October 8

What Is Addiction Treatment?

 

How is addiction treated in this country? There’s no single answer. There isn’t even a standard for what makes treatment successful. Some measure years of abstinence. Some seek moderation, but don’t consider abstinence to be part of recovery. Others seek temporary reduction in use through incarceration, or simply a reduction in socially unacceptable behavior.

One reason for this is confusion about the nature of substance abuse. Science recognizes three categories: the risky user, the physically dependent person, and the addict who returns to the substance repeatedly even after being separated from it. Medicine, on the other hand, used to recognize the first two categories. But the DSM-V, the latest version, combines all substance abuse under the single label, “Substance Use Disorder.”

Another reason is the disconnect between science and medicine on the one hand, and public policy on the other. For example, the largest single “treatment” provider for drug users is the prison system. More than half a million nonviolent drug offenders are incarcerated, at a cost to the taxpayers of around $15 billion per year. While there are some drug treatment programs in some prisons, the majority of inmates do not receive drug treatment. The National Institute of Health cites public desire for retribution rather than rehabilitation as a major barrier to drug treatment in prisons.

The amount spent on incarceration pales in comparison to the $30 billion or more spent annually on treatment facilities. In 2017, over 4 million Americans received treatment in a variety of settings. Of these, 2.5 million attended a treatment facility, residential or outpatient. Others may have received help from doctors, psychologists, or Twelve Step programs. Of the treatment facilities, 53% received government funding, meaning they are prohibited from using any spiritual or religious approach, including the Twelve Steps.

A more startling statistic is that of the 20 million Americans who needed treatment in 2017, only 12% received it at a treatment facility. Another 7% received treatment at non-specialty facilities. Still, 81% of those who needed treatment didn’t get it. The most common reason, cited by 41%, was lack of insurance coverage.

Some 10% of treatment facilities provided Medication Assisted Therapy (MAT), in which physical dependence on heroin or other opiods are treated with methadone or buprenorphine– long-acting opioids that are much harder to quit after long-term use. Of these, 95% still offered methadone, while 65% offered a choice between the two substitutes. There was no indication of how many facilities used these replacements for detoxification only, and how many used ongoing maintenance. (I’ll post another time about the nightmare of “methadone maintenance.”)

So what does all this tell us? First, most Americans who need help for substance abuse don’t get it.

Second, there’s a wide variety of approaches to treatment. Some, like prison, embrace the belief that if you punish someone enough, they will somehow magically change. Others, like substitution therapy, seek to reduce the criminal and health effects of addiction, but do not seek to actually treat addiction. Still others seek to return the sufferer to “social” use. Those that do seek abstinence measure it in various ways: abstinence for the duration of the program, or at 90 days, or at a year, or at 5 years.

A study of veterans in Twelve Step programs found that 70% of those who participated for a period of months were still abstinent at 16 years. In contrast, some treatment facilities that don’t use the Steps have abstinence rates around 10% at one year.

The most successful treatment approaches, at least for those who suffer from true addiction, seek total abstinence and a changes way of living. As noted in my previous post, it’s not enough to just get someone off drugs. Addiction is a way of life, a purpose for living, and a moral framework. For treatment to be successful, these old ways of being have to be replaced with new ways of being.

To be successful, treatment does not focus on moving away from drugs, but toward a suitable new way of life.

October 3

The Mystery of Addiction

It’s no secret that addiction is a problem in our society. It’s also no secret that, despite some advances in science, it’s not easy to treat. This is because the nature of addiction remains elusive. We can see this in the argument between those who insist it’s a disease, and those who insist it’s a choice. Some psychologists now argue that it’s both.

I don’t disagree. There are biological factors. And addicts make bad choices. I contend that, while addiction displays characteristics of both disease and choice, neither category is sufficient to explain the phenomenon.

Let me be clear that I’m referring here not to the occasional, risky user, nor to the person who becomes physically dependent on a substance but is able to abstain once separated from it. Addiction refers to those seemingly bizarre cases, now numbering in the millions, in which people return to the substance over and over, even after physical dependence has ceased.

Here’s the issue: if a person is miserable enough to want to quit, and if they have been separated from the biological need to use the substance, it makes absolutely no sense for them to return to the drug that made them miserable– unless there’s something else going on.

Enter Kent Dunnington. In his book, Addiction and Virtue: Beyond the Models of Disease and Choice, he argues that addiction is a habit in the classic sense expressed by Aristotle and Augustine. The behaviors of an addict are preconscious decisions habituated (programmed) by past reward/punishment experiences. I find flaws in Dunnington’s case for addiction as only a habit. But this introduces a third category to consider, and offers another dimension of options for understanding and treatment of addiction. The Twelve Steps, for example, can be described as a method of rehabituation.

Yet Dunnington goes further. We are habituated to our behaviors based on our view of the purpose of life. If, for example, we believe that the goal is to be wealthy, we’ll work hard and accumulate money. If it’s to seek thrills, all our efforts will point toward that goal. If it’s to follow Jesus, we’ll put our efforts into the behaviors that the Gospel describes (none of which include accumulating wealth). Indeed, James K. A. Smith argues that we can tell what we love much more reliably by what we do than by what we say we love.

Dunnington describes how addiction fills a need for transcendental experience, moral certainty, and purpose for life that are lacking in our secular society. In other words, it plays the role of a religion. Dunnington, a Christian, describes addiction as false worship. Yet he recognizes the diligence with which addicts undertake this worship, arguing that the Church could learn something about commitment from the “prophetic challenge” addicts present. Anyone who knows an addicted person can attest that we will sacrifice anything for our god, even our lives. The god may be false, but it’s the one to which we have willingly or unwillingly devoted ourselves.

If addiction is a religion adopted in response to the unsatisfying “spirituality” of secular materialism, this has implications for addiction treatment. To put it simply, the goal of treatment is not to get people off drugs– it is to replace one religion and way of life with another. This is where the disease model fails: medicine is not equipped to address the spiritual and moral nature of addiction.

Obviously, if addiction can play the role of a religion, a replacement is not limited to the Big Five: Christianity, Judaism, Islam, Buddhism, and Hinduism. For example, in the same ways that addiction serves as a religion, the Twelve Step programs do also. But, with thousands of years of practice and tradition, the established religions do have much to recommend them. I’ve found the healing power of Christ to be unique among them, but I do recognize that adherence is a choice.

From an objective perspective, my point is that it’s not enough to get a person off drugs and tell him or her to go get a job. The question that has to be answered in order for an addict to stay clean is this: “What’s the point?” Only when we can provide an answer for that question do we begin to offer hope to those mired in substance addiction.

August 5

Addiction, the Alt-Right, and Sociology

This wasn’t going to be my next post on the subject of addiction, but the mass shootings over the weekend changed my mind. At least one of the shootings was racially motivated.

What do mass shootings and the alt-right have to do with addiction? I believe they stem from common causes, namely a national ethos that gives no meaning to life other than accumulation of wealth, and a rising wealth inequality that makes the national purpose unattainable for increasing numbers of people.

But first, let’s start with some demographics. The alt-right draws primarily from the white working class. Mass shooters come primarily from the white working class. According to Ann Case and Angus Deaton, “deaths of despair,” which include overdose, alcoholism, and suicide, are rising fastest in the white working class. To understand any of these these problems, we have to ask ourselves what’s happening in the white working class.

Case and Deaton have done significant research on this. Focusing on deaths of despair, they note that only in the white working class have deaths of despair risen in proportion to the drop in income. In this demographic group, there is a direct correlation (or, technically, an inverse correlation) between income and morbidity (death). Why this correlation does not exist in other demographic groups is an interesting question, but beyond the scope of this post. I suspect minorities, because of a history of being left out of American prosperity, are less invested in the “American Dream,” and thus less despairing as the American Dream slips away, but I have no proof of that.

Statistically, whites are more likely to sink into despair over economic factors. And economic factors have not been kind to the working class over the past few decades. This has resulted in decreased life expectancy. Since 1979, opioid overdoses among whites have increased more than twice as much as opioid overdoses among blacks, from a slightly lower rate to a rate twice as high. The suicide rate among whites is more than twice as high as any other demographic group, with the exception of Native Americans who have a higher rate.

We can speculate about the cause of this despair. Unlike other economically excluded groups, the white working class used to believe they could attain the American Dream. It’s increasingly clear that they can’t. They have lost a reason for being, or telos–the main telos put forward by our economically-motivated society.

Moreover, whites are more likely to adopt Evangelical religious beliefs. Some 76% of evangelical Protestants are white. It’s difficult to generalize about this group because there is significant diversity, but there are some typical commonalities. At an Evangelical church I once attended, the pastor was fond of saying, “Any conversation about the Gospel begins with one question: Are you sure you’re going to Heaven?” This focus on afterlife was accompanied by attention to grace to the exclusion of works. They had us memorize Ephesians 2:8-9, “For by grace you have been saved through faith, and this is not your own doing; it is the gift of God— not the result of works, so that no one may boast.” But never did I hear anyone read the next verse: “For we are what he has made us, created in Christ Jesus for good works, which God prepared beforehand to be our way of life.”

What does this have to do with morbidity? Consider a person who finds himself or herself in despair. That person looks for solace at church. The church’s answer is, “It will be better in Heaven.” Is that not incentive to hurry the process along? Add to this a persistent link to the prosperity Gospel–if God has blessed you, you will prosper–and the religious outlook for the white working class isn’t exactly stellar.

Okay, you say. Perhaps this explains the rise in deaths of despair. But what does any of this have to do with the alt-right?

I’m glad you asked. Patrick Forcher and Nour Kteilly at the University of Arkansas have compiled a psychological profile of the alt-right. In their summary, the researchers noted that alt-right supporters:

  • Were more likely to be white
  • Were less likely to have more than a high school education
  • Were not optimistic about the current state of the economy.

These characteristics were shared by non-alt-right Trump supporters as well. Thus, the alt-right is, as expected, a subset of the white working class that has been negatively affected by the upward redistribution of wealth.

One big difference between the two was that alt-right supporters were more optimistic about the future of the economy. Their alt-right beliefs gave them hope for the future, much more so than their non-alt-right peers. This suggests that the rise of alt-right is a response to their deteriorating economic status.

This shouldn’t be a surprise. Fascism grew in Germany during the Great Depression that devastated the German economy. Forscher and Kteilly note similarities between the rise of the alt-right and the rise of the British National Party among the depressed working class.

What this does tell us is that a broad spectrum of American problems, including suicide, alcoholism, drug overdoses, alt-right activity, and, I maintain, mass shootings, are directly related to the economic decline of the white working class.

It’s not quite that simple, of course. Clearly there are factors that drive this demographic’s symptoms, especially compared with other demographic groups that are even more economically excluded. For one view of these causes, I recommend Joe Bagaent’s Deer Hunting with Jesus, which documents the decline in influence of rural America. The losses of the white working class are not just economic, they are political as well.

Liberals may not like that this formerly-privileged group is taking up more of our attention than other groups that have never been privileged. But it is historically true that those who are losing privilege are a greater threat than those who ever had it. This is an issue we need to address.

But more than that, we live in a society that values our existence in dollars. Under this philosophy, economic loss can only lead to despair. There is no other source of hope.

As a Christian, I look to the Gospel. We are not judged by how much wealth we have. The purpose of life is not to accumulate. Nor is it to survive until we die and go to Heaven. “The Kingdom of God is among you” (Luke 17:21). It is here, though it is (quite obviously) not fulfilled.

Christians have the Kingdom to offer those in despair. Are we showing it to them?

 

July 29

Addiction: The Crisis We Can’t Handle

You’ve read the news. Drug use has become an epidemic and a crisis. The statistics are staggering: Since 1979, drug overdoses are up 1,460%, and opiod overdoses among whites are up 2,627%. [1] According to the government agency SAMHSA, some 30 million Americans over the age of 12 use illicit drugs, and 83 million more abuse alcohol.

Yet our answers to this crisis are most often misdirected: we restrict access to drugs, and we incarcerate the abusers, compounding their problems by giving them a criminal record that prevents meaningful employment. Almost half of all federal prisoners (45%) are locked up for drug offenses.

The irony is, we claim to be a capitalist nation. The law of supply and demand, we insist, will regulate the market. Yet none of our solutions addresses the basic problem: people want to escape their reality. Demand exists. But I’ll deal with that in another post. What’s important for this post is that the War on Drugs is economically ridiculous. Any economist will tell you that reducing supply does not reduce demand, it just raises the price.

The second irony is that most of those who want to quit can’t get help. According to SAMHSA’s report, 20 million Americans sought treatment in 2017. Of these, 89% did not receive it.

That’s right. Only about 1 in 9 of those who needed treatment received it.

The same report details the reason they didn’t get it. The most common reason? Lack of insurance coverage. They either didn’t have insurance, or their plan didn’t cover treatment. (And just try to find a treatment facility that will take you if you don’t have cash!)

We’ve spent over a trillion dollars of taxpayer money– $31 billion in 2017 alone– in a doomed “war” to eliminate the supply of drugs. It hasn’t worked because the laws of economics can’t be repealed. Supply will seek to meet demand. We have to eliminate demand.

Yet those trying to get off drugs can’t get help.

It costs around $30,000 per year for each person we incarcerate for drug crimes. The average prison sentence for drug possession is 3 years. For the cost of one year of incarceration, these people could instead get a 30-day inpatient rehab and 90 days outpatient rehab. Not all will be successful at kicking their addiction. But some will. And these are people who (1) won’t be buying more drugs, and (2) won’t be costing the taxpayers money for prisons and emergency medical care.

Instead, they’ll be getting jobs, contributing to society, and above all, telling others about the nightmare they survived. Recovering addicts and their stories could be the best advertisement for staying off drugs!

Isn’t that a better way to spend a trillion dollars?

For those who think such an approach is impractical, check out this evaluation of the Gloucester Initiative, in which police refer addicts seeking help to treatment instead of arresting them. According to the police chief, “It costs the program $55 per individual treatment, whereas it costs $220 to send a low-level drug user through court.” In the first year, 90% of those who sought treatment received it. The followup evaluation showed that, yes, 40% of those surveyed did return to drugs after completing the program. But do the math: 60% didn’t.

Our current national drug policy is flawed. It has been from the start. It doesn’t help, and it may actually make things worse.

But there are alternatives.

As more and more families struggle with addiction, perhaps the stigma will begin to disappear. Perhaps we can talk about addiction logically, rather than emotionally. And perhaps we can find real solutions for those who suffer.

 

NOTES:

[1] Statistics drawn from Jeanine M. Buchanic, et. al., “Exponential Growth of the USA overdose epidemic,” Pittsburg: University of Pittsburg, 2017, 2 (https://www.biorxiv.org/content/biorxiv/early/2017/05/09/134403.full.pdf, accessed September 22, 2018). “Drug Overdoses,” National Safety Council (https://injuryfacts.nsc.org/home-and-community/safety-topics/drugoverdoses/data-details/?gclid=EAIaIQobChMIxryIk-DO3QIVDK_ICh1c7gZVEAAYAiAAEgLHnvD_BwE, accessed September 22, 2018). Monica J. Alexander et. al., “Trends in Black and White Opioid Mortality in the United States 1979-2015,” Epidemiology 29:5, September 2018 (https://journals.lww.com/epidem/Fulltext/2018/09000/Trends_in_Black_and_White_Opioid_Mortality_in_the.16.aspx, accessed September 22, 2018).

May 4

Autism and the Glycemic Index

“Autism, or autism spectrum disorder, refers to a range of conditions characterized by challenges with social skills, repetitive behaviors, speech and nonverbal communication, as well as by unique strengths and differences. We now know that there is not one autism but many types, caused by different combinations of genetic and environmental influences.” —Autism Speaks

I’m on the autistic spectrum. As a child, I was hopeless in social situations, always saying the wrong thing and unable to read body language. I also grew up on Tang, Frosted Flakes, Milky Way bars, and Kool-Aid. In my late twenties, I cut sugar out of my diet because I found that when I ate sugar, I couldn’t talk. It was like my brain locked up and wouldn’t process input. Recently, I ate a muffin that had a reduced amount of sugar in it. Within minutes, I began stuttering and floundering for words. This was during a discussion in a seminary class, so the timing was poor.

Is there a link between autism symptoms and sugar intake? A 2015 study suggests there is, and anecdotal stories from parents of autistic children abound. Other parents of ASD kids say their kids aren’t affected–and maybe they aren’t, though often the parents say their kids don’t “get hyperactive” from sugar. My own experience indicates that hyperactivity is not the only visible response. From the outside, I look like I’ve been sedated after I eat sugar. Someone who didn’t know better might think this is a good thing. But inside, I’m churning, trying unsuccessfully to process and respond to the stimulus coming in. It’s miserable.

But I do like something sweet now and again. Can you imagine going through life never having another dessert? Sugar-free commercial products are an option, though almost all contain artificial sweeteners, which I try to avoid. And the ones with sugar alcohols (like sorbitol and maltitol)– well, I won’t gross you out by describing the intestinal symptoms they cause me.

For home-baking, stevia is an option. It’s a natural plant extract with no sugars and no calories, but it’s a little too sweet and has a weird aftertaste when used alone. Stevia requires just a tiny amount, so it doesn’t bulk up a recipe like sugar does. That doesn’t matter if you’re sweetening fruit, but a cake requires the bulk and consistency of sugar to come out right. Ask me how I know. There is a 1:1 stevia product, which is stevia mixed with maltodextrin so it performs in recipes like sugar. The only store I’ve found in my area that carries it is Walmart. Amazon carries an equivalent, Stevia in the Raw, which is a bit more expensive but delivered to your door. Like stevia itself, I find the 1:1 mix has that weird aftertaste.

(Also beware of baking mixes that contain stevia and sugar, like Truvia or SugarLeaf for example, because they sort of defeat the purpose.)

So what’s the answer?

Enter the glycemic index.

“The Glycemic Index (GI) is a relative ranking of carbohydrate in foods according to how they affect blood glucose levels.” —University of Sydney

In other words, the higher the glycemic index ranking, the faster the food item causes blood sugar to rise. Glucose is rated 100. The Glycemic Index website recommends a rating of 55 or less for general health. A Harvard website ranks table sugar (sucrose) at 65, honey at 61, and fructose at 15. Clearly fructose is better for those sensitive to sugar. (Studies have shown that excessive use of fructose can raise triglyceride levels, particularly in men, so it’s not something one should eat all the time.)

The other day I was looking at a carrot cake recipe that called for a total of four cups of sugar (including the cream cheese frosting). Even using fructose, that’s a lot of sugar. But it’s easy to cut that in half while still making the recipe work. I use half fructose and half 1:1 stevia. The stevia provides sweetness with no calories or glycemic effect, and the fructose is a slow-absorbing sugar that moderates the flavor of stevia. I see the 50/50 mix as a “best of both worlds” approach.

In the frosting, I substituted neufchatel for cream cheese. That’s just a lower-fat version made with milk instead of cream. I did that not because I’m autistic, but because I’m trying to eat healthier. I also added an extra package of cream cheese to the frosting to increase the protein and further cut back on the sugar concentration. I also thought the cake might need more frosting than the recipe called for, as is sometimes the case, but I had frosting left over.

Herein lies another helpful hint: A lot of recipes can be modified a little, or sometimes a lot, to reduce the sugar content. For pies, the volume of sweetener can be cut in half and a 50/50 stevia-fructose combination can be used instead. So if your pie calls for 1 cup of sugar, skip the sugar completely and try it with 1/4 cup 1:1 stevia and 1/4 cup fructose instead. Imagine: where a recipe calls for a whole cup of brain-scrambling sugar, you may find it works just as well with 1/4 cup of slow-absorbing fructose bolstered with stevia.

If my experience is any indication, your autistic loved will thank you!

 

September 22

This Is the Day

This is the day that the Lord has made! (Psalm 118:24)

I’ve been thinking lately of my friend, Margarita Mike. We called him Margarita Mike because he got sober when he was in college, stayed sober five years, went out and drank one margarita, and came back. He stayed sober another five years.

Then Mike decided he could have another margarita. This time, things didn’t go as well. He couldn’t stop. He’d been drinking for eight months when I called him about a business situation for a mutual client. I asked him how he was doing.

“I’m not doing well at all,” he replied. “I can’t stop drinking. Would you have coffee with me sometime?”

I readily agreed. Helping people get sober as I got sober is one of the top priorities in my life. We agreed to meet the next afternoon at a local coffee shop.

That night, I got a phone call. Mike had wrapped his car around a telephone pole. My friend was gone.

I have always wondered whether things would have been different if I’d met him for coffee the day we spoke. Maybe they would have. Maybe they wouldn’t. The point is, I’ll never know–because I didn’t. I know from experience that alcoholism is a deadly disease. I almost died from it. I’ve been to more funerals than I can count on my fingers and toes.

No one expects that today is the last chance. Sometimes it is.

I’ve been thinking about this lately because of a couple of situations I’ve run into. One was a woman I rode the elevator with at the hospital. I didn’t know her and didn’t speak to her. Yet I could feel that she was toxic, so oppressed by darkness that it was rolling off of her. We got off the elevator and went our separate ways, and I said nothing. Surely she’ll realize her torment and seek help when she’s ready… right?

The other was someone I know fairly well and consider a friend, but not a close friend. As we were praying together, I felt a deep heaviness from this person. As I focused on it, I realized it was a curse. (Yes, curses exist. And Jesus died cursed so that our curses may be broken.) I brought up the subject of curses as an invitation, but my friend said nothing. We parted with no further discussion.

I have some knowledge of the ways of darkness. My family was tormented for five years. We experienced accidents, depression, psychosis, substance abuse, and illness, not to mention a ridiculous series of random setbacks in our lives. We became self-destructive. More than once, I was close to suicide. My wife nearly died twice from reactions to benign medications.

The torment of darkness can be fatal. And it’s surely miserable, especially compared with reconciliation to God. Moreover, if we believe what Christianity teaches us, the repercussions of what we do today can follow us beyond death. I’m not talking about merely accepting Jesus as Christ to avoid going to Hell. There’s far more to it than that. Sometimes, as any addict will attest, Hell follows us.

Yet most of us, including myself, don’t approach our religion with the urgency this suggests.

There are those who stand on street corners wielding a Bible and a hand-made sign proclaiming that you need to find Jesus today. I wonder if anyone listens to them. I hope so, but I never did.

There are those who go door-to-door and teach [their version of] what the Bible says. They are committed, loving people, and I think sometimes they do some good.

Most of us accept that other people are responsible for their own spiritual health. Yet when my own spiritual health was in jeopardy, I was unable to solve the problem myself. I needed help. This was as true last year when I sought deliverance as it was 32 years ago when I got sober. In both instances, I had no idea how to solve the problem. I needed someone who did.

Since Mike’s death, more than five years ago, I never put off meeting with an alcoholic or addict who asks for help. I also confront someone who appears to need help but not be willing to admit it. It often doesn’t help. Statistically, some 90% of alcoholics and addicts die from their disease. But I’m one of the 10%, and I want them to have every chance to be one, too. And never again do I want to be a day too late.

Why don’t I take the same approach with those who are suffering spiritually? I hate confrontation. I don’t have the confidence; after all, I’m new to this myself. Maybe I’m afraid of being labeled a religious nut. Maybe I’m afraid of damaging a friendship.

Would I damage a friendship to save someone’s life from addiction? Risk being labeled a nut? Step out on a limb and take a risk? You bet I would.

But religion is a private thing… right?

In a nation in which suicide rates are rising, violence against people unknown to the perpetrator is rising, drug overdose rates are rising, and antidepressant use is rising, I’m not so sure that’s true. We are a spiritually sick culture, and that sickness affects us all.

I’m tired of going to funerals of people who died too young, and seeing misery on the faces of people who are materially well off compared with much of the world. Not when there is an answer.

The challenge set before me, then, is to take the same attitude with those who suffer any kind of spiritual malady as I do toward those dying of addiction. I have been saved from misery, and it’s my responsibility to pass that on, today.

It’s a challenge I set before you, too.

 

 

July 23

The Irrationality of Alcoholics Anonymous: A Response

Gabrielle Glazier’s article in The Atlantic, “The Irrationality of Alcoholics Anonymous,” is an interesting read–thought provoking, despite the fact that it contains misrepresentations and misconceptions about AA and a good deal of irrational thought itself. I’ll come back to those points.

Let’s begin by noting the question, stated more than once, that if alcoholism is a disease, why don’t we treat it medically? The answer, obviously, is that medicine has little to offer the true alcoholic. As Glazier notes, alcoholism is a complex set of symptoms. Psychiatry has advanced a great deal since AA was founded in 1935, but it remains basically alchemy. What is known about the workings of the human brain is dwarfed by what is not known. And in practice, psychiatry itself ignores scientific method (and the well-being of the patient) in favor of generalized strategies untailored to the individual and unreliable in the hands of individual practitioners. Some time ago, over a three year period, four professionals diagnosed me with four different psychiatric conditions, each indicating a very different course of treatment. All four were wrong. We must remember that there is no test for chemical imbalance. There is no test for alcoholism.

It is also ironic that at a time when religious people and even scientists are rediscovering the power of prayer for healing, psychiatry is dismissing God as unscientific. Well, yes, it is. But science is beginning to admit that it does not have all the answers, and psychiatry in particular should be at the forefront of that admission.

Glazier notes that there is not a bright line division between alcoholic and nonalcoholic. That is true in a sense. Yet we know from scientific research that there are physical characteristics associated with alcoholism, including changes to liver cells that result in processing alcohol differently, resulting in physical addiction to alcohol. Part of the problem with the article is its fallacy of equating alcohol abuse with alcoholism. Our society has largely adopted this attitude: people who get in trouble because of alcohol are sent to AA by judges, by parents, and by treatment centers. Not all of them are alcoholic. Some may become so, and some are just going through a period of heavy drinking due to negative or positive conditions in their lives. (My brother had to “re-evaluate his drinking habits” while in college; he’s never had a problem since.)

But the main complexity in treating true alcoholics– those who have both the physical addiction and a mental compulsion to drink– is that alcohol is a treatment for an underlying condition. Despite Glazier’s assertion to the contrary, AA well recognizes this fact: “Our liquor was but a symptom. So we had to get down to causes and conditions” (Alcoholics Anonymous, 64). Of the twelve steps, only one of them even mentions alcohol. The others speak of finding a higher power, admitting fault, forgiving others, and setting things right.

The underlying condition of an alcoholic is difficult to identify. When I was drinking, I would have told you I was drinking to kill the pain. But it wasn’t physical pain. It was a deep, psychic pain. I might have told you it was the pain of living. Today, I would characterize it as a deep spiritual dissatisfaction with life that only alcohol (and various other drugs) could relieve. Until I found AA.

Therein lies the problem: Glazier relates that doctors in Finland are using a drug called naltrexone to block the components of alcohol from reaching the receptors in the brain. This would work for a person who drinks for the effect of getting drunk. Why drink if alcohol does nothing for you? But imagine for a moment that alcohol is the only thing you’ve found that makes life bearable. Take it away and life becomes unbearable. Naltrexone makes the alcohol not work. Will you live in agony, or stop taking the blocker? For an alcoholic, the answer is obvious. Absent some other way to ease the pain, we will return to alcohol again and again, regardless of the cost to our health, our families, and our careers.

Glazier, a self-described non-alcoholic, relates that she tried naltrexone and found that her desire to drink diminished. My wife (a recovering alcoholic thanks to AA) relates that to trying my prostate medication to see if it makes a difference. Absent the mental and physical addiction to alcohol, which non-alcoholics can’t grasp, an experiment like that is meaningless. Can Glazier imagine wanting a drink so badly that she would leave her baby alone in a crib while she went to a bar or liquor store, or drive drunk with her child in the car? So badly that she would drink the night before she was scheduled for a court-ordered urinalysis test to verify she was still sober? So badly that she’d drink even while taking antabuse, which would make her vomit violently and uncontrollably when she did so? So badly that, like my uncle, she would drink even if her liver had failed and the doctor told her that one drink would kill her? I seriously doubt it. I wonder of she can imagine the efficacy of naltrexone in those situations?

How can this underlying pain of an alcoholic be addressed? Carl Jung said a massive psychic change was required. AA suggests a spiritual experience. Buddhist practitioners have had success with intensive meditation. There’s been some success with Cognitive Behavioral Therapy (CBT). But in general, psychology and psychiatry have little to offer. Psychology too often fails because alcoholics themselves do not tell the truth. We fear giving up the only thing that makes life bearable, and we lie and obfuscate to ensure that doesn’t happen. Psychiatry fails because, well, it’s a science only when compared with astrology. They don’t know why an alcoholic is so maladjusted to life. How can you fix something when you don’t understand its cause?

AA offers a simple (but not easy) approach that creates a spiritual experience in the practitioner. Yes, it works. I’ve been sober 32 years. But does it work for everyone? Obviously not.

As an aside, I’ll be the first to admit that AA is difficult for atheists. I was an agnostic when I got sober, and that was a challenge. The difficulty for atheists is obvious if you go to a meeting in Buddhist countries like Sri Lanka or Thailand: there aren’t many sober Buddhists. Using AA as an atheist can be done. I’ve known atheists who have. (They often don’t remain atheists, though; the spiritual power of the process eventually causes them to acknowledge faith in God, though it may take years. I myself, formerly agnostic, am now a seminary student.) But I agree that AA is not necessarily for everyone.

Here we run into one of the first misconceptions about AA: the claim cited in the article, originally made in the 1955 version of the book Alcoholics Anonymous, that 75% of the people who came to AA stopped drinking. That number is now closer to 5-8%. But that’s not what the original claim says.

“Of alcoholics who came to A.A. and really tried, 50% got sober at once and remained that way, and 25% sobered up after some relapses…” (Alcoholics Anonymous, xx, emphasis added)

Two things are of note: first, they were dealing with alcoholics, not problem drinkers. Oldtimers who got sober in the 1950s told me that back then, hospitals wouldn’t take an alcoholic, and health insurance wouldn’t cover their treatment. People detoxing would often go into seizures in a meeting, and no one called an ambulance because it wouldn’t come. The social stigma against alcoholism was so strong at that time that you had to be pretty far gone to go to AA. You just didn’t see the casual DUI driver or tippling college student in meetings.

The second point is the phrase “really tried.” The Twelve Steps are not rocket science. AA wisdom says that no one is too dumb to work them but some of us are too smart. They demand a level of honesty and willingness that most people just can’t muster. They demand a level of commitment that comes from the certainty that there is no other possible way to survive. The dying alcoholic is a good candidate for this program. The DUI driver trying to stay out of jail or the binge-drinking college student trying to please his or her parents is not.

As more and more sources send drinkers to AA, the proportion of alcoholics who are willing to “really try” drops. Obviously, so does the success rate. What is AA’s success rate among “true” alcoholics? No one knows, because there’s no effective way to measure them. It’s an anonymous program, after all. Clearly it’s higher than 5-8%, but no one knows how many of the people being sent to AA are actually alcoholics.

It is also noteworthy that not all step-based recovery centers take the steps seriously. During my bout with mental illness, I attended one that had patients read the first three steps while undergoing therapies, CBT, and various other activities. We didn’t actually work the steps. Meetings were optional. Perhaps it was coincidental that many of my fellow patients were there for the second or third time.

Here’s one of the more frightening things I read in the article: the statistic that some 22% of those treated for alcohol dependency could return to moderate drinking. I’m not against drinking–for the nonalcoholic. But for the alcoholic, the risk is so great, why would I take a 4 out of 5 chance that I can’t  drink moderately? I’ve been told by certain ministers that if I’ve accepted Christ into my life, I can drink socially. Maybe so. But if they’re wrong, I would lose my career, my family, and probably my life. Why would I even try? That’s irrational.

Herein lies another irrationality in the thinking behind the article: that drinking is normal, and that normal is good. That idea alone drives many who struggle with alcohol back to the bottle. We desperately want to be “normal.” The truth is, from the time I first got drunk at age 16, I never wanted to just “have a drink with dinner.” I wanted to get as drunk as I could as often as I could. Yes, I’d lie to you, both about how much I wanted and how much I’d had. But honestly, I wanted to be shitfaced drunk as much of the time as I could. Periods of sobriety were miserable. (They usually lasted about ten hours while I went to work.) Why would I think that even after 32 years sober, it would be any different? More to the point, why would I take the chance? That would be irrational.

This thinking also blurs the lines between those who struggle drinking responsibly for whatever reason, and those who are alcoholic. That line can indeed be blurred, as some of the former work their way along the spectrum into the letter category. But by failing to distinguish between those who truly have an addiction and those whose drinking habits we just don’t approve of, we do both a disservice.

Glazier highlights one fact that is undeniably true: abstinence alone will not work in the treatment of alcoholism. An untreated alcoholic will crave that which gives him or her relief until he or she eventually gives in and drinks again.

Let’s put this another way: unlike the problem drinker, alcohol is not the problem for an alcoholic, it’s the self-prescribed treatment of the problem. The problem is far deeper, and is as yet unidentified by science.

Something has to change if an alcoholic is to get sober. This article, while trumpeting the scientific method, highlights that science has so far failed in the treatment of alcoholism. In the absence of real answers (or even real understanding) from the psychiatric community, and with the increasing respect for the role of God in healing, why take aim at AA? It’s not the only answer, but it has gotten million of alcoholics like me sober.

Surely that’s a good thing.