MS. DIANE REHMThanks for joining us. I'm Diane Rehm. For decades, 12-step programs alike AA have dominated the field of alcohol addiction treatment, but many experts feel that programs focused on abstinence only are not the most effective path for many patients.

MS. DIANE REHMJoining me to talk about how our thinking on alcoholism treatment is changing, Professor Bankole Johnson of the University of Maryland School of Maryland, Beth Kane-Davidson of the Addiction Treatment Center at Suburban Hospital. Joining us by phone from the NPR studios in New York City, Carrie Wilkens of the Center for Motivation and Change.

MS. DIANE REHMI'll look forward to hearing from you. Join us by phone at 800-433-8850. Send an email to drshow@wamu.org. Follow us on Facebook or Twitter. Thank you all for joining us.

MS. BETH KANE-DAVIDSONThank you.

DR. BANKOLE JOHNSONThank you so much for having me on the show.

REHMIndeed. Good to have you here. Beth Kane-Davidson, I'll start with you. You use an abstinence-based program to treat alcohol addiction in your practice. Talk about how it works.

KANE-DAVIDSONAbsolutely. We use the chronic disease model. We focus on the American Society of Addiction Medicine definition that addiction is basically primary. It's a chronic disease of brain reward. You look at memory and motivation. And what we have to do is help the patients understand what that definition means and then have them look at individually their history, their story, how do they relate to the signs and symptoms of addiction.

KANE-DAVIDSONAfter that, we help them understand the resources. And that is one thing, I can say, that has changed. I've been working in addiction since 1978. It's been a wonderful career. But I have seen the change in trying to help people look at exactly what type of recovery, ongoing recovery program, is going to be the best one for them.

REHMSo are you saying that in addition to abstinence-only plans, you're looking in other directions as well?

KANE-DAVIDSONAbsolutely. We introduce people certainly to 12 steps, to Alcoholics Anonymous, but we have ventured into smart recovery. We do have people go to therapy, individual therapy. We're using more and more of alternative ways for people to get the support they need. That's not to take away from the primary mutual peer support that we feel is crucial, but there may be other things that people need to look at.

REHMAll right. And turning to you, Professor Bankole Johnson, what are your issues with that kind of approach of abstinence only?

JOHNSONI think that when you look at the history of alcohol treatment over the last 100 years or so, one of the foundations previously had been that abstinence was really the only method in which you could treatment for alcohol dependence and progress. And, in fact, one of the things that we learned from the National (word?) Logical Study is that even if you look at individuals who are meant to have sustained abstinence over a long period of time, five, ten years, only about 11 percent of people achieve that.

REHMEleven percent?

JOHNSONAbout 11 percent.

REHMWho've been on the abstinence-only program.

JOHNSONCorrect, correct. Therefore, abstinence, even though individuals may aim for abstinence or claim to be abstinent, it's actually quite rare for people to be totally abstinent for long periods of time. And the second problem that you have is that individuals come to you when they are drinking, you know, typically. And they want to -- usually, they're ambivalent at the start.

JOHNSONThey're not sure whether they want to stop drinking. They're not sure whether they want to reduce drinking. And therefore, if you have a funnel principal in which everybody is simply going to abstinence, you don't capture a large majority of the population. A large majority of the population of people who drink excessively have varying levels of motivation.

JOHNSONAnd it takes some time for them to get into the various types of rounds to say, well, I really want to be totally abstinent. There are also other categories of individuals that it's not really very possible to insistent on abstinence. So college students, for example, college student drinking is a very serious problem in the United States, a lot of heavy drinking. And this really is something that needs to be reduced to reduce the amount of heavy drinking that's done.

JOHNSONBut in my experience, it's very difficult to get college students to come in and agree to abstinence for a lifetime at the age of 25.

REHMRight. And turning to you, Carrie Wilkens. I know you were co-founder, clinical director of the Center for Motivation and Change. What lead you to seek alternatives to the abstinence-only model and talk about ways you approach it.

MS. CARRIE WILKENSSure. I agree with a lot of what Dr. Bankole already laid out. You know, when we started the Center for Motivation and Change, my partner and I, Dr. Jeff Foot, we were really one of the only programs that would kind of treat people on the continuum, right? Because like he's saying, you really -- there are people with low level, mild dependence problems that may be having negative consequences due to their use that they're just not ready, like he said, motivated to talk about abstinence right out of the gates.

MS. CARRIE WILKENSAnd when we started the Center, those patients, those clients would tend to be turned away from other programs. They'd be told they weren't ready. You know, come back when you're ready to be abstinent because if you didn't have abstinence at the outset as your goal, they couldn't provide services to you. And evidence-based treatment strategies, which is what we use at the Center for Motivation and Change, really can work with people at all stages.

MS. CARRIE WILKENSAnd I really believe in motivational interviewing strategies and the evidence behind them support this that you can engage people at all levels of motivation, ranging from pre-contemplation -- I don't even know if I have a problem. My mom thinks I have a problem. My spouse thinks I have a problem. You can work with that person just as much as you can work with somebody whose fully in action stage.

MS. CARRIE WILKENSThey've just gotten out of rehab. They want to go to meetings every single day. They really want to change their life. We've got to be able to provide services to all of those clients. And historically, addiction treatment has not done such a good job of doing that.

REHMSo Carrie, tell me how treatment at Center for Motivation and Change actually works.

WILKENSSo it's a combination of things. The main one is that it's very individualized. You know, when people -- there's a lot of misconceptions in terms of like, okay, so if you're not abstinence-only, you, therefore, must be just supporting moderation. Well, that's not true. I mean, if I'm sitting with a client that really, clearly does need to abstain because, you know, they're drinking and driving or their marriage is falling apart or they've got horrible consequences due to their alcohol use, I'm not gonna say moderation's a great idea for that person.

WILKENSThe college kid who I'm sitting with or the woman who's actually got PTSD symptoms and is drinking in response to her PTSD symptoms, I'm going to say, hey, let's treat your PTSD and decide -- see what's happening with your alcohol use, you know, as your other problems kind of get resolved. So you've got to really be working with the person in front of you based on all the variables that they're presenting with.

WILKENSAnd every single person with a substance abuse problem has a problem for different reasons and they're gonna get out of it in different ways. So the one-size-fits-all model is, again, just really -- it's not effective and I think it's doing a huge disservice to a huge number of people who would seek treatment if they had more options available to them.

REHMAll right. But Carrie, it sounds as though what you're saying is that your approach and AA are not mutually exclusive.

WILKENSNot at all. No. At any given time, probably 50 percent of my clients that I see on a regular basis go to AA. I mean, it's an unbelievable free support system. You know, they've got great role models of sobriety and a lot of people find it really helpful. I mean, some of my closest friends, it's changed their lives. But we also know it doesn't work for everybody and there's lots of people who have tried.

WILKENSThey don't take to it. They're not comfortable with it for whatever reason and we have to be able to help them as well. And there's other people who may actually be able to moderate with, you know, the right skills training and having addressed the other variables in their life.

REHMAll right. Carrie Wilkens, she's co-founder, clinical director of the Center for Motivation and Change. Beth Kane-Davidson, directs the Addiction Treatment Center at Suburban Hospital and Johns Hopkins University and Dr. Bankole Johnson is chair of the Department of Psychiatry, director of the brain science research consortium at the University of Maryland School of Medicine.

REHMI hope you'll join us. Pardon me. Questions, comments, 800-433-8850. Beth, what about the use of moderation in your own practice?

KANE-DAVIDSONWell, Suburban is abstinence-based and I do think we're -- what we've been talking about or it's a continuum. The exciting thing about addiction treatment right now for me is that you can have people who are looking at, you know, pre-contemplative, contemplative, determination action, you know, really going through where am I on the spectrum of having a problem.

KANE-DAVIDSONAnd I see that in individual cases in therapists in the area where they may be working with somebody on that. As the person works through that continuum, they may discover I can't stop. I can't consistently stay abstinent and that's where I feel like the addiction treatment centers like Suburban Hospital outpatient, we're there for that capture, those people that are working through this issue and they know I need to be in an abstinence-based program.

KANE-DAVIDSONNow, in the abstinence-based program, we also are using these type of motivation interviewing techniques to help people come to a self diagnosis.

REHMAll right. We'll take a short break here. When we come back, we'll be talking with another individual, a journalist and author, Gabrielle Glaser. Short break, right back.

REHMAnd joining us now by phone from Montclair, N.J. to talk about some of the current medical research in the field, in particular what's happening abroad, journalist and author Gabrielle Glaser. Gabrielle, thanks for joining us.

MS. GABRIELLE GLASERThanks so much for having me.

MS. GABRIELLE GLASERGabrielle's book is titled "Why Women Drink and How They Can Regain Control." Gabrielle, I know you recently concluded a trip to Europe to find out about some of the cutting edge treatments for alcoholism going on there. Tell us what you found most especially in Finland.

MS. GABRIELLE GLASERI did. I just returned from a trip to Helsinki where an American doctor named John David Sinclair, a behavioral and neuroscientist, pioneered the use of an opioid antagonist for problem drinkers. And an opioid antagonist prevents the brain from releasing endorphins when a person drinks. And the opioid antagonists are something that have been used for 40 years. They're very safe. They're generic.

MS. GABRIELLE GLASERAnd one in particular called Naltrexone was approved by the FDA in 1994. However, according to JAMA it's hardly used in the United States at all. But in Finland it is used given -- it is given an hour before drinking, so not an abstinence-based program at all but it's given an hour before drinking. And it prevents the brain -- the drinker than takes drink, two drinks and does not feel the buzz of alcohol.

MS. GABRIELLE GLASERHe or she does have the motor, you know, uncoordination. You're not supposed to drive after you do this of course, but nevertheless overtime -- the process is something that Sinclair calls pharmacological extinction. And overtime the theory is that the brain simply stops craving alcohol. You do this for four to six months. It's been used for thousands and thousands of people.

MS. GABRIELLE GLASERA new drug called Nalmefene was just approved for use in 13 EU countries. It's produced by a Danish company called Lundbeck. And it's widely used in Europe. We do not use those approaches very readily at all.

REHMI gather that previously medication had been focused on actually making people sick when they drink. And that has not been terribly effective.

GLASERExactly. And Sinclair and the Finnish physicians and clinicians I spoke to think that that's really kind of illogical, that it's a punishing approach to what happens when you take that drug which is called antabuse. The drinker -- if the drinker drinks then he vomits and becomes extremely, extremely ill. And they believe that that's very punishing.

GLASERAnd most drinkers who get into a problem with alcohol really don't want to have that problem. You know, people that wake up in the morning and say oh I really just want to be dependent on alcohol. And this is a way that the Finnish clinicians believe is, well, I'll just say it, they see it is a far less painful way to go through...

REHMInteresting.

GLASER...to be treated.

REHMGabrielle, you have said that you think Europe is light years ahead in grabbing onto new and promising treatments and that we here in the U.S. are in the dark ages. Why do you think that is?

GLASERBecause I think the one-size-fits-all approach that we have for -- in so many rehabilitation facilities and that so many clinicians and so many general practitioners who are unaware of the new medications and new treatments, like the ones that Dr. Johnson offers, like the ones that CMC offers, they insist upon abstinence. And abstinence turns people away. If they're not ready to give up the substance entirely then it's only going to turn them further underground with their problem, with their shame, with the stigma that is attached to drinking too much.

GLASERAnd in Europe this is something that's, at least from what I saw, the primary methodology, the primary approach is one that uses cognitive behavioral therapy in conjunction with drugs. And it's a harm reduction approach.

REHMAnd is there any actual research on the books to tell us how effective this approach actually is as compared, for example, with an addiction-only approach or Carrie Wilkens' more moderate approach?

GLASERWell, Sinclair's research, which has been published in several peer review journals hits about a 75, 78 percent success rate in getting people to reduce the number of their -- of drinks that they take per week. So we're talking a little bit like about apples and oranges because the goals are different. So what the Finnish clinics showed me was something like this.

GLASERLet's say a drinker drinks typically 60 to 80 drinks a week. Now that sounds like a lot to many of us but it's something that's accepted there without judgment and, okay, what's your target going to be? What would you like to be able to get to? And typically what they try to agree upon is something that's within the safe limits -- guidelines for the -- within the EU, which would be more like 14 drinks a week for a woman, 21 drinks for a man.

GLASERNow that sounds like a lot to us. We have different metrics. We recommend half that, seven drinks for a woman a week, 14 drinks for a man. But in Finland they have a -- they use higher metrics.

REHMAll right. And Dr. Johnson, I know you'd like to comment.

JOHNSONYes. I think I agree with some -- quite a bit of the things that you said, and thank you for mentioning the importance of medications. What I'd like to do though is, you know, give a plug to the United States. I really don't think Finland are ahead of us. I mean, the National Institutes of Alcohol Abuse, NIAAA, has done a tremendous job of funding over, you know, 30 to 40 research programs on alcohol treatment. In fact, all the work that Dr. Sinclair uses in Finland were actually invented right here in the United States.

JOHNSONNow, there's -- an important problem is why don't we use them? That's -- but I think that that's a different question entirely. But a lot of the understanding and the basic science, understanding the mechanisms in the brain, whether we're using a drug called Naltrexone or Nalmefene, which are opioid antagonists that you've discussed, or drugs like Topiramate, which work on other brain mechanisms. Really a lot of that pioneering work has been done in the United States.

JOHNSONNow, you are correct. We are not good at using medicines in the United States for the treatment of alcohol dependence. And I suspect that there are three types of reasons why. One is that doctors have not been educated properly in the use of these medications and are often quite anxious or scared about it. And they're not either educated in terms of even the basic science or the medical aspects of it.

REHMBut is that changing?

JOHNSONThat is not changing as rapidly as I would like.

REHMOkay.

JOHNSONIt's not really changing very rapidly.

REHMAll right.

JOHNSONThe second is, you know, I tell my students that everyone in the world is an alcohol expert. You know, you get on a train and you ask somebody what's the treatment for alcohol dependence. And they're going to give you an answer. They'll usually say, well, you know, you have to go to AA or you have to stop drinking or something like that. And anyone, in their right minds, if you sat next to them and you asked them, you know, what's a treatment for advanced carcinoma of the lung, would start to say, well, I'll give you the treatment right now.

JOHNSONAnd so the reason is because there has been such a powerful message, either through the local media or through television programs or just basically fantasies, that individuals have decided that they know what the treatment is. And this is often a barrier to all kinds of treatment for alcohol dependence.

REHMAll right. And...

JOHNSONCould I get to the third -- could I get to the third reason?

REHMOh, sure. Okay, sorry.

JOHNSONAnd the third reason is access to treatment. We do not do a good job with access to treatment. The universities and the research centers in the United States that are involved in doing the best research, I think, in the world and have the most knowledge in alcohol and medicinal treatments treat a tiny fraction of people who have alcohol dependence completely -- you know, much less than 1 percent.

JOHNSONAnd the great majority of people who treat people who have alcohol problems in medicine are family practitioners. And the treatment access that you have to get to to find out addiction -- and I challenge anyone listening on the show to go to the yellow pages and say to themselves, I'm going to find an alcohol treatment center today. I suspect that they will still be doing that by the time we finish the show.

REHMAll right. And Beth, I think you'd like to comment.

KANE-DAVIDSONYes. Quickly I'd like to also say that NIAAA is doing an excellent job at helping people do exactly what we're talking about, is rethinking drinking. And they have a website called RethinkingDrinking.gov. And that has become a real portal for people to go in and just examine their drinking habits and where is it and what do they need to do. And it gives tools and resources.

KANE-DAVIDSONSecondly I'd like to say, you know, great that we're talking about the medications at Suburban and I know many other treatment centers are using medications that do help reduce cravings like Naltrexone. And this is all individually based. We have gone much more towards looking at the individual patient, what they need away from the cookie cutter, everybody has to take antabuse. That was in the '80s and '90s. I'm not seeing that now in treatment.

REHMAll right. And Carrie Wilkens, I know you'd like to chime in.

WILKENSYeah, I think those three points he outlined were great. And I agree, the field is changing. It's just unfortunate that it's taken this long because a lot of this research and a lot of the treatment protocols that we use, they've been available to people for 20 years, 15 years. And the treatment industry has just been slow to pick it up. And that's really unfortunate.

WILKENSSo I think just having these conversations and getting consumers educated, that they can really say, hey I would really like you to be having cognitive behavioral treatment programs available in our community. Because -- and why can't people get trained and really having, you know, programs embrace these strategies? It just needs to happen because people really do need options. And they respond to options.

WILKENSPeople want help, like Gabrielle said. Nobody wants this problem. Nobody wants to wake up and have an addiction problem. They really do want help but it depends on how it's packaged. And different people respond to different things. And we have those options available to them and everybody needs to know about it.

REHMSo Gabrielle, are you seeing the kinds of programs that you outlined that are going on in Finland, other parts of the EU, coming here to the U.S.

GLASERI think that certainly people are -- that clinicians are becoming more aware of these treatments. But it -- as Dr. Johnson said, something I'd like to pick up on, certainly it's not the NIAAA that's not doing the research but it's a problem that we don't have primary care physicians who are aware of these options.

GLASERAnd it's much like depression 20 or 30 years ago, before the advent of Prozac. People who were depressed really had to suffer themselves in silence, or if they were really terribly, terribly ill they were committed to psychiatric institutions after they had tried to kill themselves. And that was typically the treatment for depression. There wasn't -- we really didn't have great options.

GLASERAnd until we developed Prozac and its fellow SSRIs, people really didn't have relief. And what many doctors hope for, many psychiatrists who I've spoken to over the course of researching this topic for the last several years, is that one day medical or general practitioners will be able to say hey, you know what, let's talk about your drinking. And do you think you might need some help in cutting back?

GLASERYou know, hopefully it will be a conversation that's used -- that's done without judgment and in which doctors are aware and can avail themselves of these treatments.

REHMAll right. And you're listening to "The Diane Rehm Show." One question that I think is on the minds of a great many people, and any of you -- perhaps you Dr. Johnson -- can talk about this, is the idea that there may be some genetic base for alcoholism.

JOHNSONWhat a super question. I think that we have been living under the, I would say, illusion on that we -- alcohol dependence is simply one disease. We now know that alcohol dependence is probably multiple diseases. We don't know exactly how many but we do know certain important things.

JOHNSONWe know that the predisposition to alcohol dependence is probably about 60 percent biological. And in some individuals it's probably even more because they probably inherited in a multifactorial reason from their fathers or their mothers. And from those individuals it's actually very important to think about biological treatments. One of the things...

REHMAnd yet listen to this email from Lydia in Bedford, Ohio. She says, "I grew up with an alcoholic father, multiple alcoholic uncles. My siblings married alcoholics. Our lives were significantly and negatively impacted by alcoholism. However, I do not believe alcoholism is a disease of any sort. I believe it's a choice, as is the failure to try to stop drinking." Why don't you take that on, Beth.

KANE-DAVIDSONI can understand how she feels. And again...

REHMFrustrated.

WILKENS...very frustrated and, you know, we'll come back to what's already been mentioned about education. And that's all of us, everyone that interacts with a person is helping them understand, you know, what addiction is and what the recovery process is.

REHMGabrielle, how do you see it? Is it a choice or is it something biologically based?

GLASEROh, I think it's a mix of -- I don't really think it's a choice. I think it's a behavior for which there is a genetic predisposition. And I think, as Dr. Johnson said, it's a multifactorial problem that psychological, environmental, genetic and, you know -- I guess those are the things that I just...

REHMAnd Carrie, what do you think?

WILKENSI also very much think it's a mix. I mean, that's what all the evidence suggests. But you can hear the pain in that woman's story and the power -- I mean, there's so much anxiety and so much pain that people suffer when they're really in the depths of this and their families are wrecked. And I think it creates this very black and white kind of you either are or you're not, or it's this or it's that way of talking about their problem. Which, again, is understandable given the anxiety, but it really -- it's a very complex problem.

REHMAll right. And complex it is. I'm sure many of you have questions. We'll open the phones as soon as we come back. Stay with us.

REHMAnd as we talk about various approaches, some of them quite new, to treating alcoholism, we'll go right back to the phones and to Mark in Beverly, Mass. Hi, you're on the air.

MARKHi. Thank you for taking my call.

REHMSure.

MARKI have a couple of questions. The first one is, one of the advantages -- I'm in recovery 19 years now, I'm one of the rare people that Dr. Johnson spoke about who has fully abstained from alcohol.

REHMI'm glad for you.

MARKAnd -- thank you. And one of my concerns is that when someone does become ready to change their lives, that if people are telling them that the best way is to do it is by a moderation program, that they will miss out on the opportunity of an abstinence program. Because, you know, the AA model is not just about not drinking. It's about changing many things in your life once you do stop drinking. So I'm wondering if there's any sort of data about the moderation programs and what their success rate is and what their goal is. It's just to reduce the amount of drinks, or to also change the lives?

REHMOkay.

MARKAnd then also, I have one other question, which is...

REHMSure.

MARK...are any of the panelists there in recovery or part of a moderation program?

REHMAll right.

MARKThank you.

REHMThanks for your call. Let's take that second question first. I don't know if anyone would like to acknowledge that he or she is someone who has approached alcoholism and is currently abstinent. Any comments?

KANE-DAVIDSONI am not.

JOHNSONI don't actually drink very much.

REHMAnd Carrie?

WILKENSAnd I would say I probably meet criteria for having been a terrible college binge drinker that, you know, once I fully got into graduate school and had to work and kind of had other things competing with being a bored kid, I didn't drink as much. And I don't drink much now, so. But had you met me when I was 19, I was a mess.

REHMRight.

WILKENSYou know, and so I would very much like to speak to his first question...

REHMSure.

WILKENS...which, you know, the kind of -- again, this kind of way the conversation swings to these very either/or discussions of if somehow you're letting people have conversations about moderation goals, that you're somehow saying to them that's the best way to do this. That's actually just not -- that's not how we work. People have the goals that they have. And our job as clinicians, I think, is to really help them feel comfortable enough to talk about it, fully disclose how it's working or not working for them, and speed up the change process essentially, by giving them some room to critically think about it, right?

WILKENSIt's not that we're saying moderation is the best -- is the best outcome -- I mean, the best goal to have for a lot of people. In fact, I usually say abstinence is, because it is for a lot of people. But being able to kind of also accommodate moderation goals and having people kind of go through those stages in treatment with support and with a real critical kind of evaluative process I think is really important. So I don't want people to get confused that somehow, if you're not an abstinence-only program, that therefore you are only a moderation program.

WILKENSThese things are, again, on a continuum. And you're really working with an individual that is across from you.

REHMAll right. And, go ahead.

KANE-DAVIDSONJust one thing I'd like to say. You know, and I'm glad this came up. And congratulations on the 19 years of sobriety. Because as I was sitting here I was thinking one thing that I want to state is, being in a treatment program, seeing people's lives changed, seeing them get into recovery and, you know, there's nothing like somebody coming back and saying, I celebrated a year. Thank you so much. Or a young adult coming in and saying, I got my father back. Thank you. People that have alcoholism suffer greatly, as do the family members.

REHMAnd that was really his question. Do programs in moderation actually work as effectively to alter someone's entire life as does perhaps abstinence. Professor Johnson.

JOHNSONI think so. And I think that the evidence is pretty clear actually. There are a number that have been done. One of the important ones that have been done in the United States is a study called COMBINE, in which we have looked at even the rates of heavy drinking and how heavy drinking is related to outcomes -- social outcomes. How many times do you get into a DWI? How many times do you have a fight? Whether you keep your job or not. And in fact, some of the new research coming out shows that the reduction in heavy drinking may actually be even a more powerful barometer than even complete abstinence in some cases.

JOHNSONAnd that's because there is a gulf in terms of a difference, when somebody's reducing drinking, between their lifestyle at that point and the time point when they're drinking very minimum amounts. So the research actually shows that heavy drinking or reductions in heavy drinking is actually a very powerful endpoint. And people do change their lives. You know, we talked about people drinking 60 to 80 drinks a week. How about people drinking almost 60 drinks a day? And if you take that person down to drinking half a glass of wine a day or half a drink a day, I can assure you their lives are dramatically different.

REHMAll right. I want to go down to Brian in Valdosta, Ga. Hi, you're on the air.

BRIANYeah, thank you for the topic, Diane. One that's kind of dear and near to my heart. Kind of somewhat on the lines of the last caller. What I haven't heard is that it's really all about a psychic change. And I've been sober in AA for ten years now and I'm not, you know, beating the drum here for AA is the only reason. But I'm not hearing how important that is. You know, there's the term sobriety, which we think of not being drunk, and then there's what we talk about as being sober, which really entails that not, you know, changing your ways. It took me...

WILKENSSo what...

BRIAN...three and a half years of not drinking to somewhat consider myself sober. So, just not hearing anything like that. Thank you.

REHMAll right. Thank you, Brian. How about that Gabrielle?

GLASERWell, I'm, thank you, because I think it's really important to detail how people's lives change once they have more time in which they're not inebriated. And many of my sources, many of the people I've spoken to -- and again this is anecdotal, but it is backed up by research -- and Carrie talks about something called competitive behaviors. Once people stop drinking themselves into oblivion, typically at night, they have a lot more time to do things like read or play music or cook. I have one woman who actually discovered that she really had missed bird watching.

GLASERAnd she had bird watched as a child, as a Girl Scout. And once she stopped drinking to excess every night, she became very involved in her local Audubon Society and began bird watching in the evenings in California. And it's that kind of thing that I think may not be as dramatic. That story isn't as dramatic as someone who's stopped drinking forever. This particular woman stopped drinking so much. She drinks maybe on the weekends now. You know, a couple of drinks on Friday night. Maybe a drink or two on Saturday night.

GLASERAnd that's not as dramatic a story as saying, okay, I've been sober for 19 years or sober for 10 years, which is -- and it's not to take away from the drama and achievement that that is.

REHMAll right. And...

WILKENSCan I weigh in for one second?

REHMSure.

JOHNSONCan I -- can I get...

REHMGo ahead, Carrie.

WILKENSWell the -- also, the cognitive behavioral strategies what use and something called community reinforcement -- it really is all focused on building the person's life up, right? You've got to really help them enrich their work life, their family life. Teaching them better communication skills. Teaching them how to take care of their bodies in a different way. Figuring out how to find other connections in their community, whether that be their church, their local yoga class, an AA meeting.

WILKENSYou know, really saying to them, look, if you're going to take the substance out of your life, you've got to put other things in that are meaningful and enriching and tether you to wanting to feel better and not drift back towards your substance use. So that's actually the primary thing that we're talking about all the time with clients.

REHMProfessor Johnson.

JOHNSONI think that there have been a lot of important things said. But I really want to come back to a couple of things. One is the importance of personal change. One of the pieces of research that I did was giving what's called a brief intervention. This is only 15 minutes per week -- 15 minutes per week. And if you look at when individuals start to reduce their heavy drinking, as some of your guests have said, they do develop more time. And they tend to recover on their own.

JOHNSONIn fact, one of the things that we found in a study called COMBINE is sometimes, if you throw everything at someone -- family therapy, home therapy, cognitive therapy -- it's almost like giving them an overdose of a medication. And sometimes those individuals do very poorly. When we did COMBINE -- project COMBINE -- the individuals who basically had only all of that actually fared the worst in terms of treatment. And that makes sense. That doesn't mean that psychological tools are not important. It means that they are very important.

JOHNSONAnd it's like a dose of medication. It has to be titrated properly. And the right amount needs to be given to the right patient.

REHMAnd...

JOHNSONAnd this comes back to individualized care.

REHMAnd you take me to the very next question, an email from Mary. "What are the side-effects of the most effective drugs? Gabrielle.

GLASERFrom what I understand, and Dr. Johnson can speak to this a little bit too, but from what I understand, they're relatively safe drugs and have less liver toxicity than some of the more commonly prescribed medications that Americans take in great numbers, such as Lipitor and some of the statin drugs. They may cause headaches, I understand. And I think some people feel a little bit queasy. But they're not unbearable side effects from what I understand.

REHMWhat about that, Professor Johnson?

REHMWell, the drugs range in with different side effects. I mean, naltrexone has side effects on liver -- on the liver. It can produce liver toxicity in very high dosages. You know, drugs that are off-label like Topiramate can actually provide you -- make you a little ataxic, which may make you a little groggy and a little slowed down. But there are some other drugs that we have been looking at. One is Ondansetron, which is -- a very, very low dose of Ondansetron -- which actually targets a molecular abnormality in the person -- or a molecular variance is probably more accurate, and provides a very specific treatment.

JOHNSONAnd in those individuals -- I'll just get to -- in those individuals, the dose of Ondansetron is so low that the placebo has more side effects than the drug.

REHMWell, here's what I was going to ask, is if there is a genetic component here, does that mean that one may be born with a tendency toward alcoholism?

JOHNSONSuper question. Absolutely. And in my view, those people -- we're developing new knowledge and identifying those individuals. And those individuals may benefit from specific treatments, just like some people with specific cancers can be treated with specific drugs. And I think to not identify those people and simply not give them a drug is really a huge disservice to medical treatment.

REHMAnd you're listening to "The Diane Rehm Show." Let's take a caller. Here, in Washington D.C., Karen, you're on the air.

KARENHi. Thanks for taking my call.

REHMSure.

KARENI -- we had talked a little bit earlier about underlying psychiatric illnesses like PTSD. And I know that oftentimes people with alcoholism, either prior to becoming alcoholic or maybe as part of the consequences of what happens in their lives, to develop things like depression. And I was wondering what the importance is of treating underlying effective disorders and whether the focus should be on getting, like, the depression treated first or the trauma, before addiction? Or if it's still the case that it's important to treat the alcoholism first?

REHMCarrie, do you want to respond?

WILKENSSure. I think you have to be able to treat them in tandem. I mean, they're mutually affecting each other, right? I mean, sometimes people will drink in response to an underlying, you know, mental health issue. And then sometimes the -- what looks like a mental health issue is actually being caused by their substance use. So you've really got to be able to look at both and kind of really track what's causing what and help the person change their behaviors. And you do have to treat the underlying problem.

WILKENSI can't tell you how many times I've worked with somebody who has been to multiple rehabs and multiple treatment programs and, you know, they have a very serious social-anxiety disorder. They can't sit in AA meetings. Or they have PTSD, they have panic and don't feel safe with people. And they have a very hard time utilizing treatment. You have to treat those things, you know, for them to really be able to engage in substance-use treatment.

REHMAll right.

WILKENSSo I think you've got to do both.

REHMOkay. And finally, in the few moments we have left, with the awareness -- growing awareness that these kinds of treatment options are available, why do you think it is that Americans are not demanding these new treatments? Professor Johnson.

JOHNSONAnother super question. And I don't know. It's actually very frustrating. You know, sometimes we all come on to these shows. We believe a lot of people are listening and getting educated. But who's really listening? When is there going to be a group of people who are going to demand modern treatments with proper outcomes? And hospitals and treatment centers have to report their true outcomes.

JOHNSONSo I think that, in the United States, it's going to actually come to a time when somebody actually probably will take some kind of legal action. And somebody's going to say, well, I didn't get good treatment. And therefore, where are the other people who got poor treatment? And we need a change.

REHMBeth, what do you think?

KANE-DAVIDSONI will say, I think we are doing good treatment across the country. We do have dual-diagnosis programs. Gone are the days where it's, oh, you got to just focus on your addiction. And then, when you're sober for, you know, a year, you can deal with depression and anxiety. We're not doing that any more. We are really comprehensively looking at the individual and looking at medications and prescribing medications and looking at different techniques.

REHMAll right. And Carrie, to you.

WILKENSI think things are changing. It's been slow. So I just, I'm grateful for shows like this where people hopefully will just keep having more dialog about their own experiences and what's been helpful to them. And I wish more people who have moderated or had problems and gone back to moderation or, you know, found another way through this problem, would be more vocal. Because I think those -- they tend to be pretty quiet and not talk about their experiences.

REHMAnd Gabrielle, lastly to you, for just a few seconds.

GLASERWell, I think with the Affordable Care Act now demanding coverage or calling for coverage for addictions as well as mental health, people are going to start demanding far more science-based alternatives, and insurance companies will as well. So there's -- that's certainly one outcome that we can...

REHMAll right. Thank you all so much. Gabrielle Glaser, journalist, author of the book "Why Women Drink -- And How They Can Regain Control." Carrie Wilkens, she's at the Center for Motivation and Change. Beth Kane-Davidson at Suburban Hospital. Dr. Bankole Johnson at the University of Maryland School of Medicine. Thank you all.

WILKENSThank you very much.

JOHNSONThank you.

REHMAnd thanks for listening, all. I'm Diane Rehm.