Alcoholics Anonymous vs. the Benefits of Integrative Treatment
in the Biopsychosocial Framework

Another positive aspect of twelve step programs that helps continue the recovery process outside of the group meetings, is the relationship between sponsor and sponsee. The sponsor can provide insight and accountability while modeling a sober lifestyle. Additionally, this peer based; dyadic relationship helps the individual by providing additional, real-time support when an individual is actively feeling urges to relapse. It is generally recommended that a sponsor have at least one year of sobriety and is active member of the twelve-step community. The nature of becoming a sponsor in these programs coincides with the twelve-step mission of “Service”; to serve others to further their own recovery thus making a mutually beneficial dyadic relationship that sustains the community.

An AA sponsor engages with an individual on a more intimate and personal level due to their shared experiences and a mutual peer-based relationship. Sponsors provide invaluable support that can help target specific behaviors and/or urges in real time with the lived experience and empathy necessary to support the client. Though this situation may seem ideal, there are many factors that could affect this relationship due to incompatibility, inconsistency in the commitment, the risk of the sponsor to relapse, and abuse of power in the dynamic. It is generally recommended that sponsor/sponsee relationships are same gender relationship (in heterosexual dyads) to avoid the potential for romantic situations, and potentially lead to abusive situations. This is not to say that all abusive situations are romantic in nature but there are situations when those in a vulnerable state are preyed upon.

Lastly, AA overlooks comorbid mental disorders. Alcohol abuse rarely functions alone and beside comorbidity of other substances, there is also the potential presence of underlying psychological factors. Depression, anxiety, bipolar disorder, and more are some common disorders that occur comorbidly with alcohol use disorder. The use of substances can exacerbate symptoms and complicate an individual’s ability to function and live normally. AA doesn’t address how this could affect the recovery process.

The review found that overall, participants had similar days abstinence as other treatment modalities however, had more abstinent days in the early part of recovery but not continuously. Also, AA was not able to moderate levels of drinking at relapse, and the report states that participants would actually drink more heavily when relapsing vs. other modalities.

Another problem with the studies in this review is the high selection bias. As all the studies reviewed were in highly controlled environments with participants selected from voluntary rehabilitation centers and it is highly likely that these participants would outperform randomized participants or participants who are court mandated to be in AA. They were all privileged, cooperative, “socially stable, no involvement in the criminal justice system.” (Peele, 2020)

Despite the ease with twelve step groups, there isn’t this potential for independent learning and thinking or individualized treatment. Again, they do not account for any co-occurring disorders and although they have narcotics anonymous (NA) to support additional substance use, it can be time consuming to attend two different sets of meetings. There are complex nuances in the relationship between alcoholism and other mental health disorders and without the support of a professionally trained clinician, it can be difficult and overwhelming to navigate.

Naltrexone (Brand name ReVia, Vivitrol and Depade), is a non-addictive opioid antagonist that was developed in the 1960s for treatment of opioid dependency and it was approved over thirty years ago in the 1990’s by the FDA to be used in the treatment of alcohol use. Naltrexone works by blocking the endorphin effects of alcohol and over time can minimize the desire to drink overall or can help an individual manage their drinking. In past research developed by Dr. John David Sinclair it was suggested to use naltrexone while still drinking by the process of pharmacological extinction. (Sinclair, et al. 2001) In operant conditioning, extinction works against the reward response that the brain has conditioned to have in response to alcohol. It is recommended to take one dose one hour prior to having a drink and this would block the subsequent feelings of euphoria. Although these feelings are blocked, naltrexone does not block the physical functions such as motor impairment and does not prevent or stop withdrawal symptoms. Over time, the urge and cravings to drink would diminish. Due to the recommended use of taking this drug while still drinking, it was generally not supported for those participating in AA. Recent research has shown however, that naltrexone can actually be used in recovery after a period of abstinence. (Maisel, et al. 2013). Although it does not work in the same way as we see in the Sinclair method, taking the drug daily has been shown to reduce heavy drinking and cravings.

Another common drug prescribed for the alcohol dependency is acamprosate (Brand name Campral). This drug also works as an antagonist, but it works as a GABA regulator to stabilize the brain and over time, homeostasis. As acamprosate is not an opioid blocker, it is not generally recommended for individuals who have comorbid opioid-based substance use as it is only effective for alcohol.

Neither drug has psychoactive properties and they both require periods of withdrawal prior to treatment but Naltrexone is a bit easier to take; once a day, or one hour before drinking vs. three times daily for acamprosate. Naltrexone has been shown to be more effective targeting heavy drinking and cravings, while acamprosate may be better for overall abstinence. Perhaps taken together, it could be beneficial for recovery, however more research needs to be established to confirm this. (Maisel, et al. 2013), (Keifer, et al. 2003). Studies have also shown that the use of naltrexone could also help encourage individuals to be more active in therapy after experiencing less intense relapse. (Rubio, G. 2001). There are other drugs available for alcohol treatment such as Disulfiram, which incurs feelings of nausea in the body at the presence of alcohol, however the efficacy of these other drugs is not as confirmed.

Additionally, there is debate on the use of these drugs interfering with the development of “willpower”, however this is related to the ideology that alcoholics choose to continue in their addiction and need to build the strength to abstain. In AA, MAT treatment is often looked at as replacing one substance with another or creating dependency on another substance in favor of another, however, as naltrexone, and acamprosate are both non-addictive and have no psychoactive properties, it is not necessarily comparative.

There is also the argument that MAT treatment doesn’t address the causality for alcohol use disorder, however, mutual support groups alone don’t address this either. Working with a mental health practitioner, paired with MAT treatment, through skills training or psychodynamic therapy, depending on the clinician, can resolve the questions of causality with the individual. Then, based on the individual’s reasons for drinking, and after identifying specific environmental, situational, or tangible triggers, coping and mindfulness exercises can be implemented to strengthen their intervention.

For MAT treatment to be more widely used concurrently with therapy and a mutual support group, there needs to be more research and education for physicians to feel more comfortable prescribing this. As of now, naltrexone is rarely prescribed for alcohol use disorder despite the studies indicating its effectiveness and overall low cost. (Heinrich, et al 2008). Additionally, making these drugs available over the counter would make this style of treatment more accessible to those who are ineligible for insurance.

This dependence on the social structure and community of the AA program alone, although fulfilling to some, can inhibit the potential for independent growth, development, and recovery. Filling the gaps that AA doesn’t fill with therapy and MAT treatment would create successful, integrated treatment that would follow the biopsychosocial model and take a well-rounded approach to the individual while being easily modifiable to their specific needs.

References

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2. Flanagin, J. (March 2014) The Surprising Failures of 12 Steps. The Atlantic. https://www.theatlantic.com/health/archive/2014/03/the-surprising-failures-of-12-steps/284616/

3. Kelly, J.F., Humphreys K., Ferri, M. (2020) Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD012880. DOI: 10.1002/14651858.CD012880.pub2. Accessed 06 May 2022.

4. Peele, Stanton (2020) So Alcoholics Anonymous Is “Proven” to Work After All? Not So Fast. Filter. https://filtermag.org/alcoholics-anonymous-cochrane/

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8. Heinrich, C. J., & Hill, C. J. (2008). Role of state policies in the adoption of naltrexone for substance abuse treatment. Health services research, 43(3), 951–970. https://doi.org/10.1111/j.1475-6773.2007.00812.x

9. Maisel, N. C., Blodgett, J. C., Wilbourne, P. L., Humphreys, K., & Finney, J. W. (2013). Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction (Abingdon, England), 108(2), 275–293. https://doi.org/10.1111/j.1360-0443.2012.04054.x

10. Sinclair, J.D. (January 2001). Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism, Alcohol and Alcoholism, Volume 36, Issue 1, January 2001, Pages 2–10, https://doi.org/10.1093/alcalc/36.1.2

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