SOCIOLOGY AND PUBLIC HEALTH
Polarized positions seem to be the norm in journalism and culture these days. This applies to some themes of healthcare just as with many other cultural and political topics. In the world of addiction treatment, it has become somewhat en vogue for an article to take a position somewhat ‘bashing’ of peer support avenues for recovery, specifically that of Alcoholics Anonymous. We have many patients and families who will cite some of these writings, including the article “The Irrationality of Alcoholics Anonymous” from The Atlantic in 2015 or “The Sober Truth,” a text by Lance Dodes. These publications take a position that peer support avenues such as AA are not based on science and have a poor success rate in helping people recover, hence should not be recommended or facilitated at all within someone’s addiction treatment plan.
While rich in data and a review of the literature, some of the studies reported through these articles are not exactly representative of what we see in dedicated substance abuse treatment. For instance, The Atlantic piece discusses the application of “The Sinclair Method” to help people cut back their drinking. Designed by researcher Dr. David Sinclair and his lab in Finland, this approach involves regular usage of Naltrexone medication to create behavioral change in drinking. The person would periodically take naltrexone prior to planned drinking, such as before going out to a nice dinner. That person would be able to enjoy the wine without losing control, hence reinforcing the capacity for moderate and stable usage of alcohol.
Naltrexone, a pill approved by the FDA for the treatment of alcoholism, has good data that it curbs some of the euphoric effects a person may experience from alcohol consumption. Inspired by behavioral conditioning and Pavlovian learning, the Sinclair Method sought to break some of the links and attachment to alcohol such that the person could decrease their drinking from a binge pattern to a moderate pattern.
It is important to acknowledge that alcoholism is a spectrum disease. Similar to the presentation of diabetes, there are different levels of disease severity and treatment approaches need to acknowledge this variance. For some people who have very mild alcoholism or who we might categorize as ‘problem drinkers,’ the goal of helping them cut back their use to safe ranges seems feasible. We may recommend naltrexone medication for these individuals as it is associated with decreased frequency of binges per month when compared with placebo.
What the Sinclair Method fails to provide is a viable treatment approach for those with moderate to severe alcohol use disorders – exactly the patients we see in treatment at CeDAR. Despite the best intentions of those men and women to drink moderately, they continuously fail. Naltrexone medication, therefore, is best suited for these individuals as an avenue to help secure abstinence from alcohol, not simply ‘cut back.’ The repeated efforts of these individuals to cut back and control their drinking are met with repeated consequences and life harm. The hope is that they will grow to accept the nature of their disease prior to such severe harm in a person’s health or lifestyle that things are unrepairable.
One of the core messages in “The Sober Truth,” is the need for someone with alcoholism to search for an internal source for their struggles. The author discusses cases connected to mood disorders or anxiety and offers the hypothesis that resolving those conditions will ultimately resolve the alcoholism. In this schematic, alcoholic-level drinking is a symptom of a deeper problem.
This approach to addiction seems very sensible at first. It taps into a humanistic need to maintain control, and when control has been lost, to re-establish it. The assumption is that a source for the alcoholism is treatable, and by default, the alcoholism is therefore treatable through that source. Some of the data linked to this include the prevalence of comorbid conditions with addictive disorders, such as Post-Traumatic Stress Disorder and Depression.
Overall, this position is theoretically rooted in the ‘Self-Medication Hypothesis.” Initially mentioned in the American Journal of Psychiatry in 1985, this framework for explaining why people became addicted to drugs and alcohol has been highly popularized. It assumes that complex and painful emotional states, connected to numerous other conditions such as depression or anxiety, are alleviated through substance use, and the repeated substance use creates habitual and ultimately compulsive use. It assumes that substance use, even that from highly dangerous drugs, does serve a purpose for the user. It also holds a positive-regard position for that user, viewing them as trying their best to succeed even while demonstrating overall destructive substance use patterns.
The Self-Medication Hypothesis seems to apply to some people struggling with addiction, but not all. It fails to explain those individuals who vehemently love substances, lose control quickly, and are driven by extreme dopamine surges around substance use. It is overly simplistic to say that these people must have an emotional or internal ‘deficit’ by which they drink or use drugs. It is very common for them to simply love the substances, or rather, that their brain intrinsically loves the substances like no other state.
In working with patients at CeDAR, we take an integrative approach with all patients, seeking to include rather than exclude ways of thinking. This is the core failure of “The Sober Truth” – it polarizes and criticizes a supportive avenue that has led to healing for countless people over the past many decades.
A more effective avenue involves understanding the disease of addiction on neurobiological, behavioral and social levels while meeting the needs of those affected with useful healing tools. By having a multitude of tools at our disposal ranging from Medication-Assisted Treatment (MAT) to AA, we are able to meet the needs of almost all patients.
Both the Sinclair Method and the Self-Medication Hypothesis have been historically interesting approaches to tackling addiction. The presence of these theories and our ability to process them gives us a greater range in helping patients. Just as the disease of addiction is a spectrum condition, so are the array of therapeutic options for all individuals.