Hungry for the Next Fix

Behind the relentless, misguided search for a medical cure for addiction.

Stanton Peele from the May 2002 issue

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All the therapies performed equally well, but one was considerably simpler than the others: Motivational enhancement involved four sessions with each alcoholic, compared to 12 for the two other types of therapy (although, on average, subjects attended only two-thirds of the sessions scheduled for any of the therapies). Motivational enhancement brings into focus and strengthens the individual's own drive for sobriety, but it leaves the mechanics of sobriety to the alcoholics themselves.

Although the Project MATCH subjects had few counseling sessions (especially in motivational enhancement therapy), their drinking was periodically assessed following treatment. These interactions with the project, intended solely for research purposes, seem to have had the effect of keeping alcoholics focused on controlling their drinking.

Whatever treatment alcoholics received in Project MATCH, few abstained for even a year. Gordis and his colleagues instead emphasized dramatic reductions in drinking by the subjects. Whereas they averaged 25 days of drinking a month prior to treatment, after a year they were drinking only six days out of the month. Moreover, the average number of drinks they consumed each time they drank dropped from 15 to three.

In all three of these prominent studies -- the naltrexone trial, the NIAAA's national survey, and Project MATCH -- the results were essentially the same. Even with clinical alcoholics, minimal treatments were as successful as more elaborate ones, and the best indicator of success was the alcoholics' ability to cut back their drinking rather than quit altogether. But how can sugar pills or a few sessions of motivational enhancement help alcoholics control their drinking? The basic ingredients for successful treatment are 1) identifying a problem with the agreement of the addict, 2) believing change is possible, 3) placing primary responsibility on the addict for carrying out the change, 4) accepting reductions in use as well as abstinence, and 5) following up to let addicts know someone cares and wants to make sure they stay on course.

Beyond Abstinence

In the face of studies that cast doubt on traditional notions about alcoholism, Gordis seemed to consider it his duty to explain why they actually confirmed the conventional wisdom. Project MATCH in particular presented a serious P.R. problem for the NIAAA: It spent more than $30 million without fulfilling its purpose of identifying principles for matching alcoholics to treatments. This is how Gordis spun the results: "The good news is that treatment works. All three treatments...produced excellent overall outcomes."

Although Gordis relied on reduced drinking as a measure of success to put the best gloss on Project MATCH, he has always quashed any revision of the abstinence-oriented goals that characterize virtually all American alcoholism treatment. Responding to a 1997 U.S. News and World Report story on Moderation Management, a program for reducing alcohol consumption among problem drinkers, Gordis sternly warned that "current evidence supports abstinence as the appropriate goal for persons with the medical disorder 'alcohol dependence' (alcoholism)."

While abstinence may be a desirable goal for these individuals, not many accomplish it. Project MATCH engaged the top clinical practitioners and researchers in the United States in designing and supervising treatment for alcoholics. As a result of this attentive, sophisticated care, which is unlikely to be matched by any program an alcoholic could find in the real world, about a quarter of the subjects abstained for as long as a year.

Gordis' attitude seems to be: "Most alcoholics won't abstain after treatment, but they should! And we are not going to accept anything less than this worthy, if unreachable, goal." His attitude is especially disturbing since Project MATCH found that reductions in drinking were beneficial. The subjects' liver functioning typically improved, and they displayed fewer problems associated with drinking. Surely, better health and less destructive behavior are worthy goals.

Since Gordis spoke for the U.S. alcohol treatment establishment, his rigidity condemned American alcoholics to limp along, most continuing to drink, with little chance of finding assistance in limiting their drinking or reducing its negative consequences. We will never eliminate drinking and drug use. But we might be able to reduce the harm they sometimes cause if we could eliminate the pseudoscientific moralism dispensed by the likes of Leshner and Gordis.