Excerpted from

Atlantic Magazine*


Its faith-based 12-step program dominates treatment in the United States. But researchers have debunked its central tenets and found more effective treatments.

By Gabrielle Glaser

The 12 steps are so deeply ingrained in people that many, 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.

Nowhere in the field of medicine is treatment less grounded in modern science, although few people seem to realize it. Unlike Alcoholics Anonymous and other 12 step programs, prescription drugs and therapies based on modern science have been proven to help patients drink in moderation.

A 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 one million doctors in the United States, only 582 identify themselves as addiction specialists. The report stated:

The vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care.”

Alcoholics Anonymous is famously difficult to study. No conclusive data exists on how well it works. In 2006, the Cochrane Collaboration, a health-care research group, reviewed studies going back to the 1960s and found that “No experimental studies have unequivocally demonstrated the effectiveness of AA (or other 12-step programs) in reducing alcohol dependence or problems.”

In his 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’s retention rates along with studies on sobriety and rates of active involvement (attending meetings regularly and working the program) among AA members. Based on this data, he said:“AA’s actual success rate is somewhere between 5 and 8 percent.”

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 testimonials from those who say AA saved their life that we take the program’s efficacy as an article of faith.

Finding treatment centers’ success rates is also next to impossible. Facilities rarely publish their data or even track their patients after discharging them.“Many will tell you that those who complete the program have a ‘great success rate,’ meaning that most are abstaining from drugs and alcohol while enrolled there,” says Bankole Johnson, an alcohol researcher and the chair of the psychiatry department at the University of Maryland School of Medicine.

Many people believe heavy drinkers cannot recover before they “hit bottom.”Mark Willenbring, former Director of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism. told me, “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.’

For a glimpse of how treatment works elsewhere, I traveled to Finland, a country that shares with the United States a history of and a culture of heavy drinking. Finland’s treatment model is based in large part on the work of an American Neuroscientist – John David Sinclair.

I met with Sinclair in Helsinki. Sinclair researched alcohol’s effects on the brain since his days as an undergraduate at the University of Cincinnati, where he experimented with rats that had been given alcohol for an extended period. Sinclair expected that after several weeks without booze, the rats would lose their desire for it. Instead, when he gave them alcohol again, they went on week-long benders, drinking far more than they ever had before – more, he says, than any rat had ever been shown to drink. Sinclair called this the alcohol-deprivation effect. His laboratory results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment – going cold turkey only intensifies cravings.This discovery helped explain why relapses are common.

Sinclair published his findings in a handful of journals and in the early 1970s moved to Finland. He was drawn by the chance to work in what he considered the best alcohol-research lab in the world, complete with special rats that had been bred to prefer alcohol to water. He spent the next decade researching alcohol and the brain.

Sinclair came to believe that people develop drinking problems through a chemical process: each time they drink, the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol – until almost anything can trigger a thirst for booze, and drinking becomes compulsive. Sinclair theorized: stop the endorphins from reaching the brain’s opiate receptors, and the cravings would gradually subside.

To test this hypothesis, he administered opioid antagonists – drugs that block opiate receptors – to the specially bred alcohol-loving rats. He found that if the rats took the medication each time they were given alcohol, they gradually drank less and less. He published his findings in peer-reviewed journals beginning in the 1980s.

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 control their consumption. In 2001 Sinclair published a paper in the journal Alcohol and Alcoholism reporting the results: a 78% success rate in helping patients reduce their drinking to about 10 drinks per week.

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 one percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking.

I visited one of three private treatment centers, called the Contral Clinics, that Sinclair co-founded in Finland. In the past 18 years, more than 5,000 Finns have gone to the Contral Clinics for help with a drinking problem. Seventy-five percent of them have had success reducing their consumption to a safe level.

As I researched this article, I wondered what it would be like to try naltrexone, which the U.S. Food and Drug Administration approved for alcohol-abuse treatment in 1994. The first night, I took a pill at 6:30 pm. An hour later, I sipped a glass of wine. I finished the glass and poured a second. By the end of dinner, I looked up to see that I had barely touched it. I had never found wine so uninteresting. Was this a placebo effect? Possibly. But so it went. On the third night, at a restaurant where my husband and I split a bottle of wine, the waitress came to refill his glass twice; mine, not once. That had never happened before, except when I was pregnant. At the end of 10 days, I found I no longer looked forward to a glass of wine with dinner. My experiment was driven by personal curiosity, not scientific inquiry. But it certainly felt as if I were unlearning something – the pleasure of that first glass? The desire for it? Both? I can’t really say.

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; andthey’ve tried not drinking & controlling dinking without success because their cravings are too strong.

With naltrexone, 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.

Claudia Christian, an actress who lives in Los Angeles (she’s best known for appearing in the 1990s science-fiction TV show Babylon 5), discovered naltrexone when she came across a flier for an injectable form of the drug at a detox center in California in 2009. Claudia said: “the effect was like flipping a switch,” and for the first time in many years, she was able have a single drink and stop.

Claudia has become an advocate for Sinclair’s method: she set up a nonprofit organization, C3 Foundation, for people seeking information about naltrexone and made a documentary called One Little Pill.

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 a full hour in advance of every time they plan to drink, as Sinclair would advise.

Tom McLellan, a psychology professor at the University of Pennsylvania School of Medicine who has served as a deputy U.S. Drug Czar and is an adviser to the World Health Organization, says that while AA and other programs that focus on behavioral change have value, they don’t address what we now know about the biology of drinking.

Drinking makes you relax, shed inhibitions and forget your worries. Alcohol acts on many parts of the brain, making it in some ways more complex than drugs like cocaine and heroin, which target just one area of the brain. Among other effects, alcohol increases the amount of GABA (gamma-aminobutyric acid), a chemical that slows down activity in the nervous system, and decreases the flow of glutamate, which activates the nervous system. Alcohol also prompts the brain to release dopamine, a chemical associated with pleasure.

Over time, though, the brain of a heavy drinker adjusts to the steady flow of alcohol by producing less GABA and more glutamate, resulting in anxiety and irritability. Dopamine production also slows, and the person gets less pleasure out of everyday things. Combined, these changes gradually bring about a crucial shift: instead of drinking to feel good, a person drinks to avoid feeling bad.Alcohol also damages the prefrontal cortex, which is responsible for judging risks and regulating behavior—one reason some people keep drinking even as they realize that the habit is destroying their lives. The damage can be undone once consumption is under control.

Why, then, do we so rarely treat it medically? It’s a question I’ve heard many times from researchers and clinicians.

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.

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.” Few doctors accepted that it was possible to treat alcohol-use disorder with a pill. And now that the patent on naltrexone has expired, pharmaceutical companies have little financial incentive to promote naltrexone.


Gabrielle Glaser is the author of Her Best-Kept Secret: Why Women Drink—And How They Can Regain Control.

* Original publication date: April 2015

Deerhaven Gardens, the First Women’s U.S. Residential Alcohol Treatment Center to Adopt the Sinclair Method 

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