Burns M. Brady, MD, FASAM, FAAFP

1. Alcohol Use DisordersTreatmentAbstinence – vs - ModerationSobells to SuboxoneA Review of 50 Years of ControversyDisease ClarificationTreatment Revisited Burns M. Brady, MD, FASAM, FAAFP

2. Battle Lines • Alcoholics Anonymous: The disease concept – abstinence • Davies paper: “Alcohol Addicts” who returned to controlled drinking The Advent of the Behaviorist • Rand Report • Sobell and Sobell research • Audrey Kishline: G. Alan Marlatt Moderation Management – Harm Reduction Disease Clarification • 1990 – 2000: Decade of the Brain • Human genome 2003 • New Age Addict/Alcoholic

3. Battle Lines

4. Abstinence • Alcoholics Anonymous – the disease concept A.Alcoholism – an illness with a 1. spiritual solution (Steps 1, 2, 3) 2. program of action (Steps 4-12) B. No recovery goal except abstinence C. Origin USA – now worldwide D. Remains the gold standard for the treatment of alcohol use disorders E. Virtually all compulsivities have adapted and adopted the 12 Step model (fellowship, design for living) e.g., NA, SA, OA, GA Studies of outcomes vary widely. e.g., populations and resources

5. Controlled Drinking • Davies paper: “Alcohol Addicts” who returned to controlled drinking A. 1962 – D.L. Davies – British psychiatrist – long term follow up of 93 patients treated for “Alcohol Addiction” at Mandsley Hospital in London. “7 patients were able to drink normally for 7-11 years.” B. All 93 received traditional abstinence education His conclusion: “It is not to be denied that the majority of alcohol addicts are incapable of achieving normal drinking. All patients should be told to aim at total abstinence C. Follow up comments opened the door pertaining to: 1. Degree of dependence 2.Fallacy of the disease concept

6. The Advent of the Behaviorist

7. Rand Report A. NIAAA (1970) – a network of treatment centers around the US. This included a monitoring system to collect data on patients served Rx – abstinence based. Rand Corp. evaluated the efficacy of the treatment. Conclusion: 22% of treated patients were “normal drinkers” at 18 month follow up – low levels of drinking, little or no symptoms B. Response – much controversy. 4 year follow up – same % yet not necessarily same patients. “Some patients improve, some deteriorate, most move back and forth between these extremes.” Only a small number were long time abstainers. C. Rand conclusion: 1. “Individuals could be judged to be better without abstinence” 2. Long term abstinence too infrequent to make it the sole goal of Rx

8. Sobell and Sobell A. Psychologist (1970, 1978) – research a form of “individualized behavior therapy” for alcoholism One module – to train alcohol dependent subjects to drink in a “controlled” fashion. B. 70 male patients voluntarily admitted to Patton State Hospital in California – each classified as Jellinek’s gamma-type alcoholics (“loss of control”) C. Assigned 1. CD (control drinking) goal 2. Abstinence goal Assignment took into consideration patient’s goals and other factors, e.g., drinking patterns, environment support. Not pure random. D. Both groups – 17 sessions of behavioral treatment (problem solving and aversive electrical shocks) CD group – trained in drinking skills – induce non problem drinking

9. II. Sobell and Sobell (cont’d) E. Primary outcome measure – “Days Functioning Well” Conclusion – CD group significantly h days over abstinence group Rand, Davies – report showed non problem drinking in patients treated in abstinence programs Sobell, Sobell – report showed skills could be transmitted to enable controlled drinking F. Pendery, et all (1982) – scathing article in the journal Science: “Controlled Drinking by Alcoholics: New Findings and a Reevaluation of a Major Affirmative Study” 10 year follow up Sobell subjects - “one subject was maintaining pattern of controlled drinking. Eight subjects drinking excessively, six were abstinent, one lost to follow up and four dead (alcohol related)” One investigator accused the Sobells of fraud The Sobells asked for an independent evaluation of their work – 3 panels including 2 Federal appointed groups – they were exonerated of fraud. Pendery’s report was approved as fact.

10. II.Sobell and Sobell (cont’d) G. Sobell and Sobell editorial – (1995) 1. Semantic shift from controlled drinking to: a. Moderation training b. Harm reduction This to cover large groups of non dependent (abuse) drinkers and many dependent drinkers would not quit. Abstinence – anchor minimalharm Moderate drinking – harm reduction 2. Severe drinkers – abstinence (dependent) Moderate drinkers – CD (abuse)

11. Audrey Kishline – Moderate Drinking (1994) published A. Moderation Management Result of Kishline’s search of Rx for her own alcoholism. “When I began to look for moderation options – the first revelation that I came across was that many experts in the alcohol studies field do not believe that alcohol abuse is a disease. From my previous experience with traditional Rx, I had been under the impression that the disease model represented a biological and medical fact. I was amazed to find out that it was just a theory – one that has been highly criticized and discarded by many researchers in the field.” B. Kishline integrated many behavioral techniques into a self-help format. “People wishing to meet and share their experience in reducing their drinking. MM stole it from AA – I admit”

12. III. Audrey Kishline (cont’d) C. Program states it is not for dependent drinkers – advocates one month free of alcohol before beginning the program – if difficult to do this – advocates abstinence D. Kishline in 2000 left the MM program and returned to AA. She did not stop her drinking and one month later killed 2 people in a head-on collision. She spent 3½ years in prison – currently is abstinent and in AA at last published report.

13. Disease Clarification

14. 1990-2000 Decade of the Brain • Human genome 2003 • New Age addict/alcoholic