Waves of Sobriety
ON MARCH 25, 2000, an alcoholic in a blackout drove her pickup truck onto a freeway going the wrong direction in rural Washington State and collided with a car, killing thirty-eight-year-old Richard Davis and his twelve-year-old daughter, LaSchell. Such accidents rarely made national news. But the driver of the pickup was Audrey Kishline, the founder of Moderation Management, a mutual aid group that tries to help people with alcohol problems control their drinking.
Two months earlier, Kishline had admitted to members of the group that her drinking was out of control and that she was trying to stop with the help of several sobriety groups, including AA. She also reaffirmed her belief that Moderation Management worked for people who were not addicted to alcohol. In July, when she pleaded guilty to two counts of vehicular homicide, her view appeared to have changed. According to her lawyer, Kishline now believed that Moderation Management contained many people like her—“alcoholics covering up their problem.”1
Kishline’s accident reignited a bitter dispute that had begun almost forty years earlier between the alcoholism treatment community, which regarded abstinence as the goal of all alcoholics in recovery, and its critics, including many who rejected the idea that alcoholism was a disease. The controversy began in 1962 when a British psychiatrist, D. L. Davies, reported that alcoholism patients treated at a London hospital had been able to start drinking again without further problems; some had been drinking safely for as long as eleven years. Only ninety-three drunks were studied, and just seven were judged to have resumed “normal” drinking. Davies was quick to acknowledge that most alcoholics would never drink normally. But his study challenged the idea that alcoholism is inevitably progressive and that loss of control is irreversible.
Davies’s findings were received with great skepticism by most alcoholism experts. Some questioned whether the men who had returned to drinking successfully were the alcoholics described by Jellinek. “One possible explanation of Doctor Davies’ findings derive[s] from the fact that there are undoubtedly degrees of alcoholism,” one commentator observed. “All patients are not equally ill.”2
But many of those who criticized Davies did not want to debate the fine points of his research. They were alarmed by the danger that sober alcoholics would be encouraged to drink again. “For every alcohol addict who may succeed in reestablishing a pattern of controlled drinking, perhaps a dozen will kill themselves trying,” a doctor commented in the Quarterly Journal of Studies on Alcohol.3
The Davies study probably didn’t get anyone drunk. The debate over controlled drinking was confined to the pages of academic journals until 1976, when the RAND Corporation published a report that provided support for the idea. The National Institute on Alcohol Abuse and Alcoholism had commissioned RAND to evaluate the effectiveness of alcoholism treatment at forty-four federal treatment facilities. To the surprise of many, the authors of Alcoholism and Treatment, which became known as the RAND Report, concluded that the number of patients who had achieved abstinence was “relatively small.”4 Most of those who had improved were drinking again at “moderate” levels or were alternating periods of drinking and abstention. Overall, 22 percent of those receiving treatment had become “normal drinkers.”
The national press expressed skepticism about the RAND Report, but the controversy grew more heated when two behavioral psychologists, Mark and Linda Sobell, published a book two years later in which they claimed they had succeeded in training alcoholics to drink safely.5 They had studied seventy alcoholics at a state hospital in California, dividing them into a control group that was urged to pursue abstinence and a controlled drinking group that was trained to limit consumption and treated with aversive conditioning, including electric shocks. Following up with their subjects two years later, the Sobells found that the controlled drinking group had significantly more “days functioning well” than those whose goal was abstinence.6
The National Council on Alcoholism (NCA) was horrified. At a news conference, NCA executives called the RAND Report “dangerous and misleading.” “My concern is that a lot of people will try to drink again, and a lot of people will die as a result,” said Dr. Nicholas A. Pace, the president of NCA’s New York City affiliate. The Sobells were also harshly criticized. The prestigious Science magazine published an article that challenged their results, reporting that eight years after the Sobells claimed their patients were drinking normally, eight were drinking excessively, six were abstinent, and four were dead. The article claimed that most of the subjects had failed to drink safely from the very beginning, raising questions about the Sobells’ honesty. One of the authors put his suspicions in so many words. “Beyond any reasonable doubt, it’s fraud,” he said. Several investigations cleared the Sobells of any wrongdoing.7
The Kishline accident in 2000 brought the bitter dispute over controlled drinking back to center stage. NCA, which had been renamed the National Council on Alcoholism and Drug Dependence (NCADD), issued a statement that blamed the accident on Kishline’s failure to acknowledge her alcoholism. This was not her fault, it said. “Unfortunately, the disease of alcoholism, which is characterized by denial, prevented this from occurring.” But there were people to blame, NCADD said. The accident “provides a harsh lesson for all of society, particularly those individuals who collude with the media to continually question abstinence-based treatment for problems related to alcohol and other drugs.” The advocates of controlled drinking had done great harm:
What makes Ms. Kishline’s present situation even more distressing is the fact that her denial, amplified by the media, undoubtedly contributed to the progression of alcoholism and other alcohol-related problems for thousands more unidentified Americans and their families. . . . [W]e should all remember the names of Richard and LaSchell Davis the next time a problem drinker claims to be able to “drink a little” without harm.
Defenders of controlled drinking were stung by the charge that they were responsible for the accident. Stanton Peele, a leading critic of the disease concept of alcoholism who had endorsed Moderation Management, sought to distance himself from Kishline by saying he hadn’t spoken to her in five years. He also claimed that her decision to join AA made her drinking worse.8
As the backlash over the Kishline accident grew, many prominent alcoholism experts began to worry that the reputation of alcoholism treatment was being badly damaged. Three weeks after the NCADD statement, Dr. Alexander DeLuca, the director of the Smithers Addiction Treatment and Research Center in New York, found himself caught in the controversy when New York magazine reported that Smithers was offering its patients treatment that included Moderation Management. This news was shocking because Smithers had been founded with a $10 million gift from the Christopher D. Smithers Foundation, which strongly supported abstinence for alcoholics. DeLuca insisted that the report had exaggerated the changes at Smithers. “Our treatment programs never changed,” he said. But DeLuca had agreed to allow Moderation Management to begin holding meetings at Smithers in January. In the atmosphere created by the Kishline accident, the Smithers board of directors concluded that DeLuca had gone too far and forced him to resign.9
On the same day that DeLuca’s firing was announced, thirty-four scholars and prominent treatment professionals issued a statement that attempted to bring the controlled drinking controversy to an end. Ernest Kurtz, a historian of the alcoholism movement, had drafted the statement and sent it to people on both sides of the debate. He was the perfect intermediary because he was both an AA member and someone who had endorsed Moderation Management, which he believed would make it easier for many people to recognize their alcoholism. Above all, he shared the fear of many that the alcoholism community was tearing itself apart and undermining its ability to help alcoholics get sober. The statement addressed this problem directly:
That Ms. Kishline was intoxicated at the time of the crash has been claimed to indicate the failure of the approach of one or another of the mutual-help groups Ms. Kishline has attended. Such claims are not in accord with everyday experience in the field, in which relapse is common, whichever approach the drinker adopts. Recovery from serious alcohol problems is a difficult goal and there are many paths to it.
The final paragraph proposed a compromise. “We believe that the approach represented by Alcoholics Anonymous and that represented by Moderation Management are both needed,” it said.10
Under different circumstances, Kishline would probably have endorsed the statement, but she was awaiting the final disposition of the criminal charges against her. A month later, she was sentenced to four and a half years in prison. She continued to struggle with sobriety after her release and committed suicide in 2015.
The compromise over controlled drinking was the first sign of a moderating tone in the debate over alcoholism. There was still plenty of disagreement over many issues, but much of the heated rhetoric disappeared. One factor contributing to this de-escalation was a growing knowledge about the physiology of alcohol and drug addiction. In 1988, Henry Fingarette claimed that his survey of experts in “biology, medicine, psychology, and sociology” had found no evidence to support Jellinek’s concepts of tolerance, craving, withdrawal, and “loss of control.” But back in the mid-1970s, biologists and pharmacologists had conducted thousands of experiments on the effects of alcohol on animals, and many were convinced that addiction originated in the brain.
Over the next two decades, researchers identified the existence of a brain reward system that begins in the brain stem, which controls heartbeat, respiration, and other functions that ensure survival, and connects through the limbic system, the center of emotion and motivation, with the cerebral cortex. The primary function of this circuit is to reward eating, sex, and other behavior that is biologically beneficial by releasing into the limbic system a pleasure-causing neurotransmitter called dopamine.11
Scientists theorized that alcohol and other psychoactive drugs hijack the brain reward system, flooding a section of the limbic system with dopamine and producing a rush of pleasure that is far more powerful than natural neurotransmitters. But the power of alcohol and drugs wanes for regular users, creating a craving for more drugs. Alcoholics and addicts become victims of the very system that once ensured survival, seeking out drugs with the same desperation that they once sought food and water. The brain reward system becomes the instrument of their self-destruction.
In 1997, Allan I. Leshner, the director of the National Institute on Drug Abuse (NIDA), gave the government’s seal of approval to this new theory of addiction. “Dramatic advances over the past two decades in both the neurosciences and behavioral sciences have revolutionized our understanding of drug abuse and addiction,” he announced.12
As in all matters pertaining to science and public policy, however, this was not the final word in the debate. In 2014, ninety-four addiction researchers and clinicians sent a letter to the editors of Nature magazine disputing an article stating that the brain disease model of alcoholism represented a consensus among people who study addiction. One of the signers later joined two colleagues in publishing a more detailed critique of the neurobiology of addiction in the Lancet, a British medical journal. The authors raised questions about the results of the animal experiments that had played such an important role in verifying the brain disease theory, expressed doubt about the usefulness of research into the genetics of addiction, and rejected claims that the neuroimaging technologies that had made it possible to provide live pictures of brain activity during intoxication proved that drug taking is a compulsion. They concluded that NIDA’s decision to spend 40 percent of its budget on neuroscience research was not justified in light of what it had accomplished for addicts.13
Nora D. Volkow, Leshner’s successor, responded to the criticism in the Lancet. Volkow is a psychiatrist who played a pioneering role in the use of PET scans, a type of MRI imaging that was being used to study the brain of addicts. Her own research suggested modifications to the brain disease model, but she firmly defended the importance of neuroscience. “These findings, along with ongoing research, are helping us understand the neurobiological processes associated with loss of control, compulsive drug taking, inflexible behaviour, and negative emotional states associated with addiction,” she and George Koob wrote. The research had made possible several medications, including naloxone and acamprosate that helped reduce craving in alcoholics, buprenorphine-naloxone for opioid addiction, and varenicline for tobacco addiction.14
It also provided a basis for experimenting with the use of deep brain stimulation, which involved the implanting of a stimulator to send electrical impulses to parts of the brain. The technique, which was developed to treat Parkinson’s disease, chronic pain, and depression, was showing “promising results” in addiction treatment, Volkow and Koob wrote. She reproved the critics for believing “that science should immediately translate into transforming solutions.” She also asked why some people were having trouble “accepting as a bona fide disease one that erodes the neuronal circuits that enable us to exert free will.” No one questioned the importance of basic research in Alzheimer’s disease or schizophrenia.15
But the disagreement over the brain disease theory was not as great as the battle over whether alcoholism was a disease. The authors of the Lancet article acknowledged that changes in physiology played an important role in addiction. “Addiction is a complex biological, psychological, and social disorder that needs to be addressed by various clinical and public health approaches,” the authors of the Lancet article acknowledged. Volkow and Koob agreed on the importance of approaching alcoholism from multiple directions. “Understanding how genetic, developmental and environmental (including social) factors affect the susceptibility for substance abuse disorders helps develop better prevention strategies,” she and Koob wrote.16
There was also rising confidence in recovery. Once twentieth-century doctors accepted the fact that alcoholism was an illness, they had to recognize that it was not something that they could cure. George Vaillant and his associates in the Cambridge-Somerville alcoholism program, who were doing everything possible to help their patients, were naturally disappointed when they discovered that 95 percent relapsed in the first year. They had to relearn the lesson that guided the work of Albert Day and the first generation of addiction specialists. “Some men . . . must fall, at least once,” Day told his patients at the Washingtonian Home. Sometimes they relapsed repeatedly before they could accept the fact that they are addicted. AA acknowledged this in the advice it offered to alcoholics who were having doubts about quitting. “Step over to the nearest barroom and try some controlled drinking,” the Big Book suggested. “Try to drink and stop abruptly. Try it more than once.” Of course, there was a chance that you would start another binge. But “it may be worth a bad case of the jitters if you get a full knowledge of your condition.” Relapses were part of the learning process for most alcoholics.17
Vaillant came to realize this as his study of drunks continued. In addition to managing the alcoholism program, he was conducting one of the first studies to follow several groups of alcoholics for forty years. Using data from the Harvard Medical School’s Study of Adult Development that began in 1940, Vaillant and his fellow researchers were able to watch the development of alcoholism in 660 men from its first appearance. The results, which were published in 1983 as The Natural History of Alcoholism, convinced Vaillant that the goal of treatment should not be a cure. “[A]lcoholics recover not because we treat them but because they heal themselves,” he wrote.18
The most powerful evidence for this in Vaillant’s study was the dramatic increase in the number of men who became abstinent over time. While most of the men were drinking at the end of the first year, four times as many had quit eight years later. Vaillant had never stopped believing that treatment was important. “I have no doubt that by providing consultation, detoxification, welfare and shelter, we stop hemorrhage,” he wrote. “At the same time, we may need to recognize that the recovery process in alcoholism is best catalyzed not by a single episode of treatment but by fostering natural healing processes over time.” Vaillant believed that AA supported these healing processes. Two-thirds of the men who stopped drinking had eventually found their way into AA. “Joining any club takes time,” he wrote. He also pointed to other programs that worked. “[T]here are many paths to recovery in alcoholism,” he concluded.19
Then, in 1989, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded Project MATCH, the largest clinical study of psychotherapies that had ever been undertaken. The goal of the study was not to determine whether treatment worked. The assumption was that some therapies were certainly effective. What the NIAAA was trying to determine was whether drunks shared characteristics that made some treatments more effective than others. Researchers recruited 1,726 patients who had reported alcohol problems and divided them into groups that were given one of three treatments: twelve-step facilitation (TSF), cognitive behavior therapy (CBT), and motivational enhancement therapy (MET).
Members of the TSF group were encouraged to attend AA meetings, find a sponsor, and work through the first five steps. Patients in the CBT group were taught skills to avoid relapse, including drink-refusal techniques and ways to manage negative moods. MET therapists used motivational psychology to encourage individuals to consider the effect of alcohol on their lives and to develop and execute a plan to stop drinking. Individuals in the TSF and CBT groups met with their therapists once a week for twelve weeks. MET consisted of four sessions over twelve weeks.20
In 1996, the NIAAA announced a surprising result: matching did not work; the patients fared the same in all three groups. But Project MATCH also showed that all three treatments had been effective. One year after the study, half of the subjects reported they were no longer drinking heavily, and the number of days they were drinking each month had declined from twenty-five to six. These results provided important validation of the effectiveness of alcoholism treatment at a moment when it was under heavy attack from Herbert Fingarette and others. They had argued that in its heavy dependence on AA’s twelve steps, the treatment industry was perpetrating a fraud. Project MATCH provided the first scientifically valid evidence of the effectiveness of the Minnesota model. In addition, it was certainly good news that the other approaches were effective since this strengthened the argument that alcoholism was a treatable illness. Even the critics of the Minnesota model could take some satisfaction in the results, since they had argued that other treatments were more cost effective than twenty-eight-day inpatient rehabilitation.
The argument for the effectiveness of treatment was strengthened by the development of a new paradigm for understanding addiction. The advocates of this view acknowledged that alcoholism and drug addiction were not like most diseases, because drinking and drug taking were voluntary in the beginning. Yet there were other diseases that closely resembled addiction, including type 2 diabetes, hypertension, and asthma.
In a 1996 article in the Lancet, Charles P. O’Brien and A. Thomas McLellan observed that these are “conditions that show a similar confluence of genetic, biological, behavioral and environmental factors.” All three were regarded by the medical profession as “chronic” disorders because there was no expectation of a cure. They were also treated successfully as long as patients followed a strict diet and proper exercise regimen. But patients often failed to follow a doctor’s orders and experienced a recurrence of their symptoms. O’Brien and McLellan argued that there were also effective treatments for alcoholism and drug addiction and that their rate of relapse was actually lower than some other chronic diseases. “Is it not time that we judged the ‘worth’ of treatments for chronic addiction with the same standards that we use for treatments of other chronic diseases?” they asked.21
Four years later, McLellan and O’Brien renewed their plea in an article in the Journal of the American Medical Association. Physicians continued to see addiction as a social problem instead of a health issue, they said. Few medical schools required their students to take an adequate course on the subject, and most doctors were not asking about alcohol or drug use during routine exams. A survey of general practitioners and nurses found that a majority were unaware of effective medical treatments for addiction.
McLellan and O’Brien acknowledged that the rate of relapse one year after alcohol or drug treatment was high—between 40 and 60 percent. But they reiterated the fact that the relapse rates for patients with diabetes, hypertension, and asthma were also high, and this did not mean that the treatments were ineffective. In this article, they also went into great detail on some of the proven methods of treating opioid and alcohol addiction. The relapse rate for addictions would decline when alcohol and drug dependence were treated properly. “It is essential that practitioners adapt the care and medical monitoring strategies currently used in the treatment of other chronic illnesses to the treatment of drug dependence,” they concluded.22
There was already an outstanding example of a program that was executing the policies they were describing. In the 1970s, state medical boards began to respond to rising concern over addiction in the medical profession by creating physician health programs (PHP). The PHPs investigated reports of impaired doctors and then gave them a choice—accept treatment or lose your license to practice medicine. Unlike many employee assistance programs, however, the PHPs retained the commitment to rehabilitation that had inspired the sober drunks who started the first industrial alcoholism programs. Physicians who were in recovery played a key role in the program, counseling the newcomers during treatment and then helping them connect with other recovering doctors and twelve-step programs on their release. What made the PHP programs unique, however, was the fact that they played an active role in the lives of their patients for five years and sometimes more. They conducted periodic interviews and random drug tests. When doctors relapsed, they reevaluated them, deciding whether to require more treatment or to recommend disciplinary action. License revocation was relatively rare. While 25 percent suffered a relapse, many of them got sober again. PHPs reported success rates between 70 and 96 percent.
William L. White was enthusiastic about the success of the PHPs. In 2008, he sensed “an historical opportunity.” He joined McLellan in publishing an article that urged “re-engineering addiction treatment into a system of sustained recovery support.” White believed that the philosophy of addiction treatment was returning to its roots. While the members of the American Association for the Cure of Inebriety considered alcoholism a disease, they had also recognized that it was a complex disorder that resembled other chronic illnesses in its most extreme form. But this understanding disappeared with the AACI. “The emphasis on alcoholism as a chronic disease was lost in the larger battle to convey to the American public and policy makers that alcoholism was a disease,” White and McLellan wrote. Although the idea of alcoholism as chronic illness had been reborn, it had yet to change much:
While many in our field have come to consider some (not all) forms of addiction as chronic—this change in thinking has not been followed by changes in treatment strategy, monitoring methods, insurance coverage or outcome expectations.
The purpose of the article was to outline the wide-ranging changes that had to be made.23
White and McLellan began their task by attempting to clear away the wreckage of decades of debate over the nature of alcoholism. They wrote:
Our focus in this article is not on what addiction is—a disease, illness, disorder, habit, problem, etc.—but on the temporal course of addiction and how the span of the disorder from onset through sustained recovery can be most effectively managed at personal and professional level.
The first step was to make clear that not all alcohol or drug (AOD) problems were chronic. “[M]ost do NOT have a prolonged and progressive course,” they wrote. “All persons with AOD problems do NOT need specialized, professional, long-term monitoring and support—many recover on their own, with family or peer support.” But the line between problem drinking and alcoholism was hard to decipher in the early years of a drinking career. White and McLellan called for research to identify early signs of progression.24
They also sought to reassure alcoholics, drug addicts, and their families. “Among those who do need treatment, relapse is NOT inevitable, and all persons suffering from substance dependence do NOT require multiple treatments before they achieve stable, long-lasting recoveries,” they wrote. Even in the most difficult cases, partial recoveries were possible:
Recovery management strategies for persons with the most severe and persistent disorders include multiple goals: reducing the number, intensity, and duration of relapse episodes; strengthening and extending the length of remission periods; reducing the personal and social costs associated with relapse; reducing the propensity for drug substitution and other excessive behaviors during early periods of recovery initiation; and enhancing the quality of personal/family life through both the remission and relapse phases of the disorder.
Abstinence remained the goal of treatment, but under the chronic care model, it was no longer the sole measure of success.25
White and McLellan pointed to a 2006 study that concluded that the recovery rate from alcoholism was almost 50 percent. Only 18 percent of those in recovery were abstinent. The rest were still drinking but had not reported symptoms of abuse or dependence during the previous twelve months. Many had no desire to quit drinking and might have succeeded in their goal of moderating their drinking. But others continued to try to achieve abstinence. The promise of the chronic disease model was that it would develop strategies to identify all these people and help them achieve their goals. “We invite those on the frontlines of addiction treatment to join us in writing this new future for addiction recovery in America,” they wrote.26
As professionals reimagined addiction treatment, an advocacy movement was organizing to press for its realization. The spirit that had animated recovering alcoholics in the 1950s and 1960s to staff hospital wards, open chapters of the National Council on Alcoholism, and lobby for the Hughes bill faded after 1970. One exception was a sober drunk named Paul Molloy who joined with other occupants of a county-run halfway house in Silver Springs, Maryland, in taking over the lease in 1975. Molloy later launched Oxford House, which began renting homes for alcoholics and addicts who were trying to stay sober. But activism was declining. Harold Hughes attempted to reinvigorate it by organizing a Society for Americans in Recovery in 1991, but the organization closed several years later.
It was only in 1996 that veteran activists began to notice new local groups organizing around issues like the need for detox services for indigent patients or a decision to reduce the number of beds in a treatment facility. “We came from the grassroots,” one activist said. In Santa Barbara, California, one group gathered a large number of supporters at a board of supervisors meeting. “They asked all those in recovery to stand, and the whole room stood up. . . . They invited us to the table in a strategic planning process,” an organizer reported.27
The federal government attempted to encourage these new groups. In 1998, the Center for Substance Abuse Treatment, a division of the Substance Abuse and Mental Health Services Administration (SAMHSA), issued grants to nineteen community groups to assist them in organizing people in recovery to advocate for improved addiction treatment. At the same time, the Johnson Institute Foundation, which was formed to promote the early-intervention strategy of Vernon Johnson, was funding regular meetings of leaders in the addiction field.
Recognizing the potential of the community groups, organizers began to outline a plan for a public awareness campaign that would be launched at a summit meeting in St. Paul, Minnesota, in October 2001. The first step was to identify participants who represented every aspect of “the national recovery community.”
Organizers sent a questionnaire to representatives of sixty-six groups actively promoting recovery at the local level and individuals who had recovered from alcohol or drug addiction. Whenever possible, a balance was sought based on geography and cultural diversity. There was also an attempt to ensure that different methods of recovery were represented by including people from secular, twelve-step, and religious groups. A special effort was made to include those who had recovered with the assistance of medicine like methadone.
Six hundred questionnaires were distributed, and two hundred people who responded were chosen to attend, including some family members of alcoholics and addicts and representatives of recovery organizations, many of whom were also in recovery.
The Faces & Voices of Recovery Summit had two major goals. The first was to get people in recovery to identify themselves publicly. The news media were full of stories about addicted people, but almost all were active alcoholics or addicts. The few who were sober or clean were generally early in their recoveries, including celebrities who were still cycling in and out of rehabs. The public needed to see that alcoholics and addicts were living full and satisfying lives; engaged in demanding, important careers; raising children; and contributing to their communities. There were millions of potential role models. But few people were speaking up, in part because there was a widespread belief that it violated AA and NA traditions of anonymity. One of the first speakers confronted this issue directly on the opening night of the St. Paul summit. “By our silence, we let others define who we are,” she said.28
The other objective was to plan an advocacy campaign to seek changes in laws and government policies that would enhance the prospects for recovery. Summit participants were polled to identify the most important issues, and there was strong support for a campaign to end discrimination against people in recovery. At the time of the summit, one of the most pressing issues was the failure of insurance companies to provide adequate coverage for behavioral illnesses, including alcohol and drug addiction.
Legislation had been introduced in Congress and state legislatures to force the companies to provide equal treatment of mental and physical illness. But the insurance companies were lobbying hard against the parity bills. In California, they had succeeded in getting the legislature to drop addiction treatment, although recovery groups there were fighting hard to restore it. Other goals included ending job discrimination against people who had been in treatment and allowing people who had been convicted of drug offenses to gain access to government welfare and education programs that would help them make a new start.
While these were ambitious goals, a national poll conducted by the organizers showed that there was strong support for them among people in recovery. A random survey of drunks and addicts in recovery revealed that 87 percent agreed that it was important for the American people to understand the basic facts of addiction and recovery. More surprisingly, half said they were willing to talk about their experience publicly.
The 2001 summit put the recovery movement on a new footing. Faces & Voices of Recovery, which began as a publicity campaign, was incorporated in 2004, making it the national voice of the recovery community organizations (RCO). The summit also encouraged the creation of new groups, which proliferated rapidly. By 2016, there were one hundred local, regional, and state RCOs
Some of the RCOs operated community centers that helped people in recovery find services and advice. There were twenty-five recovery community centers in New England in 2012, including three centers operated by the Connecticut Community for Addiction Recovery (CCAR). In 2013, the CCAR centers recorded fifty-nine thousand visits and hosted eleven hundred events, including support meetings, GED classes, and computer classes. CCAR also sponsored a hot line that received more than fourteen hundred calls that year from people who were in danger of relapsing.
In addition, the RCOs were seeking to reverse the sharp decline in the number of people in recovery who were working in the addiction field. CCAR trained seventeen hundred “recovery coaches” in 2013 and established a Recovery Technical Assistance Group to help other RCOs establish coaching programs.
The birth of an organized movement of former drunks and addicts played an important role in expanding government support of recovery. When Senator Paul Wellstone addressed the Faces & Voices of Recovery Summit in 2001, he said there was no chance of passing his insurance parity bill if it contained addiction treatment. But, by 2008, people in recovery were making themselves heard. Wellstone had died in an airplane crash, but by the time his bill came up for a final vote in 2008, it included coverage for addiction treatment. When the Mental Health Parity and Addiction Equity Act was sitting in committee in the House of Representatives, recovery groups generated ten thousand calls to Speaker Nancy Pelosi to help move it to the floor, where it passed.
An even more important victory followed two years later with the enactment of the Patient Protection and Affordable Care Act. The centerpiece of President Barack Obama’s legislative agenda, the Affordable Care Act (ACA), expanded health-insurance coverage for millions of Americans. It had great significance for alcoholics and addicts because it defined addiction treatment as an “essential” health service and required insurance companies to provide it to all their customers. The law prohibited insurance companies from denying coverage to people with preexisting conditions, making it possible for people in recovery to seek further medical help if they relapse. The ACA also encouraged the states to extend Medicaid to make it possible for poor people, who are disproportionately affected by addiction, to receive treatment for the first time.
The Obama administration went even further in its effort to help alcoholics and addicts. Although the Clinton and Bush administrations had launched several helpful programs, the Obama administration was the first to officially embrace recovery as a cornerstone of US drug policy. The first signal of a dramatic change in policy came soon after the new president took office in 2009. The White House Office of National Drug Control Policy (ONDCP) had been established by the Reagan administration to lead the war on drugs. The leader of the ONDCP was known to the nation as the “drug czar” and had usually been a man with military or law enforcement background. After Obama was elected, a new office was added to the ONDCP and charged with encouraging recovery. Leaders of the recovery movement were invited to consult with White House officials, and recovery was announced as one of the four principles of a new national drug control strategy.
The administration also began to add recovery leaders to the ONDCP. McLellan, whose articles comparing addiction to other chronic diseases had been highly influential in the recovery movement, was hired as deputy director in 2012. He was succeeded two years later by Michael Botticelli, who had directed the Massachusetts Bureau of Substance Abuse Services. Botticelli was also an alcoholic who had quit drinking in 1988 following his arrest for drunk driving. In 2015, he succeeded his boss, becoming the new drug czar.
What was happening around the United States, however, may have been even more important in encouraging new efforts to help the addicted. The problem of alcohol and drug addiction had certainly not improved in the opening decades of the twenty-first century. As this book goes to press, the United States is in the midst of an epidemic of opioid addiction that killed 29,467 people in 2014. The Substance Abuse and Mental Health Services Administration has said that twenty-two million Americans are addicted to alcohol or drugs. Fifteen million are alcoholics; another three million are addicted to both alcohol and drugs, and four million are drug addicts.
These numbers are daunting. But the number of people in recovery is also large and growing. In January 2016, there were more than 117,000 AA groups worldwide with over 2 million members, including 1.2 million in the United States. The Partnership for Drug-Free Kids and the New York State Office of Alcoholism and Substance Abuse Services commissioned a national poll in 2011 that asked 2,526 adults, “Did you once have a problem with alcohol and drugs, but no longer do?” Ten percent of the 2,526 adults who responded said yes. A survey of more than four hundred studies on remission rates put the number of alcoholics and addicts in recovery at between 25 million and 40 million. The ranks of the recovering are growing rapidly. There were 1.8 million in treatment in 2013.29
But before this army could begin to march, the recovery movement had to persuade the troops to begin identifying themselves publicly. This was the challenge of the St. Paul summit in 2001, but it was not easily accomplished. People had to be willing to face the consequences of challenging a stigma that was still strong. There was good reason to fear that their honesty would cost them.
It was also not immediately clear whether this strategy, which was largely driven by public relations, violated the traditions that guided millions of AA, NA, and Al-Anon members. AA’s tradition six opposes endorsing, financing, or lending AA’s name to any “outside enterprise.” Tradition ten says that the organization has “no opinion on outside issues” and should not be drawn into “public controversy.” Tradition eleven is potentially the most troublesome. “Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio and films,” it says. NA and Al-Anon adopted the same language. Many members of these anonymous fellowships were bound to have questions about the wisdom of “coming out.”30
As a practical matter, this problem was easily solved. “You can speak about your own recovery and advocate for the rights of others, as long as you do not involve the twelve-step group by name,” Faces & Voices of Recovery declared in a pamphlet, Advocacy with Anonymity. The pamphlet suggested language that made it clear that alcoholics and addicts were only speaking for themselves:
I’m (your name) and I am in long-term recovery, which means that I have not used (insert alcohol of drugs or the name of the drugs you used) for more than (insert the number of years that you are in recovery) years. . . . I am now speaking out because long-term recovery has helped me change my life for the better, and I want to make it possible for others to do the same.
The pamphlet appeared to settle the matter for many. Alcoholics and addicts began identifying themselves as people “in long-term recovery” in a growing number of public places, including a 2013 documentary, Anonymous People, which tells the story of the emerging recovery movement. New groups were formed to encourage the trend. Two of them, Facing Addiction and I Am Not Anonymous (IANA), feature the names and pictures of their supporters on their websites. They sell T-shirts, buttons, and other promotional items that identify the wearer as “In Recovery” and urge people to “Unite to Fight Addiction.” An IANA T-shirt reads, “IANA: If Not Us, Then Who?”31
People in recovery began showing up at public events. SAMHSA launched Recovery Month in 1989, but it was only after the St. Paul summit that large numbers began showing up at events sponsored by local groups around the country. In 2002, more than two hundred events were listed on the Recovery Month online calendar, including the Texas Soberfest in Austin, which drew five thousand people, and Hands Across the Bridge, which involved two hundred people holding hands across the Interstate 5 bridge connecting Portland, Oregon, and Vancouver, Washington. By 2008, the number of events had tripled. The highlight of that year’s celebration was a march across the Brooklyn Bridge by ten thousand people. The federal government was represented by the national drug czar.
In 2013, it was estimated that more than 125,000 people participated in Recovery Month events, which included dances, workshops, conferences, parades, rallies, walks, and runs. Two years later, recovery advocates began organizing their biggest event yet, the Unite to Face Addiction rally and concert, which it was hoped would draw as many as a hundred thousand people to the National Mall in Washington, DC. A threatened hurricane led organizers to consider canceling the event, but the concert proceeded when the hurricane missed the city. Tens of thousands heard rock stars Steven Tyler, Joe Walsh, and Sheryl Crow perform.
Despite the reduced turnout, the Unite to Face Addiction event was a landmark in the growth of the recovery advocacy movement. On the National Mall, surrounded by the government institutions and national monuments, formerly anonymous people in recovery asserted their right to full citizenship. One of those who spoke to the crowd expressed the thoughts of many. William Cope Moyers, the son of journalist Bill Moyers, is vice president of public affairs and community relations at the Betty Ford Hazelden Foundation. He is also an addict and alcoholic who relapsed several times before he established long-term sobriety in 1994. Moyers was well qualified to speak for the crowd:
For too long, addiction has been an illness of isolation. For too long, addiction has been cloaked in the stigma of private shame . . . the stigma of public intolerance . . . the stigma of discriminating public policy.
But today . . . today TOO LONG . . . IS NO LONGER. Because today . . . HERE WE ARE!
Today on this national mall we stand TOGETHER as the antidote to addiction. . . .
WE unite to face addiction. WE unite to prove with our faces and our voices and our lives that addiction does not discriminate. . . . And to prove that recovery should not discriminate either. Because WE are the fortunate ones. The ones who got well. And it is our responsibility, our opportunity . . . to come together as one, for the sake of those who still suffer. . . . WE unite to let them know, that they are not alone. WE unite to reassure them—that it is okay to ask for help. WE unite to tell their families that there is hope. WE unite, to keep the doors of treatment open . . . and open wide, no matter how often those who suffer need to walk through them again.
NO longer do we simply dream on about the promise and possibility of recovery. Today we live on, in our reality that recovery is real. Because it sounds and looks and lives like us. All of us. United.32
There is a long way to go before the recovery advocacy movement achieves all of its goals. The latest victory is the passage of the Comprehensive Addiction and Recovery Act (CARA) of 2016. It took several years of hard work by advocacy leaders and strong support from their clean and sober supporters to pass the bill, which creates new policies and additional funds to improve prevention, treatment, and recovery support. Even as they expressed satisfaction at the passage of the bill, however, recovery leaders acknowledged that it did not go as far as they hoped. CARA will authorize only a million dollars a year for the vital support services provided by RCOs. The fact that CARA passed by overwhelming majorities in both houses of a bitterly divided Congress is not evidence that our elected representatives have suddenly recognized the importance of recovery. It is a response to the crisis caused by opioid addiction. CARA is an important step forward, but the fight for recovery will go on.
Sobriety has always come in waves that carried us forward and then receded. At times, we seemed in danger of losing all of our gains. The Washingtonians faded quickly. Prohibition sent the country in the wrong direction in its search for a solution. When interest in alcoholism as a medical problem revived after the repeal of Prohibition, no one remembered the work of J. Edward Turner, Albert Day, and the American Association for the Cure of Inebriety. Even after the importance of treatment was widely recognized in the second half of the twentieth century, drug addicts were sent to prison instead of treatment.
But the search for sobriety never ended. Handsome Lake’s Good Word was being read at Iroquois religious ceremonies more than 150 years after his death. Many Washingtonians joined the sober fraternities, which provided a home until the rise of the ribbon clubs. Leslie Keeley got rich claiming he had a gold cure for alcoholism, but he also helped tens of thousands get sober and provided the spark for a national league of sober men. Religion was a powerful force for recovery that worked through Jerry McAuley and the Salvation Army. The discoveries of science inspired Elwood Worcester and Courtenay Baylor.
In 1935, a new wave began to form. AA proved again that drunks could get sober, and as it prospered, it showed that they could stay sober for a lifetime. Sober alcoholics believed in the importance of treatment, and they convinced political leaders that it was important for the country. This argument lost ground during the 1980s and 1990s, but the treatment advocates won the war. Today, the US government recognizes that medical treatment for alcoholics and addicts is a basic human right.
There is always a possibility that this latest wave will recede. But it seems unlikely that people in recovery will allow it to happen. There are too many of them, and there has been a significant change in the way they think about themselves. For many years, AA members believed they were different from addicts. This attitude is waning as younger alcoholics join. Alcoholics and addicts in recovery are beginning to understand that what they are addicted to is less important than addiction itself and are working together to ensure that everyone has an opportunity to recover. Throughout American history, people who have survived addiction have carried the promise of recovery to fellow sufferers. Today, they are speaking directly to their fellow Americans.