Twelve-step programs are diverse, and many are adopting the medical evidence. But a broadcast of “Larry King Live” from 2007 shows that something fundamental needs fixing. Thirteen years after the FDA had determined that naltrexone is beneficial in treating alcoholism, with additional studies showing the same, Susan Ford Bales, then-chair of the Betty Ford Center, dismissed anti-craving medications upon being confronted with these data. “We do not use relapse preventative medications at the Betty Ford Center,” she said. “We will look at them once there are some statistics and that sort of information behind them.”There is no other area of medicine where disregarding easily available evidence this way would be tolerated.
Almost equally problematic is the uncompromising AA tenet that “once an alcoholic, always an alcoholic,” and the implication that abstinence is the only worthwhile treatment outcome. It is true that many alcoholics remain highly susceptible to relapse for life, and abstinence is always the safest bet. But studies also show that others are able to return to social alcohol use. And many patients are not ready to pursue abstinence. Attempting to impose on them a treatment goal they are not ready for raises unnecessary barriers to treatment. It probably contributes to the low proportion of people with alcohol problems who seek treatment.
Earlier this year, the European Medicines Agency approved nalmefene for doctors to give to patients who were not ready to attempt abstinence. This “as-needed” treatment means taking a pill prior to situations associated with high relapse risk, such as a party. This approach was clearly able to reduce drinking and improve the health of patients. But it would currently not meet with approval by the FDA because of prevailing U.S. dogma that abstinence is all that counts.
The system is broken. It must be fixed before too many more people die. If AA founders Bill Wilson and Bob Smith were alive today, I am certain they would enthusiastically pursue opportunities for treating alcoholism through research and medication.
So should we.
Markus Heilig is a physician scientist at the National Institutes of Health.