Tuesday, March 24, 2015

The Atlantic Slams Alcoholics Anonymous--The Carlat Take

The current issue of The Atlantic magazine has a fascinating article entitled "The Irrationality of Alcoholics Anonymous." In a wide-ranging and well-researched article, the author Gabrielle Glaser, begins with the story of a lawyer identified as "J.G."

"J.G." began drinking at age 15 and his habit ramped up through college and law school. Ironically, much of J.G.'s law practice is defending drunk drivers. On a typical court day, according to the article, he would start drinking after his first morning court appearance, and he bought himself a Breathalyzer to make sure he didn't end facing the same judge as his clients. At his worse, he was drinking a full liter of whiskey per day.

Eventually he checked into a rehab based on AA principles. AA famously maintains that complete abstinence is a requirement of effective treatment. It didn't work for J.G., and only led to a series of miserable white-knuckled periods of sobriety interspersed with relapses. Toward the end of the long article we learn that (spoiler alert) J.G. finally gets himself into a clinic that acknowledges the scientific evidence of the efficacy of medications for alcoholism. He is prescribed baclofen and the occasional Valium, and is now successfully sober.

In The Carlat Addiction Treatment Report (CATR) we've written at length about AA and we're generally in agreement with this article. The Cochrane Collaboration, which synthesizes the best evidence available, found only eight RCTs of adequate quality that looked at AA or 12-step Facilitation (TSF), the professional treatment approach that strongly encourages AA participation. The resulting meta-analysis concluded, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” (Ferri M et al, Cochrane Database Syst Rev 2006;3:CD005032).

The Atlantic article's timing was perfect for CATR as we just published an issue devoted to integrating medications and therapy in alcoholism treatment. You can read the article on pharmacotherapy for free here

The bottom line is that AA likely works for many people, particularly those who become active in meetings and who get a sponsor. But we know from placebo controlled trials that medications such as naltrexone and acamprosate are effective--and there's no reason not to combine meds with a 12-step program or psychotherapy. 

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