The Rehab Myth

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Nonfiction
Theory, so far 

THE REHAB MYTH:
New Medications that Can Conquer Alcoholism
By Bankole Johnson, MD
260 pp. Da Capo Press

Reviewed by David Hoekenga, MD

Alcoholism is a huge health problem in the US that affects one in three families, because seventeen million individuals abuse or are dependent on alcohol. According to the author: 

It resembles asthma, diabetes, and high bloods pressure in that all three illnesses:

• Show consistent pattern of symptom control and relapse.
• Have strong genetic and behavioral components.
• Can be reliably identified with diagnostic methods.
• Can be managed effectively with changes in behavior and medication.

The major difference between alcoholism and the other health problems mentioned above is that, in our society, alcoholism is seen as a social problem rather than a health issue. Only thirteen percent of people with drinking problems receive any treatment! 

Most addictionologists and health care professionals currently believe that Alcoholics Anonymous is the best treatment for alcoholism. However, Dr. Johnson states that while “AA reports its success rate is 95% it has proven to have a failure rate of 95%.” A five percent per year cure rate, he points out, matches the rate of spontaneous remission of alcoholism without any treatment found in a large number of studies.

The bulk of the book is devoted to a series of drugs that Dr. Johnson believes will work effectively to control alcoholism. Each is described in a chapter with a fictional case study.

First, he discusses naltrexone (Revia). It is supposed to block desire for alcohol. Taken as an injection for nine months, it worked miraculously in our fictional case. In the COMBINE trial naltrexone showed a modest improvement from 58 percent to 69 percent abstinence (not reported in the book). Furthermore, the combination of naltrexone and acamprosate (Campral), two of the agents Dr. Johnson touts, didn't increase abstinence in the COMBINE trial. Additionally, surprisingly, the combination of naltrexone and psychotherapy didn't improve results. The COMBINE study ending in 2006 is the largest study of interventions to encourage alcohol abstinence ever performed and enrolled over 1,300 patients.

The next case study involves an alcoholic, a sales “whiz kid” who benefited from topiramate (Topamax). The author feels it works well for clients who are still drinking. In one small study with 48 people in the placebo group, only 4 percent were sober. In the topiramate group half reported less craving for alcohol.

The third fictional case involves, “Abby Jensen…the kind of adult many of her sixth grade students say they want to grow up to be like.” She was placed on baclofen (Lioresal). In The End of My Addiction, Dr. O. Ameisen states that hundreds of patients have reported becoming “indifferent to alcohol” on this medicine.

The fourth drug Dr. Johnson talks about is acamprosate, which he feels works best with psychotherapy. However, the drug failed in the COMBINE trial, so I won't say anything more about it.

I was hoping for a practical book that I could use to replace the twelve steps in at least some cases. Instead, this is a theoretical book about neurotransmitters, alcoholism, and drugs that may help cure cravings in the future.

Unfortunately, it makes no suggestions as to what current alcoholics and their doctors should do. Dr. Johnson is absolutely silent about which of the four medicines--naltrexone, topiramate, baclofen, or acamprosate--is best. He does review the reasons for picking each agent at the end of his case studies in a chapter review. Sorting through the indications and cautions by flipping from chapter to chapter is tedious. When I tried to select a drug for one of my cases, after an hour of study I ended up confused.

Dr. Johnson concludes, “The revolution will burst forth from researchers (and) these new approaches should help ease the burden of ...alcohol-related problems each year...at a cost of $220 billion.”