The No-Step Program
Treating alcoholism with prescription drugs can work wonders. Wonder why almost nobody prescribes them?
by Robin Rage
“A man who drinks too much on occasion is still the same man as he was sober. An alcoholic, a real alcoholic, is not the same man at all. You can’t predict anything about him for sure except that he will be someone you never met before.”
— Raymond Chandler, The Long Goodbye
Once upon a time, I was a citizen like you. I had a house and a wife and children and a job in Hallowell, working as a counselor in a facility for people experiencing mental-health crises. That was over 20 years ago.
I knew a thing or two about madness and crisis. Beginning around age 12, I’d suffered from bouts of irrational anxiety coupled with depression. When I was 17, I stumbled upon a solution: alcohol.
I remember attending an assembly during my senior year of high school. The topic was alcoholism and there was a group of older kids from a local rehab up on stage. Their stories were much like mine. They too had suffered from anxiety, social fears, depression, loneliness. Then they’d discovered booze.
For a while, drinking had stifled their anxiety and relieved their depression and isolation. They had friends and were going to parties and doing all the cool stuff that TV shows and movies told us we should be doing at that age.
Then, the kids on stage said, alcohol turned on them and things got bad. But don’t be sad, they hastened to add. You see, these kids had taken the cure. They’d gone through detox, stopped drinking, and were now “grateful alcoholics.” According to them, life was now better than ever.
This is a win/win, I thought. Alcohol could treat my anxiety and depression, and if things got bad I could just take the cure and I’d feel even better than before!
It wasn’t so. Things got bad and stayed bad until they got worse. I got arrested for drunk driving, but that didn’t slow my drinking. Marriage did, at least for a little while. In fact, for the sake of my marriage I’d been sober for about a year and a half. Then, in 1995, the wife split and took the kids and left me with the house and the dog. Back came the bottle.
Before that sober spell, my problem had been that whenever I drank I drank too much. When the spell was broken, I just drank all the time. I still had friends, but I became one of those old pals who, when they call, you hope they don’t want to come over.
I slogged along for a few years, and even became a drug-and-alcohol counselor for a while, but I didn’t stop drinking. In 1999 I moved to Memphis with another substance-abuse counselor, and by the time I returned to Maine, a year and a half later, I was an out-of-control, hard-liquor alcoholic.
Upon my return to Augusta, I was assaulted during a mugging and sustained a traumatic brain injury. According to tests performed whilst I was incarcerated at the state cracker factory (Augusta Mental Health Institute, a.k.a. AMHI), I have a dead chunk of brain where I got hit, on the right side of my frontal lobe. That lobe is the brain’s snap-judgment center. Add alcohol to that injury and you end up with a gaggle of awful decisions.
I scored my third O.U.I., was placed on probation, and kept drinking. And driving. After a slew of probation violations (you can’t drink on probation, good people) and the aforementioned stint at AMHI, most of my family disowned me. After the fourth and fifth O.U.I.s (both accrued within the span of two weeks), most of my family hated me.
The saddest thing — the thing my family never understood (not even my sister, the doctor) — was that I really could not stop drinking. God knows I wanted to. I went to Alcoholics Anonymous meetings like a madman, burned through sponsors, climbed the steps and collected many white poker chips (a.k.a. “sobriety coins”; white for one day sober) and even a few red ones (for three straight months of sobriety).
When I got out of prison in 2011, I ended up in Portland. Thanks to a small inheritance, I was living in the Motel 6 on Riverside Street, conveniently located right across from Shaw’s, an Agency Liquor Store. That’s when I got scared. I was a binge drinker, and the period between binges was getting shorter and shorter. I think I was good for about a week of sobriety back then. I consoled myself with thoughts like, “Well, I did good in prison,” and sent e-mails to friends that basically told them, “I’ll be dead within the year.”
Instead, I was sober within the year. How did I do it?
It began with a visit to my therapist, at the city’s Health Care for the Homeless clinic on Portland Street, who helped me enroll in an intensive out-patient program. The doctor I saw at the Portland Community Health Center, on Park Avenue, had recently read a medical paper on the efficacy of using prescription drugs to treat alcoholism. The study was specifically about a combination of two drugs: naltrexone and gabapentin. They hooked me up.
At first, the naltrexone didn’t have any noticeable effect, but the “gabba” sure did. It made me feel … well, I guess the best word is balanced. I’d suffered from that nagging depression for so much of my life that I’d come to consider it my normal state of mind. Gabapentin fixed that. As they say on the street, where the drug is available as an illicit upper, “Gabba-dabba-do!”
Naltrexone won’t get you high, but it will save your life. It damn sure saved mine.
I was only on naltrexone for three or four months, but its effect has now lasted for three years. Naltrexone didn’t take away my desire to drink. It freed me from the need to drink. For example, if I drank on Tuesday night, I no longer had the overwhelming desire to drink on Wednesday morning. I might go a month or two before having another alcoholic beverage. For someone like me, that’s nothing short of miraculous.
Naltrexone removes the biological urge to get drunk by blocking opioid receptors in the brain. Partly for that reason, it’s often confused with naloxone (a.k.a. Narcan), the injectable drug that saves junkies from overdose deaths. Naltrexone has been prescribed to opiate addicts, but it’s not nearly as effective for junkies as it is for alcoholics like me.
Naltrexone is not some new wonder drug. The Food and Drug Administration approved its use to treat alcohol abuse in 1995 — the same year my life fell off a cliff. If I’d had access to naltrexone back then, who knows what horrors I’d have been spared?
Consider the fact that around the time I began taking naltrexone, my inheritance money ran out, so I moved out of the motel and eventually became homeless, living in the woods that once stood between the Fore River and West Commercial Street (see my first story for The Bollard, “Sherwood Forest: Life as an outlaw on the Fore River,” November 2014, for more on those days). Even under those stressful circumstances, surrounded by other homeless people with substance-abuse issues, I didn’t drink.
The burning question now is: Why aren’t millions of other alcoholics benefitting from naltrexone?
The short answers: ignorance, greed, and Puritans.
“Reality is just a crutch for people who can’t cope with drugs.”
— Robin Williams
To better understand naltrexone and why it isn’t more widely prescribed, I called Dr. Mark Publicker, an addiction specialist who practices in Portland and advocates for sane solutions to Maine’s opiate and alcohol epidemics.
“Naltrexone is a wonderful drug, and for the right person, for people who’ve relapsed time and time again, it’s a miracle,” Publicker told me. “If a person’s alcoholism is of the sort that primarily gets triggered by a lot of conditional cues, naltrexone works wonderfully. It’s my first go-to drug.”
“But,” I said, “I was only on naltrexone for three or four months.”
“That is why Vivitrol” — the injectable, extended-release version of naltrexone — “is so nice for alcoholism,” he said. “A once-a-month injection and you really only need three or four months of it. Some people need to stay on it, others don’t.”
Publicker confirmed a suspicion I’ve had for quite some time now, that the opiate crisis gripping Maine and the nation has shifted attention away from alcoholism — which, in terms of the number of people afflicted and the societal cost, continues to dwarf the smack and pill problems combined. I’m not saying the junkies don’t deserve help, but hey, let’s not forget the drunks!
“I think it’s pretty reliable that the incidence of alcoholism is always roughly about 10 percent of the population,” said Publicker. “What is the prevalence of opiate addiction? It’s far smaller. I mean, it’s much more dramatic and, of course, I treat opiate addiction, but my concern is that nobody’s treating alcoholism, and alcohol has been forgotten. When you read any of the initiatives, where’s alcohol?”
“The problem with Vivitrol has been that, with the opiate epidemic, the drug companies are not marketing it for alcoholism,” Publicker added. “I can’t get them to say it. Sometimes I think that I’m the only doctor up here [in Maine] treating alcoholism. Up here, as far as using naltrexone for alcoholism, if you polled a hundred doctors I’d be shocked if more than two had even heard of it, and I’d be shocked if more than one had even prescribed it. And it’s a miracle.”
One reason few doctors are aware of drugs like naltrexone is a lack of publicity and media coverage. Among the few articles I found was an April 2015 piece in The Atlantic titled, “The Irrationality of Alcoholics Anonymous.” I’ll get to the critique of AA in a minute, but first a few quotes.
“The American Medical Association estimates that out of nearly 1 million doctors in the United States, only 582 identify themselves as addiction specialists,” wrote the article’s author, Gabrielle Glaser, bolstering Publicker’s sense that he’s practically alone in his field in Maine. “Most treatment providers carry the credential of addiction counselor or substance-abuse counselor, for which many states require little more than a high-school diploma or a GED,” Glaser continued. “Many counselors are in recovery themselves.” Yup, that was me!
“Naltrexone has been found to reduce drinking in more than a dozen clinical trials,” Glaser reported. “The results have been largely overlooked. Less than 1 percent of people treated for alcohol problems in the United States are prescribed naltrexone or any other drug shown to help control drinking.”
The pharmaceutical industry’s lack of enthusiasm for naltrexone is another big reason doctors aren’t aware of it. Glaser quotes Stephanie O’Malley, a researcher at Yale, who called the lack of naltrexone prescriptions “baffling.”
“There was never any campaign for this medication that said, ‘Ask your doctor,’” O’Malley told Glaser. “There was never any attempt to reach consumers.”
“Few doctors accepted that it was possible to treat alcohol-use disorder with a pill,” wrote Glaser. “And now that naltrexone is available in an inexpensive generic form, pharmaceutical companies have little incentive to promote it.”
In other words, a big reason this “miracle” drug isn’t being prescribed to more than a handful of the roughly 130,000 Mainers (10 percent of our state’s population) abusing alcohol is because it’s not very profitable to do so for drug companies, doctors, and the operators of privately owned rehab facilities, who cash in on wealthy clients (or those with good insurance) every time they fall off the wagon.
Who pays for the impoverished alcoholics, like me, who don’t have insurance and can’t afford to dry out on a yoga mat at some lakeside retreat? That’d be you, good citizen, in the form of untold billions of tax dollars spent on government-funded treatment programs, cops, jails, courts, and myriad other expenses.
Case in point: the ominously named Operation Bayside, an effort launched this summer to curb the chaos that’s plagued that downtown Portland neighborhood for decades, mostly by beefing up police patrols, fixing sidewalks and improving street lighting. The “streetscape and lighting upgrades” alone will cost Portland property owners well over $1.2 million, the Portland Press Herald reported last month.
Neighborhood activist Steve Hirshon blamed the bulk of the bad behavior in Bayside on “‘the regulars’ and the people who are content to hang out on the street corners all day drinking alcohol and causing a ruckus,” reporter Randy Billings wrote. Yup, that used to be me, too!
Now ask yourself: Might there be a more cost-effective — not to mention humane — way to address this problem, which everyone agrees is being caused by, at most, a few dozen obnoxious booze hounds? (Hint: According to the website drugs.com, the retail cost of 15 naltrexone tablets is about $37.
“One poor chap committed suicide in my home. He could not, or would not, see our way of life.”
— Bill Wilson, co-founder of Alcoholics Anonymous
In her article for The Atlantic, Glaser writes about John David Sinclair, a neuroscientist who pioneered efforts to find a medication-based treatment for alcoholism. In one drug program he tested, Sinclair had patients take naltrexone one hour before drinking — a regimen now known as The Sinclair Method that’s being championed by a small but passionate group of true believers (the C Three Foundation).
“The Sinclair Method … has been found to be successful in about 80% of alcoholics,” Sinclair wrote in a testimonial posted on the foundation’s website (cthreefoundation.org). A 2001 paper Sinclair published in the medical journal Alcohol and Alcoholism reported a 78 percent success rate helping patients reduce their drinking to about 10 drinks a week, Glaser reported, and some “stopped drinking entirely.” Glaser goes on to note that at the clinics Sinclair co-founded in Finland, 75 percent of patients “have had success reducing their consumption to a safe level.”
The treatment programs Sinclair ran in Finland typically lasted six months and paired therapy sessions with doses of naltrexone or a newer, similar drug called nalmefene. The cost of that six-month program: about $2,500, “a fraction of the cost of inpatient rehab in the United States,” Glaser wrote, “which routinely runs in the tens of thousands of dollars for a 28-day stay.”
It’s findings like these, showing that naltrexone can help about three out of four alcoholics get their life back on track, that lead men of science like Publicker to use words like “miracle.”
But, as you may have noticed, there’s a hitch: most of the alcoholics who benefit from naltrexone still drink, albeit moderately (e.g., the aforementioned 10 drinks a week, which amounts to, say, one cocktail and a couple sips from the sidecar every evening). To the Puritanical mindset that guides public policy in this country, the idea of a treatment that allows alcoholics to drink any amount of alcohol at all is heresy. Like abstinence-only sex education and the “Just Say No” anti-drug campaign, the cold-turkey approach to curing alcoholism has been an obvious and colossal failure. But to point that out takes more courage than most people in positions of authority can muster.
Which brings us to AA, a sacrosanct, criticism-proof institution if ever there was one. In “The Irrationality of Alcoholics Anonymous,” Glaser notes that AA has also claimed a 75 percent success rate — at least among those who have attended meetings and, as The Big Book says, “really tried.” But Glaser also cites a recent book by a retired Harvard Medical School psychiatry professor, Lance Dodes, titled The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry, in which he uses data to peg AA’s “actual success rate somewhere between 5 and 8 percent.”
There are aspects of Alcoholics Anonymous that some find troubling — like its stress on the “powerlessness” of alcoholics, and all the supernatural references to God and prayer — but I’m not going to bash AA. My adopted father found sobriety through the 12 Steps. He brought me along to meetings well before I had my first drink. And given the high degree of isolation people experience in our fractured, tech-obsessed, cutthroat-capitalist society, I think the gathering of a group of people with a common goal and peer support is a great thing. I’ve met beautiful, spiritual people at meetings. I’ve seen people rise from the trash heap of alcoholic despair to attain periods of complete abstinence. I’ve been in and out of “the program” for the last 20 years, and at times it’s enabled me to collect some time in sobriety.
But I would always end up drinking again. I couldn’t stop and I didn’t stop — until I scored a scrip for naltrexone.
Even with naltrexone, it hasn’t been smooth sailing. On the rare occasions when I have indulged during the past couple years, the day after was insufferable, and twice I admitted myself to detox for fear I was headed back down into the hole. These days I just leave the stuff alone.
And naltrexone alone is not the answer. Counseling or therapy is a key component, as are lifestyle changes. “Alcoholism rarely exists in a vacuum,” Peter Wohl, a social worker with Behavioral Health Resources of Maine, a mental health clinic in Portland, told me. For many alcoholics, the disease is compounded by poverty, homelessness, incarceration and mental illness.
Again, that was me! I first met Peter while I was locked up on the unit for the criminally insane at AMHI. Not long after that, when I was admitted to the Kennebec County Co-Occurring Disorders and Veterans Court (a drug court for those of us with mental issues in addition to addictions), Peter was a team member and my drug-and-alcohol counselor. I did well within the tight structure of the court program and for two weeks after I graduated, until I drank (again) and ended up in jail (again).
Peter agrees that ignorance of meds like naltrexone and baclofen (another drug that’s worked wonders for many alcoholics) is a nationwide problem, as is the dearth of addiction doctors like Publicker. He’s pleased about the lifestyle changes I’ve made that have helped me maintain my sobriety, like my move last year from Bayside to an apartment in Freeport, USA.
I rarely entertain guests at my new pad in Freeport, but a friend recently showed up with someone I didn’t know, and they’d both been drinking. My friend hadn’t drank in quite a while, due to a particularly scary incident, but there he was, getting soused in my kitchen.
Now, before naltrexone I’d have been slugging ’em back with them, but I had no desire — only concern. I had to get to an appointment, and we all left my place together. They went to get more beer.
When I got out of my appointment, I went down the street to check on my friend, and he was a bloody mess. The flesh around his eye was all torn up and he had a huge gash on the back of his head. In the past, I was the one with the “mystery wounds,” the one you called the ambulance for. This time, I called the ambulance, and off he went.
The other day I learned that they’d moved him to the psych ward; he’d started screaming suicide. Good move, I thought. If he hadn’t pulled the suicide card, they would have just stitched him up and sent him home. This gave him a couple more days to get his head together, so to speak. I’d played the same card a couple times myself, back when I lived a drunken life of crime in Augusta.
I spoke to my friend today. No one at the hospital or the psych ward offered him naltrexone or any other scientifically proven medical alternative. They did give him a list of local AA meetings.