Wednesday, April 18, 2018

AA has no opinion on whether God exists

From another of my recent Disqus postings:

The existence of God is a theological question, not a question that can be answered by science. However, we can measure how much AA helps alcoholics stay sober.

We know that the more often people go to meetings (especially in the first year), the more likely they are to stay sober. Moos and Moos 2006 shows an undeniable correlation. Humpreys 2014 makes a strong case that the AA program is the cause for meeting makers making it. Galanter 2016 goes even further: It shows objective scientific evidence that praying helps successful AA members stay sober.

Now, we don't have peer reviewed science asking people “did you work the steps as written in the first 164 pages to the best of your ability?”, but we do have Gabriel Segal's essay "How an addict's power of choice is lost and can be regained" which makes a very strong case that 99% of alcoholics who get serious about the program stay sober.

Monday, April 16, 2018

Moderate drinking redux; also more on the Sinclair Method

Let me just post some of my recent disqus postings:

The fact is that the Sobell 1973 study [a study which claimed alcoholics could moderately drink again] was so bad, a fraud investigation was opened. As a 1984 New York Times article put it (look for “Panel finds no fraud by alcohol researchers”):

>>The panel also said it had found ''several errors'' and ''use of ambiguous terminology'' in scientific publications by the Sobells, which indicated that they were ''careless in preparing their manuscripts for publication.'' But the panel said it had seen no evidence that these errors and ambiguities ''represent scientific misconduct - defined as 'fraudulent or highly irregular research practices.' ''<<

Anyway, facts are facts. Those “moderate” drinkers from the Sobell 1973 study were either drinking alcoholically again, or were dead from drinking, or were abstaining from alcohol when a 10-year-followup was performed.

--

Sobell 1973 and the moderate drinkers: Four of those “moderate drinkers” died. Also: Six were abstinent, nine of the “moderate” drinkers were engaging in out of control drinking. There was only one person who, ten years later, could be considered a “moderate” drinker. Please read Pendery 1982 or any of the numerous books which correctly cite it.

Sobell 1973 in comparison to the non-moderate drinkers: This is cherry picking data. The Sobells only compared the fatalities of the “moderate” drinkers with the non-moderate drinkers. I have not seen the abstinent or out-of-control drinking figures for this other group; and it is telling that the Sobells never shared (or, it would seem, even bother to get) those figures.

Since there were only 20 subjects in each study, whether six or four died is an error of approximation, nothing more.

Davies 1962: These “moderate” drinkers also reverted to serious drinking again. Reference: G. Edwards. "D.L. Davies and 'Normal drinking in recovered alcohol addicts': the genesis of a paper" Drug and Alcohol Dependence 35.3 (1994)

Rand report: The 1980 four-year followup shows many of the 1976 Rand report moderate drinkers relapsing.

Moderation management: No peer-reviewed science was ever done with this group, but it’s very telling that its founder drank heavily, to the point police took her to detox in handcuffs while she was still the leader of Moderation Management. She soon afterwards killed two people while driving drunk and eventually killed herself [1].

Point being, pretty much any study showing successful “moderate” drinking, when followed up, shows those same “moderate” drinkers drinking heavily again.

[1] There are claims that the Moderation Management founder was a member of AA at the time of her crash, but as per her autobiography, she did not work the 12-step program in any meaningful way. Instead, she was coming up with excuses for not going to meetings.

--

In response to a claim that the “moderate” drinkers in Sobell 1973 had better success rates than people trying abstinence:

In terms of more recent studies, people who choose to work the AA program have between a 75% (Vaillant 1995) and 67% (Moos and Moos 2006) success rate. The Sobell moderation group had, by comparison, a 30% abstinence success rate and a 5% moderation success rate.

--

In response to a claim that the Sinclair method works better when trying complete abstinence, and works better the longer it is applied:

OK, let me go back to PMC3970823. They use a ”magic number” called “g” which is summarized near the end: “the aggregated Hedges’ g for naltrexone and acamprosate compared to placebo was 0.209 (CI: 0.157 – 0.262) – indicating a small but significant effect. In comparison to other medications prescribed for mental health (e.g., for depression), the effects of naltrexone and acamprosate are somewhat smaller”

So, this information in mind, let’s look at table 2 in PMC3970823. Naltrexone has an abstinence aggregate of .116—which is not very different than a placebo. However, the numbers for “heavy drinking” (.189), craving (.144), and both heavy drinking and craving (.180) are not much better—they are “small but significant.”

It also looks like, when looking at multiple studies, the effect diminishes when doing follow-ups: “naltrexone studies tended to have effect sizes for heavy drinking outcomes at the last follow-up point (g = .135, k = 6) that were slightly smaller compared to end-of-treatment (g = .189, k = 39). Although only two studies provided data, the naltrexone-placebo effect sizes for craving at the last follow-up point were close to zero (g = .053).” In other words, this meta-study didn’t see naltrexone helping people not drink heavily over longer periods.

In light of Pendery 1982, and in light of what happened with the founder of Moderation Management (while she claimed to drink moderately without problem for years, she killed two people while driving drunk, and eventually killed herself), when people suggest moderation as an outcome for alcoholics, I will remain very very skeptical until when and if we have 10-year-followups with very high “g” values and very low “p” values.

Saturday, April 14, 2018

The Sinclair method revisited

An advocate for the Sinclair method pointed out, in an online debate, the study “Targeted Naltrexone for Problem Drinkers.”  Here is my response:

That 2011 study (“Targeted Naltrexone for Problem Drinkers”) is a 12-week trial, and the study considers “moderate drinking” a successful outcome. This is a very short trial period, and short-term studies since the 1960s showing alcoholics “successfully” drinking moderately have, if followed up, shown the same drinkers having serious drinking problems five or 10 years later (the most famous example of this is Sobell 1973, showing “moderate” drinking among alcoholics, but Pendery 1982 showed that the same “moderate” drinkers were either dead, abstinent, or drinking heavily a decade later).

The meta-study (a study looking at other studies) “Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful?” (PMC3970823) points out that “Several reviews and meta-analyses have reported small or mixed effects for each medication (both naltrexone and another medication called acamprosate), and treatment providers cite concerns over efficacy as one barrier to greater medication use.”

This isn’t the first study which showed good results for Naltrexone, but considering the number of other studies which show only a modest effect, and considering the need for a long term follow up to see if an alcoholic is in fact successfully moderately drinking, I will need to see studies with five-year or 10-year follow ups showing continued “moderate” drinking before I will believe this drug is a functional way to let alcoholics control their drinking.

Thursday, April 5, 2018

12 Steps is not too many (Miller 2008)

Back in 2009, Time magazine published an article claiming 12 steps are too many. This article, in addition to having a section praising Naltrexone (a pill with limited value), uses a single study to conclude the 12 steps are not helpful.

The dubious study was led by pro-moderate-drinking-for-alcoholics advocate William Miller, and is entitled “Spiritual direction in addiction treatment: Two clinical trials.”

This paper is an outlier. A 2012 meta-study of hundreds of papers about religion, spirituality, and health (Religion, Spirituality, and Health: The Research and Clinical Implications by Harold G. Koenig) looks at hundreds of similar studies.  Of the 178 studies about depression and spirituality with the highest methodological rigor, the 2008 Miller paper is one of only 13 which showed spirituality resulting in more depression symptoms. In addition, this meta-study looked at whether spirituality helps people get clean and sober. Of the 145 studies with the best methodologies directly investigating the question of whether spirituality helps overcome substance abuse, 131 showed that it did, and only one could make the case that spirituality hurts someone’s chances of getting off of alcohol and/or drugs.

Koenig 2012 is not the only paper that contradicts Miller 2008. J. P. B. Goncalves et al. 2015 (Religious and spiritual interventions in mental health care: a systematic review and meta-analysis of randomized controlled clinical trials) looks at 23 studies; Miller 2008 is the only study they look at which concludes there is a negative correlation between spirituality and better results. 

Another paper may explain the issues with the methodology in Miller 2008. Greene 2012 (Gary Greene and Tuyen D. Nguyen The Role of Connectedness in Relation to Spirituality and Religion in a Twelve-Step Model) speculates that Miller 2008 “may point to the  immeasurable therapeutic value of the spiritual connectedness between members of  twelve-step and other groups and a measurable disconnect often present in research trial” (emphasis in original). In other words, Greene 2012 speculates that the subjects of Miller 2008 who got “spiritual” guidance did not get it in the form a newcomer gets it in the rooms of 12-step meetings, since the subjects did not experience the same connectedness.

Cherry picking a single study whose results are different than the results of the majority of similar papers does not make for a very compelling case against using the 12 steps to stay clean and sober.

The 12 steps work. A single study saying otherwise does not change this fact.

Tuesday, April 3, 2018

A tale of two papers

I look at two papers in this blog entry, one of which will be questionable, the other of which is well written.

The Alcohol industry is funding a “Moderate Drinking” study

The New York Times has published an exposé last month showing how the NIH solicited contributions from the alcohol insustry for a “Moderate drinking” study.  It would seem that, in order to fund an expensive study on drinking called the “Moderate Alcohol and Cardiovascular Health Trial (M.A.C.H.)” trial, the alcohol industry has spent millions of dollars to make this study a reality.

Whatever finding this study has about moderate drinking are at best suspect, especially for anyone who is a potential alcoholic; the NY Times piece reports that “many people whose health might be compromised by light drinking — anyone with a history of addiction, psychiatric, liver or kidney problems, certain cancers or a family history of breast cancer — will not be allowed to participate. People who have never drunk alcohol also are excluded.”

Knowing how studies are quoted out of context by the kinds of people with an agenda against Alcoholics Anonymous, and knowing how often those kinds of people try to justify moderate drinking for alcoholics, even though that is, as I pointed out before and will point out again, is a fool’s errand, I would not be surprised if those kinds of people, years down the road, use this study to “prove” that Alcoholics Anonymous’ model of abstinence is “harmful.”

A realistic look at Alcoholics Anonymous

Marc Galanter, who helped write a paper showing how prayer helps AA members stay sober, has another excellent paper out there.

Entitled “Combining medically assisted treatment and Twelve-Step programming: a perspective and review”, this paper goes over, among many other things, why Cochrane 2006 had methodological issues in concluding that AA does not work any better than other methods.

A very good paper well worth reading. Nicely enough, this paper is not paywalled.

Monday, January 8, 2018

Naltrexone, acamprosate, and the Sinclair Method

Since I have been in an online debate with someone who claims AA doesn't work and advocates the Sinclair Method, I should go over the newer medication assisted therapies.

The Sinclair Method is simply suggesting to use the medication Naltrexone along with engaging in moderate drinking. There have been studies showing that people can more easily moderately drink when taking Naltrexone, but the effect has also been described as being modest

The Sinclair Method has the same problem all other moderation methods have: Yes, it shows some, albeit modest, level of short term success, but we do not have long term studies. Short-term studies advocating moderate drinking are unreliable; long term follow ups show the "moderate" drinkers drinking heavily again. Until we have a 10-year follow up study showing people still using Naltrexone to moderate their drinking, or being able to abstain from drinking altogether after using Naltrexone for a while, I am very skeptical. We have had too many people die deceiving themselves with "moderate drinking" approaches; I have not seen evidence that Naltrexone is a silver bullet that will change things.

Naltrexone is not an effective therapy for people who want to abstain; there are two studies showing this drug has little to no effect when the patient pursues abstinence. 

Acamprosate, on the other hand, seems to work better when the goal is abstinence. The effect is "small but significant", but it may help alcoholics achieve abstinence when used with other therapies.

I think, when used with the 12 steps and regular Alcoholics Anonymous, Acamprosate may be a helpful drug for achieving long-term sobriety. Bill Wilson had no objection to the use of medications to successfully work the AA program. That said, while the effect for both drugs is there, it's small.

Sunday, January 7, 2018

I also oppose dogmatism in AA

There is remarkable little I disagree on with the author of https://www.recoveringfromrecovery.com/

The fact of the matter is this: A quarter of a century ago, when a home computer was an investment which cost as much as a good used car, and the internet was only something only occasionally mentioned in magazines, people were a lot more dogmatic in AA meetings. The steps, outlined in the first 164 pages of the Big Book were the only way to save sober, and if you didn't get serious about working the steps right now you would surely relapse again. People enjoyed beating the program over people's head and using the program as an excuse to bully newcomers. 

I found the dogmatism of those people repulsive, and managed to stay sober, even though I had to fire my sponsor just before working my fifth step. According to the AA fundamentalists, I was on the path to relapse since I didn't finish the steps. It took me a decade to finally finish up the steps (where step nine has been by and large living amends), a decade where I never relapsed.

The point being: I was not, for large parts of my recovery, a Big Book thumper. There was a brief period when I started thumping the Big Book pretty heavily at meetings, to the point someone with more time than me told me to stop beating the drum. The program, as written in the first 164 pages of the Big Book, is a very effective program, but I no longer pretend that it is the only, or even necessarily best, way to stay sober.  

And, the AA program has changed. It used to be standard fare to hear people proclaim "The program as written in the first 164 pages is the way to stay sober." Recently, I got in a heated discussion when I pointed out that a person can stay sober with just the 164; telling people they must work the program a certain way is just not how things are done at AA meetings any more.

Atheists, who used to hide in the corners, now openly proclaim their atheism in the rooms. Indeed, the Gravevine is looking for atheists and agnostics who are still sober to publish their stories in official AA literature. They may still be Big Book meetings, but there are also people with years clean and sober who openly admit that they do not like the Big Book in meetings.

That said, the fanaticism of people with an agenda is even worse. https://www.recoveringfromrecovery.com/anti-aa-forums-and-blogs/ describes them well. When they were a loud spoken minority, that was one thing. Once Lance Dodes's book made their viewpoints get printed in mainstream journals, that was when a line was crossed. I knew, from my decades of experience with AA, that claims of AA not being helpful were simply not true. I started reading scientific papers, started to understand what was being discussed; the page http://slatestarcodex.com/2014/10/26/alcoholics-anonymous-much-more-than-you-wanted-to-know/ is a good, reasonably balanced introduction to what the science has to say about AA effectiveness. 

AA works if you work it. The science shows that. The AA Big Book, in the preface to the second edition, claims a 75% success rate among "alcoholics who came to A.A. and really tried." Multiple observational studies support this figure, to name just three: Valliant 1995, Fiorentine 1999, and Moos and Moos 2006

No, AA is not for everyone. There are people who may be better off staying sober using SMART Recovery, Life Ring Fellowship, The Sinclair Method, whatever. Or the first 164 pages of the Big Book: I have well over 10,000 days clean and sober working the Big Book program. But making false claims that AA fails the majority of people who really try the program is downright dishonest. Making claims that AA has a 5% success rate is downright dishonest. Using 38-year-old or 50-year-old studies to claim AA doesn't work while ignoring studies from this century showing AA effectiveness is downright dishonest.

Hence, this blog. I correct the record when people with an agenda against AA use outdated or inaccurate information to downplay AA's huge success keeping people sober.