For a glimpse of how treatment works elsewhere, I traveled to Finland, a country that shares with the United States a history of prohibition (inspired by the American temperance movement, the Finns outlawed alcohol from 1919 to 1932) and a culture of heavy drinking.
Finland’s treatment model is based in large part on the work of an American neuroscientist named John David Sinclair. I met with Sinclair in Helsinki in early July. He was battling late-stage prostate cancer, and his thick white hair was cropped short in preparation for chemotherapy. Sinclair has researched alcohol’s effects on the brain since his days as an undergraduate at the University of Cincinnati, where he experimented with rats that had been given alcohol for an extended period. Sinclair expected that after several weeks without booze, the rats would lose their desire for it. Instead, when he gave them alcohol again, they went on week-long benders, drinking far more than they ever had before—more, he says, than any rat had ever been shown to drink.
Sinclair called this the alcohol-deprivation effect, and his laboratory results, which have since been confirmed by many other studies, suggested a fundamental flaw in abstinence-based treatment: going cold turkey only intensifies cravings. This discovery helped explain why relapses are common. Sinclair published his findings in a handful of journals and in the early 1970s moved to Finland, drawn by the chance to work in what he considered the best alcohol-research lab in the world, complete with special rats that had been bred to prefer alcohol to water. He spent the next decade researching alcohol and the brain.
Sinclair came to believe that people develop drinking problems through a chemical process: each time they drink, the endorphins released in the brain strengthen certain synapses. The stronger these synapses grow, the more likely the person is to think about, and eventually crave, alcohol—until almost anything can trigger a thirst for booze, and drinking becomes compulsive.
The Finns are famously private, so I had to go early in the morning, before any patients arrived, to meet Jukka Keski-Pukkila, the CEO. He poured coffee and showed me around the clinic, in downtown Helsinki. The most common course of treatment involves six months of cognitive behavioral therapy, a goal-oriented form of therapy, with a clinical psychologist. Treatment typically also includes a physical exam, blood work, and a prescription for naltrexone or nalmefene, a newer opioid antagonist approved in more than two dozen countries. When I asked how much all of this cost, Keski-Pukkila looked uneasy. “Well,” he told me, “it’s 2,000 euros.” That’s about $2,500—a fraction of the cost of inpatient rehab in the United States, which routinely runs in the tens of thousands of dollars for a 28-day stay.