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Does Rehab Work as a Treatment for Alcoholism and Other Addictions?

Before her death, Amy Winehouse had cycled in and out of rehab. Many celebrities have done the same, with some having more success than others at staying on the wagon. A neuroscientist explains why traditional therapy often seems to fall short of expectations
Amy Winehouse in concert



WIKIMEDIA COMMONS/DANIEL ARNOLD

Singer Amy Winehouse's fame and infamy have now been forever linked to one word: rehab. She is only one of many recent high-profile cases in which attempts at rehabilitation from substance abuse failed. Amidst strange public outbursts earlier this year, actor Charlie Sheen asserted that it was not rehab, but rather he, himself, that had been his secret weapon against abusing cocaine and booze.

And celebrities are not the only ones with untreated substance abuse problems. More than 20 million Americans ages 12 and older needed—but were not receiving—treatment as of 2007, according to the Substance Abuse and Mental Health Services Administration.

The cause of the 27-year-old singer's July 23 death is still unknown. Initial autopsy results were inconclusive, and toxicology tests will likely take at least two weeks. But the Grammy Award–winner had a recent history replete with physical health problems, psychological difficulties, and drug and alcohol abuse. In 2007 Winehouse was admitted to the hospital after overdosing on a combination of alcohol, cocaine, ecstasy, heroin and ketamine. She had at least a few stints at in-patient rehabilitation clinics but did not entirely stay clean afterward.

In her 2007 hit "Rehab" Winehouse repeatedly shrugged off the suggestion with the refrain ("They tried to make me go to rehab, but I said, 'no, no, no,'") in her dark, bluesy voice. Was she right to be skeptical of this classic treatment? Many of these programs, including 12-step plans such as Alcoholics Anonymous, often embrace at least some aspects of an abstinence-only approach and reliance on a "higher power." At least one overview of decades of research on AA's effectiveness suggests it works for many problem drinkers in conjunction with professional help. Nevertheless, the majority of people who enter more formal treatment centers suffer relapses.

Scientific American spoke with Bankole Johnson, a professor of neuroscience at the University of Virginia (U.V.A.) School of Medicine. He is also the editor of the new text Addiction Medicine, and has worked on the development of new pharmacological approaches to treating addiction.

[An edited transcript of the interview follows.]


Are there differences in trying to treat alcoholism versus other drug addictions or combinations of addictions?
There's no general difference. You use the same approach of determining what the patient needs. A lot of addictions do have a pharmacological component. We don't have a good drug for cocaine addiction, but we have drugs for alcohol addiction, opiate addiction and a wide range of addictions.

How well does traditional rehab work?

I don't believe that traditional rehabilitation using self-help methods is effective. In fact, the data suggest that they're not much better than spontaneous rates of recovery. For alcoholism, up to a quarter of people respond on their own, and a lot of recovery centers have rates that are not even that high. So-called rehabilitation centers should publish their rates of improvement, and they should be required by law to do so. Cancer centers do. But rehabs are just this black box.

Is it fair to generalize across different rehabilitation centers and programs? Are they all black boxes or do many of them use similar approaches?
Most rehabs in the United States are based on the Minnesota model. They have a lot of groups, they follow 12-step self-help programs. They tend not to be medication-based.

The myth is that people have to reach rock bottom to get treatment, but that is not the case if they are being provided with evidence-based medicine.

Is there a way to know what sorts of rehab approaches will work best for which people?
Sometimes you can tell by the patient's profile. Then you can combine what you think are the essentials for what you might need psychologically and medically.

There have been treatment-matching programs. Project MATCH aimed to determine whether different types of psychotherapy would be better. After the study there was not that much difference in the psychotherapies. It might mean that they do work well—and that the dose-effect is very small.

In another study, COMBINE, people received behavioral intervention, cognitive therapy, family therapy—every therapy they could think of. And those patients did worse than a brief intervention and a placebo pill.

Do you see a place for combining newer pharmacological interventions with more traditional therapies?
We use such approaches at U.V.A. I believe that the combination of the two is right for most patients.

Is there a different term that you would use to describe the medication-based approach?
I wouldn't call it a "rehabilitational" approach. I would use the term evidence-based treatment, which is really what I think is required. The medicines that work are better than the psychological treatment alone. To not have someone have a medicine is like tying your hands behind your back.

Alcoholism is about 60 percent genetic and biological—that's about the same percent as asthma or high blood pressure. And no one would dream of treating asthma with psychological methods alone. No one would dream of telling someone with high blood pressure to just relax and take it easy. Why then, with alcohol and drug dependence, would that be a reasonable treatment? With diabetes, yes, you can have behavioral control for diabetes—you tell them not to eat too much sugar or not to eat a whole cake, but at the end of the day you still give them insulin.

Is there anything we can learn from the case of Amy Winehouse's history and death?
Obviously it's a tragedy for anyone to die of alcohol or drug addiction. There's a lesson to be learned: People should demand more evidence-based treatment. This should make people think about asking the question: How should we deliver the best treatment?

Does overcoming addiction really depend on a person's decision and willpower to do so?
It's a complete myth. And it's one of the myths that has to be dispelled. One of the presumed tragedies of Amy Winehouse,—if this turns out to be related to drug and alcohol use—is that she didn't want to go to rehab. But rehab might not have been necessary. Maybe medical treatment from a personal doctor would have been an option.

The key to addiction treatment is that anyone who wants treatment gets effective treatment. And it doesn't depend on any power—higher power, lower power, willpower. It takes the level of compliance of anyone going to a doctor to get checked out.

When people realize it might be possible to get treatment without superhuman power, maybe it will make people want to seek treatment. It's a message of hope.

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