On the Social Contract, Part 2

     Recently, I suggested the social contract underlying Big Medicine has come unraveled and suggested we in medicine needed to answer three questions. First, what do we currently do that represents a real improvement in the lives of our people? Second, how can we make these items available to everyone at a cost that is sustainable? Third, how do we expand our and the public’s understanding that healthcare is more than what occurs inside the walls of the hospital or clinic?

     Rather than starting off with a list of “successes,” I want to focus on an area where we have not been notably successful: substance abuse.

     “Although AA is well-known and used by millions around the world, mental health professionals are sometimes skeptical of its effectiveness,” Humphreys said.
Psychologists and psychiatrists, trained to provide cognitive behavioral therapy and motivational enhancement therapy to treat patients with alcohol-use disorder, can have a hard time admitting that the lay people who run AA groups do a better job of keeping people on the wagon.” 1

     This report to the public was based upon a Cochrane Database Review by Keith Humphreys, PhD, of Stanford University School of Medicine, who noted that early in his career he thought: “How dare these people do things that I have all these degrees to do?”
Now, he thought his job was to prepare patients to pursue an AA program.

     “AA works because its based on social interaction, Humphreys said, noting that members give one another emotional support as well as practical tips to refrain from drinking. "If you want to change your behavior, find some other people who are trying to make the same change" he said.

     One area of controversy, though, is how successful are AA programs at helping members achieve sobriety? In a review published in 2009, Kaskutas found good evidence that: 2

     “Rates of abstinence are about twice as high among those who attend AA; higher levels of attendance are related to higher rates of abstinence; these relationships are found for different samples and follow-up periods; and prior AA attendance is predictive of subsequent abstinence.”

     The abstinence rate at 12 and 18 months with no therapy or follow up was found to be 20-25%, which implies that even with active participation and attendance, somewhere up to half of patients will maintain abstinence. Addiction specialists would point out that
abstinence is a prelude to sobriety, but sobriety requires serious reordering of “stinking thinking” that characterizes addiction. This requires a great deal of time and individual effort. And, as my friends who are ardent believers in AA will point out, a relapse is a
common part of recovery, need not be permanent and need not indicate failure. So, defining “success” is not straight forward nor easy to measure.

     What about opioid use disorder, which may or may not be different from alcohol addiction? Here the issue has become use of Suboxone® (buprenorphine and naloxone) for maintenance therapy.

     “Among addicts and addiction experts alike, the practice of using Suboxone for maintenance therapy is a hotly contested issue. And, in truth, both sides of the argument have valid points. For example, Suboxone supporters believe that long-term buprenorphine treatment is a much better alternative to turning to a life of
crime, unemployment, poverty and dope-sickness. Some even say Suboxone helps to stave off the chronic depression that often follows detox. On the other hand, most people who oppose Suboxone say that prolonged use of the drug brings about potentially devastating results … both physically and mentally. For this group, Suboxone is nothing short of a looming disaster speeding toward the addiction
community.” 3

     Again, there are few studies, but those that have been done suggest about half of participants maintain therapy and avoidance of other opioids at one year, whereas somewhat less than 10% maintain abstinence off therapy.

     What no one disputes—addiction is disruptive to both the individual and the family of the person afflicted, often through subsequent generations, so the need for effective therapies is important. But as AA programs emphasize, treatment must include the addict and his support system, who are likely co-dependent in maintaining the addiction. Here is yet another area where we in medicine have little to offer, even if insurance would pay for it.

     In the context of the social contract argument we are started with, we in medicine need to recognize and admit to our hubris and understand the limits of the medical and “scientific” model. While labeling addiction as a disease may have lessened some of the
social stigma attached to being addicted, we need to explore and support other approaches that may, like AA, be difficult to study scientifically, but have success rates that are at least as good as medical therapy. And, of course, AA is vastly cheaper than individual
psychotherapy.

2 August 2025


1 Erickson, M. Alcoholics Anonymous Most Effective Path to Alcohol Abstinence. 11 March 2020.
https://med.stanford.edu/news/all-news/2020/03/alcoholics-anonymous-most-effective-path-to-alcohol-
abstinence.html. Accessed 12 May 2025.

2 Kaskutas, LA. Alcoholics Anonymous Effectiveness: Faith Meets Science. J Addict Med 2009;28(2):145-157.
doi:10.1080/10550880902772464.

3 https://drugabuse.com/blog/suboxone-debate-dont-rehabs-use-buprenorphine/. 22 April 2024. Accessed
12 May 2025.

Further Reading

A Season for Everything
Maybe it is time to rediscover the art of medicine.

Beyond Evidence-Based Medicine

On the Social Contract, Part 1
Critics of Big Medicine cite mortality statistics where the US is worse than most other advanced countries. We often blame diseases of despair, but a recent retrospective analysis shows survival in the richest US quartile is about the same as the poorest Northern and Western European quartile.

Seasons
Seasons are a part of life and we seem to be in both astronomical and sociological winter, so we should expect hazardous driving conditions in both areas.

The Limits of the Medical Model