Drunks

by Christopher Finan

  White believed the threat came from within as well as without. As the treatment industry became increasingly professional, it had lost its passion for service. The sober alcoholics who had once played such a prominent role as counselors were disappearing from the field. The professionals who replaced them had been trained for the work, but they lacked the experience of personal recovery that gave sober drunks credibility with still bleary alcoholics. White, whose book documented the collapse of many previous recovery efforts, knew that it could happen again. “How much of the current system of addiction treatment will survive and be recognizable a decade from now is open to question,” he wrote. But history also gave White hope:

  The movement to generate and sustain support systems for recovering alcoholics and addicts in this country has been, and will continue to be, unstoppable. Every time formal systems of treatment collapse, new grassroots movements rise up to rebuild or replace those systems.

  White was counting on the passion of drunks and drug addicts who had survived their addiction.44

  CHAPTER TEN

  Waves of Sobriety

  ON MARCH 25, 2000, an alcoholic in a blackout drove her pickup truck onto a freeway going the wrong direction in rural Washington State and collided with a car, killing thirty-eight-year-old Richard Davis and his twelve-year-old daughter, LaSchell. Such accidents rarely made national news. But the driver of the pickup was Audrey Kishline, the founder of Moderation Management, a mutual aid group that tries to help people with alcohol problems control their drinking.

  Two months earlier, Kishline had admitted to members of the group that her drinking was out of control and that she was trying to stop with the help of several sobriety groups, including AA. She also reaffirmed her belief that Moderation Management worked for people who were not addicted to alcohol. In July, when she pleaded guilty to two counts of vehicular homicide, her view appeared to have changed. According to her lawyer, Kishline now believed that Moderation Management contained many people like her—“alcoholics covering up their problem.”1

  Kishline’s accident reignited a bitter dispute that had begun almost forty years earlier between the alcoholism treatment community, which regarded abstinence as the goal of all alcoholics in recovery, and its critics, including many who rejected the idea that alcoholism was a disease. The controversy began in 1962 when a British psychiatrist, D. L. Davies, reported that alcoholism patients treated at a London hospital had been able to start drinking again without further problems; some had been drinking safely for as long as eleven years. Only ninety-three drunks were studied, and just seven were judged to have resumed “normal” drinking. Davies was quick to acknowledge that most alcoholics would never drink normally. But his study challenged the idea that alcoholism is inevitably progressive and that loss of control is irreversible.

  Davies’s findings were received with great skepticism by most alcoholism experts. Some questioned whether the men who had returned to drinking successfully were the alcoholics described by Jellinek. “One possible explanation of Doctor Davies’ findings derive[s] from the fact that there are undoubtedly degrees of alcoholism,” one commentator observed. “All patients are not equally ill.”2

  But many of those who criticized Davies did not want to debate the fine points of his research. They were alarmed by the danger that sober alcoholics would be encouraged to drink again. “For every alcohol addict who may succeed in reestablishing a pattern of controlled drinking, perhaps a dozen will kill themselves trying,” a doctor commented in the Quarterly Journal of Studies on Alcohol.3

  The Davies study probably didn’t get anyone drunk. The debate over controlled drinking was confined to the pages of academic journals until 1976, when the RAND Corporation published a report that provided support for the idea. The National Institute on Alcohol Abuse and Alcoholism had commissioned RAND to evaluate the effectiveness of alcoholism treatment at forty-four federal treatment facilities. To the surprise of many, the authors of Alcoholism and Treatment, which became known as the RAND Report, concluded that the number of patients who had achieved abstinence was “relatively small.”4 Most of those who had improved were drinking again at “moderate” levels or were alternating periods of drinking and abstention. Overall, 22 percent of those receiving treatment had become “normal drinkers.”

  The national press expressed skepticism about the RAND Report, but the controversy grew more heated when two behavioral psychologists, Mark and Linda Sobell, published a book two years later in which they claimed they had succeeded in training alcoholics to drink safely.5 They had studied seventy alcoholics at a state hospital in California, dividing them into a control group that was urged to pursue abstinence and a controlled drinking group that was trained to limit consumption and treated with aversive conditioning, including electric shocks. Following up with their subjects two years later, the Sobells found that the controlled drinking group had significantly more “days functioning well” than those whose goal was abstinence.6

  The National Council on Alcoholism (NCA) was horrified. At a news conference, NCA executives called the RAND Report “dangerous and misleading.” “My concern is that a lot of people will try to drink again, and a lot of people will die as a result,” said Dr. Nicholas A. Pace, the president of NCA’s New York City affiliate. The Sobells were also harshly criticized. The prestigious Science magazine published an article that challenged their results, reporting that eight years after the Sobells claimed their patients were drinking normally, eight were drinking excessively, six were abstinent, and four were dead. The article claimed that most of the subjects had failed to drink safely from the very beginning, raising questions about the Sobells’ honesty. One of the authors put his suspicions in so many words. “Beyond any reasonable doubt, it’s fraud,” he said. Several investigations cleared the Sobells of any wrongdoing.7

  The Kishline accident in 2000 brought the bitter dispute over controlled drinking back to center stage. NCA, which had been renamed the National Council on Alcoholism and Drug Dependence (NCADD), issued a statement that blamed the accident on Kishline’s failure to acknowledge her alcoholism. This was not her fault, it said. “Unfortunately, the disease of alcoholism, which is characterized by denial, prevented this from occurring.” But there were people to blame, NCADD said. The accident “provides a harsh lesson for all of society, particularly those individuals who collude with the media to continually question abstinence-based treatment for problems related to alcohol and other drugs.” The advocates of controlled drinking had done great harm:

  What makes Ms. Kishline’s present situation even more distressing is the fact that her denial, amplified by the media, undoubtedly contributed to the progression of alcoholism and other alcohol-related problems for thousands more unidentified Americans and their families. . . . [W]e should all remember the names of Richard and LaSchell Davis the next time a problem drinker claims to be able to “drink a little” without harm.

  Defenders of controlled drinking were stung by the charge that they were responsible for the accident. Stanton Peele, a leading critic of the disease concept of alcoholism who had endorsed Moderation Management, sought to distance himself from Kishline by saying he hadn’t spoken to her in five years. He also claimed that her decision to join AA made her drinking worse.8

  As the backlash over the Kishline accident grew, many prominent alcoholism experts began to worry that the reputation of alcoholism treatment was being badly damaged. Three weeks after the NCADD statement, Dr. Alexander DeLuca, the director of the Smithers Addiction Treatment and Research Center in New York, found himself caught in the controversy when New York magazine reported that Smithers was offering its patients treatment that included Moderation Management. This news was shocking because Smithers had been founded with a $10 million gift from the Christopher D. Smithers Foundation, which strongly supported abstinence for alcoholics. DeLuca insisted that the report had exaggerated the changes at Smithers. “Our treatment programs never changed,” he sa
id. But DeLuca had agreed to allow Moderation Management to begin holding meetings at Smithers in January. In the atmosphere created by the Kishline accident, the Smithers board of directors concluded that DeLuca had gone too far and forced him to resign.9

  On the same day that DeLuca’s firing was announced, thirty-four scholars and prominent treatment professionals issued a statement that attempted to bring the controlled drinking controversy to an end. Ernest Kurtz, a historian of the alcoholism movement, had drafted the statement and sent it to people on both sides of the debate. He was the perfect intermediary because he was both an AA member and someone who had endorsed Moderation Management, which he believed would make it easier for many people to recognize their alcoholism. Above all, he shared the fear of many that the alcoholism community was tearing itself apart and undermining its ability to help alcoholics get sober. The statement addressed this problem directly:

  That Ms. Kishline was intoxicated at the time of the crash has been claimed to indicate the failure of the approach of one or another of the mutual-help groups Ms. Kishline has attended. Such claims are not in accord with everyday experience in the field, in which relapse is common, whichever approach the drinker adopts. Recovery from serious alcohol problems is a difficult goal and there are many paths to it.

  The final paragraph proposed a compromise. “We believe that the approach represented by Alcoholics Anonymous and that represented by Moderation Management are both needed,” it said.10

  Under different circumstances, Kishline would probably have endorsed the statement, but she was awaiting the final disposition of the criminal charges against her. A month later, she was sentenced to four and a half years in prison. She continued to struggle with sobriety after her release and committed suicide in 2015.

  The compromise over controlled drinking was the first sign of a moderating tone in the debate over alcoholism. There was still plenty of disagreement over many issues, but much of the heated rhetoric disappeared. One factor contributing to this de-escalation was a growing knowledge about the physiology of alcohol and drug addiction. In 1988, Henry Fingarette claimed that his survey of experts in “biology, medicine, psychology, and sociology” had found no evidence to support Jellinek’s concepts of tolerance, craving, withdrawal, and “loss of control.” But back in the mid-1970s, biologists and pharmacologists had conducted thousands of experiments on the effects of alcohol on animals, and many were convinced that addiction originated in the brain.

  Over the next two decades, researchers identified the existence of a brain reward system that begins in the brain stem, which controls heartbeat, respiration, and other functions that ensure survival, and connects through the limbic system, the center of emotion and motivation, with the cerebral cortex. The primary function of this circuit is to reward eating, sex, and other behavior that is biologically beneficial by releasing into the limbic system a pleasure-causing neurotransmitter called dopamine.11

  Scientists theorized that alcohol and other psychoactive drugs hijack the brain reward system, flooding a section of the limbic system with dopamine and producing a rush of pleasure that is far more powerful than natural neurotransmitters. But the power of alcohol and drugs wanes for regular users, creating a craving for more drugs. Alcoholics and addicts become victims of the very system that once ensured survival, seeking out drugs with the same desperation that they once sought food and water. The brain reward system becomes the instrument of their self-destruction.

  In 1997, Allan I. Leshner, the director of the National Institute on Drug Abuse (NIDA), gave the government’s seal of approval to this new theory of addiction. “Dramatic advances over the past two decades in both the neurosciences and behavioral sciences have revolutionized our understanding of drug abuse and addiction,” he announced.12

  As in all matters pertaining to science and public policy, however, this was not the final word in the debate. In 2014, ninety-four addiction researchers and clinicians sent a letter to the editors of Nature magazine disputing an article stating that the brain disease model of alcoholism represented a consensus among people who study addiction. One of the signers later joined two colleagues in publishing a more detailed critique of the neurobiology of addiction in the Lancet, a British medical journal. The authors raised questions about the results of the animal experiments that had played such an important role in verifying the brain disease theory, expressed doubt about the usefulness of research into the genetics of addiction, and rejected claims that the neuroimaging technologies that had made it possible to provide live pictures of brain activity during intoxication proved that drug taking is a compulsion. They concluded that NIDA’s decision to spend 40 percent of its budget on neuroscience research was not justified in light of what it had accomplished for addicts.13

  Nora D. Volkow, Leshner’s successor, responded to the criticism in the Lancet. Volkow is a psychiatrist who played a pioneering role in the use of PET scans, a type of MRI imaging that was being used to study the brain of addicts. Her own research suggested modifications to the brain disease model, but she firmly defended the importance of neuroscience. “These findings, along with ongoing research, are helping us understand the neurobiological processes associated with loss of control, compulsive drug taking, inflexible behaviour, and negative emotional states associated with addiction,” she and George Koob wrote. The research had made possible several medications, including naloxone and acamprosate that helped reduce craving in alcoholics, buprenorphine-naloxone for opioid addiction, and varenicline for tobacco addiction.14

  It also provided a basis for experimenting with the use of deep brain stimulation, which involved the implanting of a stimulator to send electrical impulses to parts of the brain. The technique, which was developed to treat Parkinson’s disease, chronic pain, and depression, was showing “promising results” in addiction treatment, Volkow and Koob wrote. She reproved the critics for believing “that science should immediately translate into transforming solutions.” She also asked why some people were having trouble “accepting as a bona fide disease one that erodes the neuronal circuits that enable us to exert free will.” No one questioned the importance of basic research in Alzheimer’s disease or schizophrenia.15

  But the disagreement over the brain disease theory was not as great as the battle over whether alcoholism was a disease. The authors of the Lancet article acknowledged that changes in physiology played an important role in addiction. “Addiction is a complex biological, psychological, and social disorder that needs to be addressed by various clinical and public health approaches,” the authors of the Lancet article acknowledged. Volkow and Koob agreed on the importance of approaching alcoholism from multiple directions. “Understanding how genetic, developmental and environmental (including social) factors affect the susceptibility for substance abuse disorders helps develop better prevention strategies,” she and Koob wrote.16

  There was also rising confidence in recovery. Once twentieth-century doctors accepted the fact that alcoholism was an illness, they had to recognize that it was not something that they could cure. George Vaillant and his associates in the Cambridge-Somerville alcoholism program, who were doing everything possible to help their patients, were naturally disappointed when they discovered that 95 percent relapsed in the first year. They had to relearn the lesson that guided the work of Albert Day and the first generation of addiction specialists. “Some men . . . must fall, at least once,” Day told his patients at the Washingtonian Home. Sometimes they relapsed repeatedly before they could accept the fact that they are addicted. AA acknowledged this in the advice it offered to alcoholics who were having doubts about quitting. “Step over to the nearest barroom and try some controlled drinking,” the Big Book suggested. “Try to drink and stop abruptly. Try it more than once.” Of course, there was a chance that you would start another binge. But “it may be worth a bad case of the jitters if you get a full knowledge of your condition.” Relapses were part of the learning process for most alcoholics.17 />
  Vaillant came to realize this as his study of drunks continued. In addition to managing the alcoholism program, he was conducting one of the first studies to follow several groups of alcoholics for forty years. Using data from the Harvard Medical School’s Study of Adult Development that began in 1940, Vaillant and his fellow researchers were able to watch the development of alcoholism in 660 men from its first appearance. The results, which were published in 1983 as The Natural History of Alcoholism, convinced Vaillant that the goal of treatment should not be a cure. “[A]lcoholics recover not because we treat them but because they heal themselves,” he wrote.18

  The most powerful evidence for this in Vaillant’s study was the dramatic increase in the number of men who became abstinent over time. While most of the men were drinking at the end of the first year, four times as many had quit eight years later. Vaillant had never stopped believing that treatment was important. “I have no doubt that by providing consultation, detoxification, welfare and shelter, we stop hemorrhage,” he wrote. “At the same time, we may need to recognize that the recovery process in alcoholism is best catalyzed not by a single episode of treatment but by fostering natural healing processes over time.” Vaillant believed that AA supported these healing processes. Two-thirds of the men who stopped drinking had eventually found their way into AA. “Joining any club takes time,” he wrote. He also pointed to other programs that worked. “[T]here are many paths to recovery in alcoholism,” he concluded.19

  Then, in 1989, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded Project MATCH, the largest clinical study of psychotherapies that had ever been undertaken. The goal of the study was not to determine whether treatment worked. The assumption was that some therapies were certainly effective. What the NIAAA was trying to determine was whether drunks shared characteristics that made some treatments more effective than others. Researchers recruited 1,726 patients who had reported alcohol problems and divided them into groups that were given one of three treatments: twelve-step facilitation (TSF), cognitive behavior therapy (CBT), and motivational enhancement therapy (MET).