Wasted: An Alcoholic Therapist's Fight for Recovery in a Tragically Flawed Treatment System (37 page)

As I watch his interview on my laptop, he pauses, somewhat exasperated.

“Now for any other
chronic condition, a twenty-five per cent complete remission for some and an eighty-seven per cent reduction in symptoms for everybody else would be astonishingly successful. Yet we really disadvantage ourselves by saying you’re a failure if you have even a single recurrence. That’s self-defeating, that’s depressing.”

But we don’t talk about great outcomes. Our culture is addicted to spectacular
“bender” stories. They begin in our teenage years with sentences like, “Oh man. I got so wasted last night.” They multiply as we regale ourselves with stories of some problem drinker’s increasingly outrageous behaviour, which leaves all the rest of us who can control our drinking feeling superior. Over time, all of these stories coalesce into a giant file folder marked “fail.”

Dr. Miller
believes our perception of failure is result of only seeing and amplifying stories of the “fails.”

He continues, “If you follow up with people over time—which is what we did in research, try to find everybody that we’ve treated—most of them are doing way better. If you just wait for people to come back, then you only see the folks who are struggling. Especially if you think of it in black-and-white
terms that if you drank at all—then that’s a treatment failure.”

Even Hazelden Betty Ford, the group of institutes known for maintaining the gold standard in substance use disorder treatment, has moved away from abstinence as their only standard for success. As their website states, “Our scientific evidence treatment method gets results. Over eighty per cent of our adult patients either
remain continuously abstinent or dramatically reduce their use in the year after treatment, and we encourage participation in a twelve-step program as one means of support.”

When respected institutions like Hazelden Betty Ford and men as learned and wise as Dr. Humphreys and Dr. Miller don’t consider Mike’s relapse a fail, why should I? In five-and-a-half years of health, Mike has had
one recurrence
.
I know that’s the success story.

• 41 •

BY CATEGORIZING MIKE’S
relapse as anything other than a failure of abstinence, I know I’m swimming upstream.
AA
’s Big Book outlines a program called the twelve steps, a plan for spiritual and character development, which, if worked religiously, it claims will lead to sobriety.
AA
’s slogans are now so ubiquitous,
we all recognize the references: “One day at a time,” or “Accept the things we cannot change and the wisdom to know the difference.”
AA
is embedded in our pop culture, playing a major role in films and
TV
shows from 1962’s
Days of Wine and Roses
to 2008’s
Breaking Bad.
Its influence is so pervasive that when anyone admits a drinking problem, our instant response is, “You need to go to
AA
.”

Dr. Humphreys believes the public knows very little about addiction other than what
AA
tells them. “If you have a drinking problem, someone’s going to suggest
AA
and not have anything else to offer you, and may badger you if you’re not going. So in addition to having the problem, you have to deal with a lot of pressure and potentially a lot of shaming from people around you... And that’s
not good for human health, that’s not good for recovery.”

Dr. Humphreys says all that pressure can backfire, “So that people won’t go even if it’s possibly going to be good for them because they don’t like being treated like they’re five years old.”

During the worst of his substance use disorder, Mike was forced to attend three
AA
meetings a day.

Mike told me he found many
of those meetings he attended to be toxic, demoralizing affairs, with plenty of emphasis on a person’s character flaws. Relapsing meant going back to Step One again, over and over. No matter how many times he did Step Four, “Make a searching and fearless moral inventory,” it never seemed to prevent him from picking up the bottle again. Over time, especially in the two recovery homes, the relentless
criticism from those around him led Mike to feel hopeless and suicidal. All that judgment doesn’t come from the fellowship of
AA
, but rather, is a result of modern interpretation, according to Dr. Miller. “I do not hold
AA
responsible for that moralistic, judgmental way of looking at things. That’s not Bill W. That’s other voices that have appeared in the meantime. How is that supposed to be helpful?
We have this peculiar idea—and I think it’s especially strong in America—that if you can just make people feel bad enough they’ll change.”

Mike does credit the fellowship of men who shared his compulsion with saving his life. He once told me, “Some of the guys in
AA
never gave up on me when everyone else had. And while I respect people who found sobriety or health through
AA
, I just wish
they’d recognize it doesn’t work for everyone.”

Most addictions experts know we can do better for people for whom
AA
doesn’t work. And while the number of people fitting that description is debatable, it is a sizable group. The best evidence to date tells us that while
AA
is enormously successful for some, it does not work for the majority of people who try it. Though there is no one treatment
that works best for all substance use disorders, there are many more options that very few people know about. The problem is, most people think there is only
AA
.

Dr. Humphreys wants the same treatment standards applied in addiction medicine as in other areas of medicine. To explain, he uses the analogy of a serious lung infection that’s resistant to treatment. “We say, well let’s try a
different antibiotic. It’s not working for this infection, so we do something else.” There has to be choice because people who suffer from substance abuse disorders are diverse: they have different lives, different capacities, different preferences. A good addiction treatment agency will have
AA
as one trick in its bag—but it will have a number of other options to suit the range of people coming
in the front door.

Dr. Miller thinks
AA
makes a great starting place. “Everyone should be encouraged to go to Alcoholics Anonymous to try it. And no one should be
required
to do so.” I think that’s pretty good advice. Try it out. It’s a free option in a field where treatment can get pretty expensive. It’s available pretty much 24/7 and has a reasonable track record. Just go see, give it
a shot. But maybe it’s not for you.

According to Dr. Miller, the founders of
AA
would never have wanted their fellowship to be mandatory, but it has become so in many situations. Courts routinely sentence offenders to attend meetings. Some treatment centres make going to
AA
meetings a condition of entry. Some addiction specialists mandate daily meetings for their patients. “Requiring people
to go to meetings clashes with the original intent of the twelve-step program, and may even set people against it. When you’re made to do something, it doesn’t increase your openness to it. It wasn’t meant to be court ordered; it wasn’t meant to be coerced and mandated.”

Considering how life-threatening Mike’s substance use disorder was, I know how catastrophic his evening of drinking
could ultimately be. At the height of his substance abuse disorder, he’d lost everything and lived in a world where shame and humiliation was heaped upon him every day. And still he didn’t quit drinking.
AA
and twelve-step programs didn’t work for Mike. So what will?

• 42 •

WHEN WE INTERVIEWED
Stanford’s Dr. Humphreys, he put it bluntly: “When I hear people say there’s only one route to recovery—and coincidentally it’s always the route they followed—I wonder, am I in church, or am I in a medical school? If you have cancer and you get better from cancer, nobody ever says, ‘Well,
that doesn’t count unless you had chemotherapy,’ or, ‘It doesn’t count if you didn’t have surgery.’ We’re just really happy. You had this terrible disease and now you’re doing well. That’s the sensibility we should have in addiction treatment. I want people to get well.”

We’re a long way from that sensibility.

A landmark study from 2012 by The National Center on Substance Abuse
at Columbia University defines the problem well. “This profound gap between the science of addiction and current practice related to prevention and treatment is a result of decades of marginalizing addiction as a social problem rather than treating it as a medical condition... Much of what is offered in addiction ‘rehabilitation’ programs has not been subject to rigorous scientific study... This
is inexcusable given decades of accumulated scientific evidence attesting to the fact that addiction is a brain disease with significant behavioral components for which there are effective interventions and treatments.”
1

A change of attitude is urgently needed because the problem is getting bigger, especially among young people. Risky substance use and addiction are both the largest preventable
and most costly public health problems in the U.S. and Canada. They are the leading causes of preventable death and cause or contribute to more than seventy other conditions requiring medical care. The U.S. National Institute on Drug Abuse states substance misuse costs the U.S. $700 billion a year in health care costs, crime and lost productivity.
2

Alcohol misuse alone costs $223.5 billion
a year.
3

Dr. Evan Wood, head of Addictions Medicine for Vancouver’s Coastal Health, who we also interviewed for the film, is clearly frustrated. “I would estimate that in Canada, of those struggling with severe alcohol addiction, far less than ten per cent—I would hazard to guess about one per cent—are actually being prescribed evidence-based treatments for alcohol addiction. I’d estimate
it’s only slightly better in the U.S.”

In fact, for treating addiction, we do know what’s effective. Dr. Miller says there are probably one thousand randomized clinical trials of treatment for alcohol, smoking and illicit drugs to date. “When I got treatment for cancer, I read the whole literature on prostate cancer. And there were three randomized clinical trials. So we have an enormous
array of pretty well-designed and conducted scientific trials to guide the practice [of treating alcohol addiction]. But there’s no requirement to use [these methods] until payers begin to say wait a minute, we want you only to deliver treatments that are evidence-based.”

Dr. Wood told me, “To improve the health of our society, to save the tax dollars that are being spent because we’re
not intervening, I think we have to look deeply at ourselves as a society and recognize that we have long-held moralistic views and stigma towards people with addiction.”

That stigma extends to the medical community. Dr. Eickelberg at Betty Ford in Palm Springs explains it this way: “We wonder, why is it, when this is one of the major causes of morbidity and mortality in our society—why
doesn’t it get the respect that it deserves at the level of medical school training, and in identification and treatment? I think there are so many barriers. One is a lack of acceptance that people develop conditions where they don’t have control over their behaviours. It looks from the outside as if they should be able to simply stop.”

But as Mike’s struggle would attest, it’s just not
that simple.

• 43 •

OVER THE LAST
few months I’ve learned that the consensus among scientists is that alcohol or drug addiction, now called substance use disorder, mild, moderate or severe, is not a moral failing, but hijacked brain reward circuitry. Dr. Rob Malenka, a neuroscientist at Stanford University, helped solve the puzzle of how drugs and
alcohol change the brain. While filming at Stanford, he invited Mike and me into his lab for a little Neuroscience 101. “Reward circuitry evolved for survival purposes,” says Dr. Malenka, as I rewatch the video. “We needed something in our brain to tell us that food tastes good when we’re hungry, sex is good, warmth feels good when we’re cold.”

When we experience something pleasant, our
brains are flooded with a neurotransmitter, or chemical messenger, called dopamine. This happens in our brain’s centre of reward circuitry, the nucleus accumbens, but also in the prefrontal cortex, the part of our brain responsible for what is called executive function, or decision-making.

Dr. Malenka draws a rudimentary model of the brain on his whiteboard, followed by a graph to illustrate
giant spikes in dopamine levels. “We now know that alcohol and all drugs of abuse cause this release of dopamine in the nucleus accumbens. But when alcohol and drugs drive the release, it happens in
unnatural
ways, in ways that I would argue our brains haven’t evolved to handle. In natural reward circuitry, that dopamine release is gradual. With substance abuse, the dopamine spikes in strengths
hundreds of times stronger than what is natural.”

Our brains have developed processes by which nerve cells called neurons talk to each other. Between each neuron there’s a small gap called a synapse; on either side of the synapse, there is a presynaptic ending that sends the information and a postsynaptic ending that receives the information. That information is delivered by chemical messengers—neuro-tra
nsmitters like serotonin, dopamine and glutamate. These messengers bind themselves to the receptors on the postsynaptic receiving cell.

“So what does this have to do with drugs and alcohol?” Dr. Malenka’s eyes light up as he reveals an “aha” moment in neuroscience. “Drugs (and alcohol) interfere with the way these chemical messengers work, making them less effective. It turns out what makes
our brains entirely different from the hardware in a computer or the hardware in our cellphone is this process.” What he means is that no matter how often you make the same action on your computer, the computer itself doesn’t change. But the more a certain message in our brain is delivered, the more the brain changes in response to that activity. That means, the more a substance like alcohol
or cocaine causes the unnatural spike of dopamine, the more actual brain structure changes. That’s how reward circuitry is hijacked. And when that happens, it’s almost impossible to reverse it.