How successful are 12-step meetings for alcohol?
In November 2019, I recorded a short solo episode about two questions. Do 12-step meetings work for people with alcohol dependence, and is there anything a doctor can offer? The starting point was an NPR article that had been shared with me about Dr. Lance Dodes, a psychiatrist who wrote a book with Zachary Dodes questioning 12-step recovery.
This is an archive episode, recorded when the show covered addiction and recovery broadly.
What did Dr. Dodes argue about Alcoholics Anonymous?
From 1:07, I read his central claim to listeners. Dr. Dodes told NPR that 12-step recovery simply does not work. He pointed to a large body of evidence suggesting that only a small minority of people who attend Alcoholics Anonymous (AA) succeed with it.
At 1:22, I asked the obvious question. If the success rate is that low, why do so many people believe that 12-step programs work so well?
Why do success stories make a program look better than it is?
At 1:32, I raised something the article did not mention, called survivorship bias. You walk into a gym full of big, muscular people and conclude that the gym really works. What you do not see are the people who walked in, tried it, and never came back. There could have been thousands of them.
The same thing can happen in a meeting room. Someone who attends will hear many positive stories from people who have been sober for years. Yet the quiet people in the back of the room, and the people who came and never returned, are not the ones telling their stories.
So, the stories of success do not necessarily represent the success rate.
What happens when a court orders someone to attend meetings?
At 2:24, I turned to the part of the argument that went further. Dr. Dodes believes that the people the program does not help are not simply missing out on a benefit. In his view, they are being harmed.
From 2:41, I asked listeners to imagine being sent to meetings by a drug court. To satisfy the court, a person has to come back with a paper signed by the chairperson of a 12-step meeting. That chairperson is basically a volunteer, unpaid and not certified or credentialed.
The article did note, to its credit, that AA describes itself as a brotherhood rather than a treatment.
Should someone with a drinking problem still try meetings?
At 3:10, I asked the question listeners were probably asking themselves. My answer on air was a qualified one. I compared the low success rate with other low-odds choices people make, such as chemotherapy for some cancers or buying a lottery ticket, and said that meetings do help some people, though not as much as we would hope.
I also drew a line. If the meetings work against a person, I said, then maybe that person should not go. Still, meetings were never the only option, and the rest of the episode was about what else a person can do.
Is there medical treatment for alcohol dependence?
From 3:35, I said the next step is a doctor. Naltrexone blocks opioids, competing with them for the opioid receptors in the brain, and it was originally used for opioid dependence, and the U.S. Food and Drug Administration (FDA) has also approved it for alcohol dependence.
As I described it then, naltrexone can reduce the urge to drink and help a person remain abstinent. It can also interfere with the desire to keep drinking after a slip.
Of course, it is not for everyone. Some people should not take it, and anyone dependent on opioids such as heroin or morphine has to stop them before starting it.
What do disulfiram and injectable naltrexone do?
At 4:21, I described disulfiram, sold under the brand name Antabuse. It blocks an enzyme, so the effects of a hangover arrive almost immediately after drinking. Even a small amount of alcohol can bring flushing, a throbbing headache, nausea, vomiting, chest pain, a fast heart rate, low blood pressure, and fainting.
In that sense, disulfiram works as a deterrent. A person taking it will think twice about drinking, because they know they will get very sick.
At 5:03, I mentioned Vivitrol, which is naltrexone given as a monthly injection and also approved for alcohol dependence. My point was simple. There is medical treatment for alcohol dependence.
Do meetings and medical care work against each other?
From 5:15, I listed other sources of help. I pointed listeners to SAMHSA, the Substance Abuse and Mental Health Services Administration, a government agency with a free, confidential national helpline and treatment locators. I also said that anyone having a problem with alcohol should see a psychologist.
At 5:45, I made a further point. AA has no position against a person getting medical care. In fact, I said that if it did, I would tell people not to go.
Did one of the founders of AA want a medication for alcohol?
At 5:55, I told a story from Dr. Adam Bisaga’s book, Overcoming Opioid Addiction. Bill Wilson, one of the founders of AA, was very much in favor of medical treatment for alcohol dependence. He met with the founder of the methadone maintenance program, at a time when, as I understood it, heroin was the main problem in New York.
The two talked about how well methadone was helping people get off heroin. Wilson asked whether a similarly successful drug could be developed for alcohol, because recovery would be much easier with medical treatment to support it.
Interestingly, the answer he hoped for now exists. At 6:44, I pointed out that we have medications such as naltrexone and disulfiram.
Is it safe to stop drinking suddenly?
From 6:49, I turned to safety. For someone who drinks a lot, I said, stopping abruptly carries some danger. Alcohol withdrawal syndrome can develop, and it can include a seizure.
So, my advice on air was to talk to a doctor and to stop under medical observation and care for a period of time, in a hospital or a supervised detox setting.
At 7:23, I described what comes after. Over the long term, a family doctor or an addiction specialist can continue medical care, for example by prescribing naltrexone and possibly disulfiram. A psychologist or a family therapist can help as well.
What can listeners take away from this episode?
Success stories alone cannot tell you how well a program works, because the people it did not help are rarely the ones in the room. However, meetings were never the only choice. Medications for alcohol dependence exist, a doctor can prescribe them, and stopping heavy drinking is safest with medical help rather than alone.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For alcohol dependence I use the Sinclair Method. The person takes naltrexone about an hour before drinking, and over time the drinking itself becomes less rewarding, so the urge fades gradually instead of being fought every day. It does not require stopping on day one, and it does not rely on willpower or meetings.
Like a slow taper, it lets the brain change at its own pace. For many people that makes it a more humane path than a sudden stop, which can also be medically dangerous for someone whose body depends on alcohol.
Call 911 or go to an emergency department if there is a seizure, confusion or hallucinations, or thoughts of self-harm. For thoughts of suicide or any mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (9 minutes)
Dr. Mark Leeds [00:09] Welcome to The Rehab on the Mental Health News Radio Network. I am Dr. Mark Leeds and I will be your host. Join me in exploring the world of addiction treatment. How can we improve the ways that we help individuals to overcome addiction? The goal of treatment is to save lives and help people to get back on track to a path towards success and happiness in life. Now, this is interesting. I have this article here that was shared with me, and this is on NPR. Obviously, National Public Radio is a reputable source, and this is about a psychiatrist who is apparently debunking 12-step recovery. This is Dr. Lance Dodes and the book is by Lance Dodes and Zachary Dodes. And Dodes tells NPR that 12-step recovery simply doesn’t work. Dr. Dodes says that the success rate of AA based on a large body of evidence, so there’s a large body of evidence now looking at AA success rates and they say it’s between 5% and 10%. So why is it that so many people believe that 12-step works so well? And he doesn’t mention this here, but maybe in the book he does. There’s something called survivorship bias where you look at the survivors of something, the successes in a program. For example, you go to the gym and the gym is full of big muscular people, and you’re like, wow, this gym really works. People get big and muscular by working out here. And what you don’t know is of those, say, 20 people that are big and muscular, how many people walked into the gym, tried it and left and never came back? There could have been thousands. So the success rate is not necessarily represented by the anecdotes or the stories of the successes that you see. If you go into an AA meeting, you’re going to hear a lot of positive stories from people who are sober for 10, 20 years. But what you don’t focus on as much are the quiet people in the back of the room, the people that have come and gone and never come back. And Dr. Dodes makes the argument that not only are the 90 percent that it’s not working for, not only are they not getting any benefit, he believes that they’re being harmed. Recovery programs are mandated by drug court, prescribed by doctors and widely praised by reformed addicts. And that’s true. But imagine that a drug court tells you have to go to 12-step meetings where the chairperson of the meeting will have to sign off on your paper from the court. To be compliant, legally compliant, you have to come back with a signed paper from someone at a 12-step meeting who’s basically a volunteer. They’re not being paid to do this. They haven’t been certified or credentialed. They say, to its credit, AA describes itself as a brotherhood rather than a treatment. What should a person do? Should they go to AA? Well, why not? Five to 10 percent. I mean, people go for chemotherapy for cancers where they have a success rate of five percent. People buy lottery tickets where they have a one in 15 million chance of winning or sometimes even lower. Why not give it a try? It does work. It doesn’t work as much as we would hope it works, but it does help. You know, if it works against you, then then maybe don’t go. But what else can you do. You can go to your doctor. Naltrexone is a medication that blocks the effects of drugs known as opiates or narcotics. It competes with these drugs for opioid receptors in the brain. Originally used to treat dependence on opiate drugs, it now has also been approved by the U.S. Food and Drug Administration, FDA, as treatment for alcohol dependence. People who are dependent on opiate drugs such as heroin or morphine must stop their drug use at least seven days prior to starting naltrexone. Some people should not take naltrexone. Naltrexone can reduce a patient’s urge or desire to drink. Naltrexone helps patients remain abstinent. Naltrexone can interfere with the patient’s desire to continue drinking more if she slips and has a drink. So naltrexone is a medication. It’s a medical treatment for alcoholism. Disulfiram, Antabuse, a drug used to support the treatment of chronic alcoholism by producing an acute sensitivity to ethanol, drinking alcohol. Disulfiram blocks an enzyme causing many of the effects of a hangover to be felt immediately following alcohol consumption. Disulfiram plus alcohol, even small amounts, produces flushing, throbbing in head and neck, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitations, dyspnea, hyperventilation, fast heart rate, low blood pressure, fainting. Disulfiram, which is sold under the brand name antabuse is a deterrent. So if you’re taking it, you’re going to think twice about drinking because you’re going to get really sick. There’s also Vivitrol. Vivitrol is naltrexone. Same thing. The only thing is Vivitrol is a monthly injectable form of naltrexone, but it is approved for treating alcoholism. There is medical treatment for alcoholism. What else can you do? SAMHSA is a good resource. This is a government agency that implements a lot of programs to help with addiction and alcoholism. They have a national helpline, free confidential 24-7, 365 days a year. There’s treatment locators, SAMHSA.gov. You can see a psychologist. In fact, you should see a psychologist if you are having a problem with alcohol. So you can see your medical doctor, and you can also go to AA. AA is not a program against you getting medical care. If it was, I would say don’t go to it, but AA has no position on you getting medical care. One of the founders of AA, Bill Wilson, was very much in favor of the idea of medical treatment for alcoholism, and there’s a story which is told in the book Overcoming Opioid Addiction by Dr. Adam Bisaga, where he tells the story of Bill Wilson and the founder of the Methadone Maintenance Program. So those two had a meeting, and they talked about how great methadone is working to help people get off of heroin and opioids. I think heroin was really the problem at that time in the 60s in New York. And Bill Wilson said, is there any possibility of developing such a great, successful kind of a drug to treat alcoholism? Because it would be a lot easier for people to work their program and recover and get better if they had some kind of medical treatment to support them. And we do now. You just saw we have things like disulfiram, naltrexone. If you’re trying to quit alcohol and you’re drinking a lot, it would be a good idea to consider checking into a rehab program or a detox program because there is some danger of when you stop drinking that you can have alcohol withdrawal syndrome, you can have a seizure. I mean, there is some danger to quitting alcohol abruptly without being under observation and treatment and care for a period of time. Talk to your doctor, but also consider going to a hospital, going to an inpatient residential rehab type program or detox program to detox you off of the alcohol. And then long term, your family doctor or an addictionologist can continue maintaining your medical care by prescribing naltrexone and maybe disulfiram or antabuse. Also, you can see your psychologist, family therapist. So there’s a lot you can do. I would recommend definitely getting the medical care in addition to going to AA. So that’s going to be it for today. And thank you for joining me on this presentation of The Rehab Podcast. Thank you for joining us today on The Rehab on the Mental Health News Radio Network. I hope that you have found this show to be interesting and useful. If so, please subscribe to The Rehab Podcast and share on social media. I appreciate your taking the time to listen to The Rehab.
