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Wellness Corner May 2015 - Are the 12-Steps Enough? - by Dr. Gary Pace


 Are the 12-Steps Enough?

by Dr. Gary Pace

Alcoholics Anonymous and 12-step programs have become familiar treatment methods to deal with addictive behaviors in the US. Almost all of us know someone involved in AA, and their tenets about people who abuse alcohol being powerless, having to hit a bottom before being ready to get help, and being unable to benefit from medication-based treatments pervade our thinking. Are there other options to help people who suffer from problematic drinking if they don’t want to quit completely, or if they aren’t able to fit into the 12-step model? 

Alcoholics Anonymous 

Started in 1935, AA has become an international phenomenon with over 2 million participants worldwide, and countless people credit “the program” with turning their lives around.

These successes are extremely impressive, but is this the final word? Understanding alcoholism as a progressive disease, holding complete abstinence as the only goal, and seeing surrender to a higher power as essential to recovery are core principles of AA, yet are they necessarily true? For many people trying to improve their lives impacted by heavy alcohol use, some of these ideas may not sit well. Also since the emergence of AA, there has been scientific research conducted that contradicts some of these foundational beliefs.

Does AA work? Attempts to study it have not been very successful. The organization is decentralized and no records are kept due to anonymity. Official literature suggests a high rate of success – over 50% – if people are ready to quit and really try to adhere to the program. On the other hand, a recent study by Dodes found a rate of 10% for people who start AA being able to maintain abstinence, which probably correlates with the experience of people working in the field.

Other Treatment Options 

There is movement within the medical world to combine various modalities to tailor treatment to the specific needs of each individual with an alcohol problem. Goals may include abstinence or simply decreasing the heavy drinking that leads to problematic behavior. Treating underlying issues like depression and anxiety that may contribute to alcohol abuse and “self-medication” can be helpful.

Various approaches include:

 • Having a healthcare provider talk about alcohol use and helping the patient explore their motivation to change drinking habits can be effective, especially for those who are non-dependent, but at-risk.

 •  Cognitive Behavioral Therapy, a structured form of therapy where learning how one’s thoughts affect behavior, has proven helpful for some people needing to decrease their drinking. 

 • Peer support groups, AA or similar models, usually aim for abstinence through group sharing.

 •  In-patient treatment (Betty Ford being the most famous) provides a 24-hour, alcohol-free environment for patients at high risk of relapse at home. They are geared towards folks with more severe problems, and they offer varying types of treatment at different facilities.

As much as 70 percent of individuals relapse after psychosocial treatment alone. Use of medications has mostly focused on altering the reinforcing effects of alcohol use through blocking some of the pleasure pathways. 

 •  Naltrexone, the first-line recommendation, while infrequently used in the United States is getting some attention (“The False Gospel of Alcoholics Anonymous,” Atlantic Magazine, April 2015). Patients taking opioids cannot use this medicine, since it works by blocking the opioid pathway. A documentary, “One Little Pill,” recounts one woman’s successful change of her alcohol use with the help of naltrexone. She took it before going out to drink, and her drive to drink to excess disappeared.

 — Baclofen, Acamprosate (Campral), and Topamax are other medications that have some success at decreasing the cravings for alcohol possibly through effects on the neurotransmitters. Antabuse, a time-honored treatment that makes people ill when they consume alcohol, is especially effective for people who want to abstain and have the discipline to take the daily medication.


The Affordable Care Act mandates substance abuse treatment coverage by insurers, including MediCal. Currently, $35 billion annually is spent on alcohol and substance abuse treatment. It seems wise to evaluate how well the predominant abstinence-based model of recovery really works. Talk to your provider or your therapist about your drinking, and consider other options if AA has not been successful for you in the past. 

Dr. Gary Pace - Wellness Corner