Alcoholics Anonymous: The Evidence is In !

An Updated review shows it performs better than some other common treatments and is less expensive.

For a long time, medical researchers were unsure whether Alcoholics Anonymous worked better than other approaches to treating people
with alcohol use disorder. In 2006, a review of the evidence concluded we didn’t have enough evidence to judge.
That has changed.
An updated systematic review published Wednesday by the Cochrane Collaboration found that A.A. leads to increased rates and lengths of
abstinence compared with other common treatments
. On other measures, like drinks per day, it performs as well as approaches provided
by individual therapists or doctors who don’t rely on A.A.’s peer connections.
What changed? In short, the latest review incorporates more and better evidence. The research is based on an analysis of 27 studies
involving 10,565 participants.
The 2006 Cochrane Collaboration review was based on just eight studies, and ended with a call for more research to assess the program’s
efficacy. In the intervening years, researchers answered the call. The newer review also applied standards that weeded out some weaker
studies that drove earlier findings.
In the last decade or so, researchers have published a number of very high-quality randomized trials and quasi-experiments. Of the 27
studies in the new review, 21 have randomized designs. Together, these flip the conclusion.
“These results demonstrate A.A.’s effectiveness in helping people not only initiate but sustain abstinence and remission over the long
term,” said the review’s lead author, John F. Kelly, a professor of psychiatry at Harvard Medical School and director of the Recovery
Research Institute at Massachusetts General Hospital. “The fact that A.A. is free and so widely available is also good news.
“It’s the closest thing in public health we have to a free lunch.”
Studies generally show that other treatments might result in about 15 percent to 25 percent of people who remain abstinent. With A.A., it’s
somewhere between 22 percent and 37 percent (specific findings vary by study). Although A.A. may be better for many people, other
approaches can work, too. And, as with any treatment, it doesn’t work perfectly all the time.
Rigorous study of programs like Alcoholics Anonymous is challenging because people self-select into them. Those who do so may be more
motivated to abstain from drinking than those who don’t.
Unless a study is carefully designed, its results can be driven by who participates, not by what the program does. Even randomized trials
can succumb to bias from self-selection if people assigned to A.A. don’t attend, and if people assigned to the control group do. (It may go
without saying, but we’ll say it: It would be unethical to prevent people in a control group from attending Alcoholics Anonymous if they
wanted to.)
Despite these challenges, some high-quality randomized trials of Alcoholics Anonymous have been conducted in recent years. One,
published in the journal Addiction, found that those who were randomly assigned to a 12-step-based directive A.A. approach, and were
supported in their participation, attended more meetings and exhibited a greater degree of abstinence, compared with those in the other
treatment groups. Likewise, other randomized studies found that greater Alcoholics Anonymous participation is associated with greater
alcohol abstinence.

Alcoholics Anonymous is often paired with other kinds of treatment that encourage engagement with it. “For people already in treatment,
if they add A.A. to it, their outcomes are superior than those who just get treatment without A.A.,” said Keith Humphreys, a Stanford
University professor and co-author of the new Cochrane review.
Alcoholics Anonymous not only produced higher rates of abstinence and remission, but it also did so at a lower cost, the Cochrane review
found. A.A. meetings are free to attend. Other treatments, especially those that use the health care system, are more expensive.
One study found that compared with Alcoholics Anonymous participants, those who received cognitive behavioral treatments had about
twice as many outpatient visits — as well as more inpatient care — that cost just over $7,000 per year more in 2018 dollars. (Cognitive
behavioral treatments help people analyze, understand and modify their drinking behavior and its context.)
Another study found that for each additional A.A. meeting attended, health care costs fell by almost 5 percent, mostly a result of fewer
days spent in the hospital and fewer psychiatric visits.
A.A. meetings are ubiquitous and frequent, with no appointment needed — you just show up. The bonds formed from the shared challenge
of addiction — building trust and confidence in a group setting — may be a key ingredient to help people stay on the road to recovery.
Worldwide, alcohol misuse and dependence are responsible for 3.3 million deaths per year, 10 times the number of fatalities from all illicit
drugs combined.
In the United States, alcohol is a larger killer than other drugs; accounts for the majority of all addiction treatment cases; and is
responsible for at least $250 billion per year in lost productivity and costs related to crime, incarceration and health care. Moreover,
American deaths related to alcohol more than doubled between 1999 and 2017.
Reducing the human and financial burdens of alcohol is an often overlooked public health priority, and the new evidence suggests that on
balance one of the oldest solutions — Alcoholics Anonymous has been around almost 85 years — is still the better one.


Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of
Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter @afrakt
Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine and the Regenstrief Institute who blogs on health research and policy at The Incidental
Economist and makes videos at Healthcare Triage. He is the author of “The Bad Food Bible: How and Why to Eat Sinfully.” @aaronecarrol

Predisposition to addiction may be genetic, study finds

People who have a high sensation-seeking personality trait may be more likely to develop an addiction to cocaine, according to a Rutgers study.

Although many people try illicit drugs like cocaine or heroin, only a small proportion develop an addiction,” said lead author Morgan James, a member of the Rutgers Brain Health Institute and an assistant professor in the department of psychiatry at Rutgers Robert Wood Johnson Medical School. “The interaction found between sensation-seeking traits and the drug-taking experience show that predisposition to addiction has a genetic basis, and that this interacts with environmental factors such as patterns of drug use. The sensation-seeking trait was predictive of rats’ likelihood to exhibit stronger motivation for drugs when we gave them the opportunity to take cocaine.”

The findings, published in the journal Neuropharmacology, shed light on what predisposes people to addiction and may help with substance use screening and treatment.

The lab study found that high sensation-seeking rats — those with a strong desire for new experiences and a willingness to take risks to be stimulated — were more prone to developing behavior that reflects human addiction. The findings suggest that high sensation-seeking people have a greater risk of losing control over their drug intake, which makes them more vulnerable to drug addiction.

A major goal of addiction research is to identify behavioral biomarkers that predict addiction vulnerability. Future studies can build on these findings to determine what is different in the brains of those who are high sensation-seeking to see what predisposes them to addiction.

Alcohol Related Deaths Increasing in the United States

An analysis of U.S. death certificate data by researchers at the National Institute on Alcohol Abuse and Alcoholism (NIAAA), part of the National Institutes of Health, found that nearly 1 million people died from alcohol-related causes between 1999 and 2017. The number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017, the year in which alcohol played a role in 2.6% of all deaths in the United States. The increase in alcohol-related deaths is consistent with reports of increases in alcohol consumption and alcohol-involved emergency department visits and hospitalizations during the same period. The new findings are reported online in the journal Alcoholism: Clinical and Experimental Research. “Alcohol is not a benign substance and there are many ways it can contribute to mortality,” said NIAAA Director Dr. George F. Koob. “The current findings suggest that alcohol-related deaths involving injuries, overdoses, and chronic diseases are increasing across a wide swath of the population. The report is a wakeup call to the growing threat alcohol poses to public health.”

Two illustrations of the human liver. left: a healthy liver; right: a liver showing signs of cirrhosis

 In the new study, Aaron White, Ph.D., senior scientific advisor to the NIAAA director, and colleagues analyzed data from all U.S. death certificates filed from 1999 to 2017.  A death was identified as alcohol-related if an alcohol-induced cause was listed as the underlying cause or as a contributing cause of death.  The researchers found that, in 2017, nearly half of alcohol-related deaths resulted from liver disease (31%; 22,245) or overdoses on alcohol alone or with other drugs (18%; 12,954). People aged 45-74 had the highest rates of deaths related to alcohol, but the biggest increases over time were among people age 25-34. High rates among middle-aged adults are consistent with recent reports of increases in “deaths of despair,” generally defined as deaths related to overdoses, alcohol-associated liver cirrhosis, and suicides, primarily among non-Hispanic whites. However, the authors report that, by the end of the study period, alcohol-related deaths were increasing among people in almost all age and racial and ethnic group. As with increases in alcohol consumption and related medical emergencies, rates of death involving alcohol increased more for women (85%) than men (35%) over the study period, further narrowing once large differences in alcohol use and harms between males and females. The findings come at a time of growing evidence that even one drink per day of alcohol can contribute to an increase in the risk of breast cancer for women. Women also appear to be at a greater risk than men for alcohol-related cardiovascular diseases, liver disease, alcohol use disorder, and other consequences. “Alcohol is a growing women’s health issue,” said Dr. Koob. “The rapid increase in deaths involving alcohol among women is troubling and parallels the increases in alcohol consumption among women over the past few decades.” The authors note that previous studies have shown that the role of alcohol in deaths is vastly underreported. Since the present study examined death certificates only, the actual number of alcohol-related deaths in 2017 may far exceed the 72,558 determined by the authors.     “Taken together,” said Dr. Koob, “the findings of this study and others suggests that alcohol-related harms are increasing at multiple levels – from ED visits and hospitalizations to deaths. We know that the contribution of alcohol often fails to make it onto death certificates. Better surveillance of alcohol involvement in mortality is essential in order to better understand and address the impact of alcohol on public health.” Reference: Aaron White, PhD, I-Jen P. Castle, PhD, Ralph Hingson, ScD, Patricia Powell, PhD. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999–2017 Alcoholism: Clinical and Experimental Research. Published online January 8, 2020

The Difference Between Character Defects and Addiction

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The following article comes to us from our friends at the Pain News Network. It does not necessarily reflect the views of the Recovery Radio Network or it’s affiliates. We do believe though that the information is pertinent to those wishing to improve their understanding of addiction so, we publish it in the spirit of cooperation and communication.

By Dr. Lynn Webster, PNN Columnist

Rush Limbaugh was as controversial as he was politically influential. In fact, Nicole Hemmer, a research scholar at Columbia University, called Limbaugh “the man who created Donald Trump” and opined that Limbaugh created the political foundation that catapulted Trump to power.

In 2020, President Trump returned the favor by awarding Limbaugh the Medal of Freedom, our highest civilian honor, for his “decades of tireless devotion to our country.”

But the Independent points out that Limbaugh also left behind a legacy of “divisiveness, cruelty, racism, homophobia, bigotry, and sexism.” And Rolling Stonesaid the radio host “trafficked in bigotry and cruelty.”

RUSH LIMBAUGH
RUSH LIMBAUGH

It’s hard to argue with either of those statements. To me, Limbaugh was a deeply flawed human being who caused harm. But some statements about him go too far.

When Limbaugh died this week after a lengthy battle with lung cancer, Mark Frauenfelder, editor of The Magnet, tweeted: “Rush Limbaugh, the sex tourist and drug addict whose four marriages, mockery of people after their deaths, and overt racism and misogyny made him a beloved icon of American conservatism, is dead at 70.” 

That statement is troubling. Overt racism and misogyny are character flaws. Drug addiction, however, is not. It’s unfortunate to see Limbaugh’s detractors point to his well-documented problems with painkillers as moral failings. This supports my firm belief that our culture holds deeply negative views of people with addiction.  

History of Back Pain and Drug Use 

Limbaugh began abusing prescription painkillers after his spinal surgery in the 1990s. He was eventually arrested on drug charges — specifically, charges of fraud to conceal information to obtain prescriptions, also known as “doctor shopping.” In exchange for having the charges dropped, Limbaugh agreed to undergo drug treatment and pay $30,000 in court costs. He posted $3,000 bail and was released.

I wrote about Limbaugh’s prescription drug problem in my book, “Avoiding Opioid Abuse While Managing Pain.” What we knew about Limbaugh’s problem, as I said at the time, was that he abused large quantities of prescription opioids for several years; kept his abuse secret from family, friends and colleagues; entered a rehabilitation program twice, but relapsed each time; remained successful without a visible reduction in functioning while he used drugs; and was suspected of buying drugs illegally. 

What we didn’t know, and perhaps now can never ascertain, is whether Limbaugh had an addiction or an undiagnosed psychiatric disorder (although some may argue his professional conduct was evidence of a disturbed personality). We also can’t know whether his main motivation for using drugs was to control physical pain, to mask emotional pain or stress, to seek a “high,” or some combination of those reasons.  

The answers to these questions — about his history of drug abuse, mental health and motivation — would have told us whether his opioid use disorder (OUD) was treatable with better pain control or, tragically, was an incurable disease.  

Limbaugh exemplifies the type of patient most physicians face when treating serious pain conditions. Sometimes, opioids fail to provide adequate relief for them. And, increasingly, patients cannot access the opioids they need due to misguided polices and regulations.   

How Society Views Addiction 

Some people may agree with Limbaugh’s political and social views, and others may not. But conflating his drug abuse and associated illegal activities with the opinions he expressed about social issues harms people who suffer from the disease of addiction. It also makes it more difficult for people with severe pain to receive the care they deserve, whether their abuse is caused by addiction or, as is often the case, a symptom of undertreated pain. 

Many of those with addiction may not have the power or influence to bail themselves out of prison or pay tens of thousands of dollars in court costs. They may remain in prison for years and suffer the loss of their careers, reputations, homes and even their families.  

Generally, our society views people with addiction as flawed, weak and hopeless. We distance ourselves from those who have the disease, and we allow the criminal justice system to have jurisdiction over them, making it difficult or even impossible for them to receive treatment.  

We may never know why Rush Limbaugh made the choices he did. But, just as we would never think of berating him for falling victim to lung cancer, we also shouldn’t chastise him for misusing painkillers. We may have a right to judge Limbaugh’s behavior, but we cannot, in decency, judge his disease. 

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book The Painful Truth, and co-producer of the documentary It Hurts Until You Die. Opinions expressed here are those of the author alone and do not reflect the views or policy of PRA Health Sciences.

Do Prescription Opioids Increase Social Pain and Isolation?

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Long-term use of opioid medication may increase social isolation, anxiety and depression for chronic pain patients, according to psychiatric and pain management experts at the University of Washington School Medicine.

In an op/ed recently published in Annals of Family Medicine, Drs. Mark Sullivan and Jane Ballantyne say opioid medication numbs the physical and emotional pain of patients, but interferes with the human need for social connections.

“Their social and emotional functioning is messed up under a wet blanket of opioids,” Sullivan said in a UW Medicine press release.

Sullivan and Ballantyne are board members of Physicians for Responsible Opioid Prescribing (PROP), an influential anti-opioid activist group. Ballantyne, who is president of PROP, was a member of the “Core Expert Group” that advised the CDC during the drafting of its controversial 2016 opioid guideline. She has retired as a professor of pain medicine at the university, while Sullivan remains active as a professor of psychiatry.

In their op/ed, Sullivan and Ballantyne say it is wrong to assume that chronic pain arises solely from tissue damage caused by trauma or disease. They cite neuroimaging studies that found emotional and physical pain are processed in the same parts of the human brain.  While prescription opioids may lessen physical pain, they interfere with the production of endorphins – opioid-like hormones that help us feel better emotionally.

“Many of the patients who use opioid medications long term for the treatment of chronic pain have both physical and social pain,” they wrote. “Rather than helping the pain for which the opioid was originally sought, persistent opioid use may be chasing the pain in a circular manner, diminishing natural rewards from normal sources of pleasure, and increasing social isolation.

“To make matters worse, the people who need and want opioids the most, and who choose to use them over the long term, tend to be those with the most complex forms of chronic pain, containing both physical and social elements. We have called this process ‘adverse selection’ because these are also the people who are also at the greatest risk for continuous or escalating opioid use, and the development of complex dependence.”

Sullivan and Ballantyne say doctors need to recognize that when patients have both physical and social pain, long-term opioid therapy is “more likely to harm than help.”

“We believe that short-term opioid therapy, lasting no more than a month or so, will and should remain a common tool in clinical practice. But long-term opioid therapy that lasts months and perhaps years should be a rare occurrence because it does not treat chronic pain well, it impairs human social and emotional function, and can lead to opioid dependence or addiction,” they wrote.

Angry and Depressed Patients

It’s not the first time Sullivan and Ballantyne have weighed in on the moods and temperament of chronic pain patients. In a 2018 interview with Pain Research Forum, for example, Ballantyne said patients often have “psychiatric comorbidities” and become “very angry” at anyone who suggests they shouldn’t be on opioids.

“I’ve never seen an angry patient who is not taking opiates. It’s people on opiates who are angry because they’re frightened, desperate, and need to stay on them. And I don’t blame them because it is very difficult to come off of opiates,” she said.

In a 2017 interview with The Atlantic, Sullivan said depression and anxiety heighten physical pain and fuel the need for opioids. “People have distress — their life is not working, they’re not sleeping, they’re not functioning,” Sullivan said, “and they want something to make all that better.”

JANE BALLANTYNE                        MARK SULLIVAN
JANE BALLANTYNE MARK SULLIVAN

In a controversial 2015 commentary they co-authored in the New England Journal of Medicine, Sullivan and Ballantyne said chronic pain patients should learn to accept pain and get on with their lives, and that relieving pain intensity should not be the primary focus of doctors. The article infuriated both patients and physicians, including dozens who left bitter comments.

Drinking linked to a decline in brain health from cradle to grave

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The evidence for the harmful effects of alcohol on brain health is compelling, but now experts have pin-pointed three key time periods in life when the effects of alcohol are likely to be at their greatest.

Writing in The BMJ today, researchers in Australia and the UK say evidence suggests three periods of dynamic brain changes that may be particularly sensitive to the harmful effects of alcohol: gestation (from conception to birth), later adolescence (15-19 years), and older adulthood (over 65 years).

They warn that these key periods “could increase sensitivity to the effects of environmental exposures such as alcohol” and say harm prevention policies “must take the long view.”

Globally, around 10% of pregnant women consume alcohol, with the rates considerably higher in European countries than the global average, they write.

Heavy alcohol use during pregnancy can cause fetal alcohol spectrum disorder, associated with widespread reductions in brain volume and cognitive impairment. But data suggest that even low or moderate alcohol consumption during pregnancy is significantly associated with poorer psychological and behavioural outcomes in offspring.

In terms of adolescence, more than 20% of 15-19 year olds in European and other high income countries report at least occasional binge drinking (defined as 60 g of ethanol on a single occasion), they add.

Studies indicate that the transition to binge drinking in adolescence is associated with reduced brain volume, poorer white matter development (critical for efficient brain functioning), and small to moderate deficits in a range of cognitive functions.

And in older people, alcohol use disorders were recently shown to be one of the strongest modifiable risk factors for all types of dementia (particularly early onset) compared with other established risk factors such as high blood pressure and smoking.

Although alcohol use disorders are relatively rare in older adults, the authors point out that even moderate drinking has been shown to be linked to a small but significant loss of brain volume in midlife, although further studies are needed to test whether these structural changes translate into functional impairment.

Furthermore, demographic trends may compound the effect of alcohol use on brain health, they write. For example, women are now just as likely as men to drink alcohol and experience alcohol related harms, and global consumption is forecast to rise further in the next decade.

The effects of the covid-19 pandemic on alcohol use and related harms are unclear, but alcohol use increased in the long term after other major public health crises, they add.

As such, they call for an integrated approach to harm reduction at all ages.

“Population based interventions such as guidelines on low risk drinking, alcohol pricing policies, and lower drink driving limits need to be accompanied by the development of training and care pathways that consider the human brain at risk throughout life,” they conclude.