Medicine Will Never Cure Alcoholism.

A couple of online conversations have me thinking. I’m about to put forth a fairly long “No True Scotsman” description of alcoholism. I am friends with a bunch of neuroscientists. Many of them study addictions. I am not going to pretend that I understand the first thing about neuroscience. I don’t even understand basic cell biology at the high school level, much less the cutting edge of brain science. My best attempt at a precis of their basic argument about the ability of science and medicine to cure alcoholism goes like this: “As we come to understand how substances affect and make changes to the brain, and understand the way that addicts’ brains behave differently from normal people’s brains, we will be able to make targeted interventions which will relieve symptoms and causes of addiction. These interventions may take a variety of forms, including therapy, pharmaceuticals, surgery, or something that hasn’t been developed yet. But understanding the brain will lead us to relieving and preventing the suffering from addictions.”

I want to stress again that this is my understanding of their argument, and could be flawed. It’s not a quote from any person, but a brief synthesis of many discussions in a variety of venues. One area which has been specifically described to me by a couple of my neuroscientist friends who study addiction is the area of relapse. Several neuroscientists have told me that they believe that “a pill to prevent relapse” is a reasonable possibility. Maybe not soon, but eventually. Essentially, they seem to believe that we could, with appropriate understanding, devise a pharmaceutical intervention which relieves addicts of all cravings, and thus prevent them from returning to use.

I am happy that people are making these efforts. I suspect that they will, in the long run, be useful for some people who struggle with addiction. And as I have repeated over and over here, I believe in the value of medicine for treatment of addictions, especially in the acute phase of detoxification and withdrawal. When I quit alcohol I was at extreme risk for seizure and death. I quit cold turkey, going from a bottle (or more) of 80 proof liquor a day to nothing in the period of 24 hours. I took Depakote, and Atavan. I didn’t have any seizures.

I stopped taking Atavan within 3 days of abstinence. I stopped taking Depakote a few months after that. I have taken and anti-depressant from time to time, but other than that, I take no medicines other than aspirin. But I would, if I needed to and was under the supervision of a physician. There are medicines, like Chantix, which purport to help quell cravings. It did not work for me when I took it for nicotine withdrawal. Apparently, it has worked for others for a variety of substances.

But the idea of a pill that prevents chronic relapse is ludicrous to me. But first, the issue of definitions.

Now. Not all problem drinkers are alcoholics. Not all alcoholics are the same, and what works for one may not work for another. Scientists and physicians tend to use particular and specific definitions for “abuse” and “dependency” which are, frankly, irrelevant to those of us in the trenches with “real” alcoholism. When I talk about alcoholism here, I am talking about a state far, far advanced compared with what meets the scientific thresholds for  “abuse” or “dependence”. Those definitions are so broad as to envelop huge numbers of drinkers who have no need for AA, or who are able to moderate or quit without outside assistance of any kind.

When I speak of alcoholism, I eschew the denotative definitions. In some ways, even having those definitions at all is counterproductive. We alcoholics, we can use any deviation from a medical definition we find to justify that we don’t have a problem. And any definition that does not allow us to wiggle out from under it will be too broad to be meaningful. The very existence of an attempt at a rigorous definition causes harm to alcoholics like me. And yet, without one, scientists and physicians cannot treat or study the disease.

Now, as I said before, medicines in the acute phases of withdrawal are perfectly appropriate. I had some awful cravings, and having those relieved would have been lovely. But a pill that could be taken long-term to prevent relapse in a chronic sense is absurd because it wouldn’t be treating anything. No one I’ve met or heard of with sobriety of a duration longer than a year says they continue to have cravings. No one I’ve met or heard of who has relapsed after long sobriety has said they did so because of cravings. Cravings exist in acute withdrawal, and then cease to exist. I haven’t had one since day 12.

People who relapse after long sobriety do so because, almost uniformly, they have stopped doing the things they need to do to maintain their sobriety. None of which have anything to do with alcohol, really. And if there were a pill that somehow – magic by today’s standards – prevented a person from taking another drink, they would still have to take that pill. We don’t relapse because we suddenly want alcohol. We relapse because we stop engaging with treatment. So any pill to prevent chronic relapse is almost by definition useless: it is treating something that doesn’t exist; and people who will assiduously take it don’t need it, because they already remain engaged with their sobriety.

The problem with addiction science is the same as its strength: it is focused on addiction. As such, medicine has done a wonderful job of treating the medical issues associated with cessation of substance abuse. Alcoholics used to die with alarming frequency while in acute withdrawal. Now, not so much. Thanks to science and medicine.

However, what addiction science and medicine cannot seem to accept is that treating my alcohol abuse and dependency was easily, far and away, by leaps and bounds, the least important part of my recovery. Alcohol is not my problem. I’m just addicted to it. That’s not really that big a deal. The big deal is that I am a person who likes to treat my discomfort with obliteration. Treating that required some enormous efforts, none of which were medical, or required medical intervention. And without which any attempt at treating my addiction to alcohol would have been futile, because I would not honestly engage with any treatment for my addiction to alcohol.

Barring some kind of childhood injection which fundamentally alters human responses to alcohol and/or misery, there will never be a cure for alcoholism based on science and medicine. Nor do we need one. Science and medicine have already done their heavy lifting, in my opinion. They have dramatically softened the course from active alcoholism to abstinence. But they continue to have nothing to say about sobriety. Alcoholics of the type that I am, which is a lot of us, cannot be maintained in sobriety  – that is, long-term, fruitful and happy abstinence – by science and medicine.

Those of us who do not want sobriety cannot be compelled to it. We can be compelled to abstinence, but those I know who have been down that road tell me it is worse that active alcoholism. There will be no triumph for the scientist who compels abstinence on unhappy alcoholics. That life is no better than drinking. And that path may actually cause great harm. Placing our sobriety in the hands of a physician gives us permission to fail: we can rationalize the failure to be someone else’s doing. Sobriety is emphatically not about will power. But we alcoholics often like to believe it is, so that we can blame our failures on frailty, or the failure of medicine to support our will. We will recruit anything at all to justify returning to alcohol.

And those of us who want and are willing to be sober have no need for science and medicine after the first initial detoxification. There is already a path to sobriety for us, and there is no way to make it easier by treating our addictions. Our addictions are not the problem. Our addictions are our perverse solutions to the disquiet in our selves. Treating that disquiet, daily and for the rest of our lives, is how we become sober, and happy, and free. It requires no medicine. No will power. Only willingness, and another alcoholic to talk to.