuinely want to get better then they can make good use of medications as aids to recovery; the same goes for AA, NA , SMART and other recovery support groups. Acceptance and willingness being all important. All these different groups, services , medications and psychotherapeutic interventions can be combined to suit the particular needs of the individual. Has not AA always suggested a co-operative (not the same as affiliation) attitude towards the medical profession and those concerned with alcoholism. “Let’s be friendly with our friends” does it not say somewhere in the literature?

    As for allowing heroin addicts etc to smoke weed and drink alcohol in treatment (mentioned in the article)… ignorant and misguided comes to my mind! There is a treatment centre near me that used to allow clients to drink if they had only previously used heroin etc; alot would end up getting drug and relapsing on their so called “drug of choice”. I’m pretty sure this practice was stopped. My experience is that alcoholics/addicts tend to substitute addictions. The science suggests that alot of drugs affect the same neurotransmitters and areas of the brain. Also, the same causes and conditions exist whatever the particular addiction.

    AA just suggests one method of recovery, and I’m pretty sure Bill W. said that it didn’t have a monopoly on the subject. The fellowship has no opinion on outside issues, so can’t be against the use of medications, and or, other therapies. Whatever works for you.

    PS. the effectiveness of participation in 12 Step groups (not the program) is “evidence based.” According to multiple research studies since the 1990’s.

    And finally…. AA is not the same as the rehab industry, lets not confuse them.

    • life-j says:

      Steve, yes there is a fair amount of methadone abuse and dependence going on – but I have not seen it anywhere that naltrexone has been abused, or even can be abused or create dependence, other than of course, like our favorite medical analogy, diabetics are dependent on insulin, something similar can be said for naltrexone, but does insulin get a diabetic high? Do they obsessively look forward to their fix? Ok, so just because two substances each are used in some manner in treatment of addiction does not make them similar in every respect. Their action may be very, very different, as indeed it is the case.

      As for CBT and how NHS is typically not all that favorably disposed toward AA, yes, that’s GB, most european countries are composed of rather sane people, the US on the other hand by and large is made up of irrational people, look, there’s not only 85% religious people, as compared to what, 50% or less in GB, but there are probably 40% or more that would vote for Trump. Most of them poor people whose objective interests it would be entirely contrary to, but he will make America great again, so WTF?

      Not sure what I’m doing living in a country which is basically insane, but I can’t quite see moving at this point. This is where I happen to have my life. But it’s hard to imagine this level of irrationality if you haven’t lived with it up close.

      • Steve K says:

        Take your point on board re: naltrexone life-j. I’m not so sure about most european countries being composed of sane people though – we have our share of the insane too.? Trump’s popularity is very worrying though; and you are right – I’ve never lived in the US and so cannot really appreciate the differences between countries.

  9. John L. says:

    Why was this article published? — by a woman who in her Atlantic article attacked the very heart of AA? As expressed in the AA Preamble and the Third Tradition, AA is about two things: the Fellowship and abstinence. The Third Tradition is about a desire to stop drinking, not a desire to drink “in moderation”. The heart of AA is alcoholics talking to each other; Gabrielle Glaser and those she’s promoting would change that to alcoholics talking to therapists. Instead of staying away from the First Drink, Glaser et al. open the door of drinking “in moderation”, which for true alcoholics means opening the door to death.

    The approach of Glaser et al. is that of the psychiatric-pharmaceutical complex, with all of its harmful commodities. We don’t need more junk diagnostic labels or more drugs, and we certainly don’t need the siren song of “moderate drinking”.

    In her Atlantic article Glaser favourably mentions people who committed fraud and got away with it — fraudulent research claiming that controlled drinking is a viable option for alcoholics. This fraud is exposed in an article by Irving Maltzman:

    Two books by James R. Milam — Under the Influence and Ending the Drug Addiction Pandemic — describe the pernicious influence of psychiatry on alcoholism recovery, the danger of promoting “moderate” drinking for alcoholics, and the dangers of mind-altering drugs for alcoholics. I have reviewed both books in AABeyond Belief:

    Some earlier works by Milam are on my website: “The Alcoholism Revolution” and “More on the Alcoholism Revolution” .

    We may criticise the things in AA that are wrong and ought to be changed, but we should defend the things that are right. We should defend abstinence and the Fellowship.

    • life-j says:

      John, I think you and I have argued about this before. I see abstinence as a goal, too.

      If however I have to choose between a treatment mode which gets 5% abstinent by promoting complete abstinence, and one that gets 40% abstinent by promoting moderation (with hopeful abstinence), I’d be very inclined to look closely at the latter, even if it also got 40% to only cut their drinking down to non-suicidal levels.

      I know, those that only cut their drinking in half or better, I should be very upset that they aren’t out working hard at drinking themselves to death until they finally get “it” and are ready to crawl to the cross, but to me the goal of alcohol treatment in the first instance is to save lives, regardless of how badly it conflicts with my philosophy of abstinence.

      • Ron H says:

        Crawl to the cross? There are many philosophies and religions that don’t believe in Christianity or some like Buddhism that don’t believe in any gods. The program pushes monotheism – the belief in one god or one HP. Be nice if all beliefs were accepted. Not just Christian or monotheism, neither of which are universal.

    • Jim says:

      I see that you are firmly stuck.

  10. Lubow says:

    I too congratulate on this posting. Yes science is finally addressing alcoholism and drug addiction. A variety of treatment models are now available. We need to encourage people suffering from the disorder of addiction to pursue all, and any, venues available to achieve a life free of active abuse of both or either.

    Not only are there different approaches to treatment but (as with any other disease/disorder) there is more than one form of this disorder, e.g. some people start their career of addiction during teenage or preteen years, there are those that start to drink alcoholically later in life (after completing education and learning life skills), recent research suggest that there may be female alcoholics who have the addictive genetics but the alcoholism is finally triggered by hormone imbalances. Many suffer additionally from other co morbid disorders. The same approach may not be equally successful with each variant of the disorder.

    The one, most important aspect of AA is the fellowship, the constant reminder of the danger of this disorder, the support offered to the struggling new recovering alcoholic/addict. AA must be open to supporting every alcoholic, regardless of the treatment that works for him or her.

    I have a suggestion, a challenge, to convene and host a mini AA conference to debate the future of AA, the role of AA in the 31st century, can there be various forms of AA? Answering these questions by AA members will define the future of AA and its viability.

    I also suggest that this be done not by AA Agnostica but by AA members who care about other alcoholics and the future of AA. I also suggest that these mini conferences can first be initiated at the local city level, ensuring feedback from both long term members, new members as well as alcoholics who did not benefit from the AA programme.

  11. annalia says:

    Once, when I was 20 some years sober, I went to a small women’s AA meeting with 8 members. In the discussion, I mentioned I was on antidepressants. Seven of the 8 other members admitted they were also on antidepressants, but had never admitted it before because they saw how others were treated when they did. If I had not had antidepressants, I doubt I would be alive today. I first planned suicide at the age of 8. (Now I have 40+ years sober.)

  12. Brent P. says:

    Bravo! As one who was really at the end of the line after a 30 year search for treatment that worked for me, almost six years later I remain clean from crack cocaine, opioids and alcohol. What did it take? A couple of months at a credible (medically up to date) rehab, work with two doctors on my severe anxiety/panic disorder and, finally, an ongoing relationship with a doctor/addict who has me on suboxone and an anti depressant. I can function which means I can get on the subway, which I couldn’t before, speak before others with little anxiety, and I can reliably perform work. That’s all I ever wanted. But why did it take 30 years? Because I tried to work the AA program that didn’t work for me.

    When I finally presented my problem to doctors trained in the field, who were able to identify and quantify my disorders and treat them with medications, I got better.

    Funny how often the diabetes metaphor gets used in AA to justify regular attendance and the full acceptance that AA is the insulin I so desperately need. It’s a flawed analogy because the diabetic doesn’t go to meetings with other diabetics and pray away his/her condition. They take the substance their body doesn’t produce, insulin, and they go about their business.

    Modern science doesn’t have a cure for addiction, but it knows the dimensions of the problem and can describe what is largely lacking in the biochemistry of the addict. So in providing solutions to those problems, many addicts become functioning, productive contributors to their communities, families and employers. They, like the diabetic, get the medicine that stabilizes their biochemical anomalies and, strangely, they seem to get better.

    As for meditation and so on, one of the doctors I worked with, that’s all we did. It is a tremendous adjunct to my life overall but I couldn’t have sat still for more than a minute without the medications I take today.

    The longer AA goes without changing a single word in its doctrine the more it sounds like voodoo. It’s a fact of science, we’re either moving forward or we’re dying. For all the entrenched apologists AA has among its members, in not allowing for new information they are making certain the program has no relevance or reason for being. They are killing it by insisting on remaining ignorant.

  13. steve b says:

    I think it’s best to go with whatever works, whether it’s medication, counseling, AA, or some combination. And it’s important to learn more. If AA stands in the way of progress, it will need to change or else it may come to be seen as old-fashioned and ineffective. If AA modernizes, that’s fine with me. And if it doesn’t, I’m perfectly ok with its extinction.

  14. Ron H says:

    I don’t see the practice of meditation meantioned or neroplastisity. Meditation attacks the thinking disease. What if, like me, people could remain mentally silent most of the day and choose their thoughts and be able to see the patterns. Meditation changes the structure of the brain. The western world does not seem to use the very wise methods of the East.

    • Chris G. says:

      I agree. Getting some basic meditation training (Shambala flavor) and developing a daily practice has positively changed my “life as an addict” nearly as much as getting sober in the first place did. Unfortunately, there is also a lot of “woo-woo” and snake oil out there in the meditation world.

      I know several fellow alcoholics who think they have tried meditation and report no success — but they still have no idea what it really is, and don’t seem to want to know. Some local neighborhood guru with some incense and funny music has totally taken them off track. Modern hippies, trying to contemplate the infinite.

      I would like to see meditation in the arsenal of any evidence based treatment program; but just like the drugs, it has to be presented by somebody who knows what he’s doing. Amateurism has gotten AA only so far, and it is anathema to scientific recovery.

  15. life-j says:

    Now of course this article is mostly about opioid use, but the point is the same: Once you start looking at AAs success with an open mind, you find that while, as Chris importantly states above:

    including elements that are the essence of AA: the fellowship, the camaraderie, the unselfish helping hands, and the pride of tribal membership

    the “program” itself really doesn’t DO much.

    At present it seems that all roads lead toward Naltrexone.

    There are a couple of YouTubes with Glaser, that are good to watch, though the synchronization is so bad it is almost painful to look and listen at the same time:

    What Alcoholics Anonymous Doesn’t Get Right
    The False Gospel of Alcoholics Anonymous

    We’re likely on this quest to wind up mostly abandoning AA, because it is so set on moving in the direction of religion, while almost strenuously avoiding scientific approaches. AA will probably implode within fewer years than we can imagine right now.

    • life-j says:

      Would like to add that typically American commercial culture has a tendency to replace everything good that is community oriented with material commodity substitutes, and so the big challenge as this process of moving toward a scientific solution unfolds will be to not throw the baby out with the bath water and wind up where each alcoholic sits at home taking their naltrexone and the community and fellowship and mutual help get entirely lost.

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