For some, 12 steps are 11 too many.
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Since it was established way back in 1935, it's not too surprising that some of the messaging from Alcoholics Anonymous is a little out of date. Five of the program's 12 steps explicitly mention god, which can be tough for atheists and agnostics to swallow. And there's that whole chapter in its accompanying bible, The Big Book titled "To Wives," which is full of gems like, "Our next thought is that you should never tell him what he must do about his drinking. If he gets the idea that you are a nag or a killjoy, your chance of accomplishing anything useful may be zero."
But hey, "it works if you work it," right?
Well… maybe. There actually isn't a ton of definitive research saying the program is effective. In a 1990 paper, researchers compiled membership surveys and found that 81 percent of attendees stopped showing up within a year. Just 5 percent of those surveyed had been going to meetings for more than a year. Some experts put AA's actual success rate somewhere between 5 and 8 percent, as The Atlantic noted in 2015.
So what's the alternative?
There's no quick fix, of course, and AA does work for some people. But if you're not one of them, there are handful of prescription medications that can help treat alcoholism—medications that doctors may not have told you about in fear of theoretically replacing one drug with another.
"One of the issues here is that there isn't a good understanding that there are some relatively effective drug treatments available," says Peter Yellowlees, a professor of psychiatry at the University of California Davis. "They are dramatically underused in this country."
For John, who prefers to use his first name only, awareness of the drug Naltrexone came not from his doctor but from a magazine article. The recently divorced Iowan had been drinking heavily and decided to quit, so he entered a three-day detox program.
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Naltrexone is one of three prescription drugs that can be used to combat alcoholism. The oldest of these is Disulfiram, or Antabuse, which was approved by the FDA in 1951. The way it works isn't incredibly pleasant—the daily tablet essentially results in an almost immediate, horrible hangover should you down a drink while you're taking it—which Yellowlees says tends to be pretty effective in that "it just sort of makes you a bit frightened to drink." If you do throw one back while on it, side effects can range from headaches and fatigue to nausea, vomiting, blurred vision and, in some cases, heart attack or liver failure. (That means that patients taking Disulfiram should also avoid mouthwash, vinegar and any cooking sauces that contain even trace amounts of alcohol.)
Two more recent drugs—Naltrexone (which is also used to treat opioid dependence) and Acamprosate—combat alcoholism a little differently and without the nausea or vomiting. Instead, they work by curbing the craving for alcohol. Unlike Antabuse, you can still drink while taking Naltrexone and Acamprosate. "And a lot of people do," explains Yellowlees, who says he prescribes Naltrexone to his patients fairly routinely. But by looking at studies, he found that those who are continuing to drink actually drink a significant amount less.
A realist, Yellowlees doesn't necessarily expect that all patients who struggle with their relationship to alcohol will completely quit. The Big Book says that people who can't make the program work are those "who cannot or will not completely give themselves to this simple program," but he isn't entirely sold on that whole 12-step, all-or-nothing, absolute-abstinence-or-bust thing. "That's a particularly American approach—the sort of black and white, sobriety only approach," says Yellowlees, who practiced in Australia for 20 years after studying in London.
While there's no doubt that some patients need to be completely sober, quitting cold turkey isn't a bender be all and end all. Instead, Yellowlees says that for a number of his patients, he finds it totally reasonable to take a harm-minimization approach: "We just don't want you to get smashed, we don't want you to drink while you're driving, but maybe the occasional drink is not too bad for you."
Yellowlees is quite comfortable with that method, but wants to make sure his patients are not drinking too much—that one beer with dinner doesn't turn into 13 drinks and a night passed out on the floor—and Naltrexone or Acamprosate can prevent that from happening. And in this way, he finds he's able to cut down on the total overall volume of alcohol they drink.
That may mean fewer medical complications down the line; it can also eliminate problems in the short term by keeping drinkers from, say, downing a bunch of shots and getting behind the wheel. And he says he finds that many people who are able to cut down consumption thanks to prescription medications do eventually taper their use until they're drinking very little or not at all.
But where's the line between a drinker who's disciplined enough to toss a few back and one who needs to stop sipping and start working the steps immediately? "This is a philosophical question rather than a medical question, quite honestly," Yellowlees says. Individual needs differ, of course, and he notes that even if an all-in sobriety plan doesn't work for everyone, it's still important for those who want to quit to get the counseling and psychological services they need.
John agrees. For him, Naltrexone is a tool in the toolkit—something that's helped in addition to a 12-step support group. Together, the combination seems to be working; he's cut back his dose from 50 mLs to 25, and he still doesn't have a desire to drink. He hasn't in over a year. But he wants to make it clear that the pill alone won't cure you. He compares giving up drinking to dieting—there's no magic pill, and someone trying to quit has to want the change badly.
Staying in control is paramount, just like it would be with any type of addiction-related craving, John asserts. "I can take a pill, and it helps, but I still have to do the right thing," he says. "I can still buy booze. I can still drink booze, just like I can still eat cheeseburgers and go to Five Guys three times a day."
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