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C U L T U R E & I D E A S
The
Drinking Dilemma
By
calling abstinence the only cure, we ensure that the
nation’s $100 billion alcohol problem won’t
be solved
by
NANCY SHUTE
“Would
you like something to drink?” the waitress asks Elisa
DeCarlo as she plops into a chair in an Asian restaurant
on Manhattan’s Upper West Side. DeCarlo, a 37-year-old
actress, would love something to drink. She has just finished
a performance of her one-woman show at an off-Broadway theater.
Only a dozen people showed up, and they laughed in the wrong
places. After a show, when she is thirsty and wound up,
is the time she loves a drink most.
“Nothing
at the moment, thank you,” DeCarlo says, reaching
for a water glass and draining it. She drinks two more glasses
of water and waits for the food to arrive before ordering
a good French pinot blanc. By the end of the night, she’s
had three glasses of wine; more than her usual two, but
still within the limits of Moderation Management, the controlled-drinking
self-help program she has followed for the past 16 months.
A self-described problem drinker who used to pound down
so much booze after a show she felt lousy the next morning,
she had checked out Alcoholics Anonymous but was put off
by the group’s famous first step: “We admitted
we were powerless over alcohol-that our lives had become
unmanageable.”
“If
you choose to overdrink, you choose to overdrink and you
know it,” DeCarlo says. She was happily married; she
had published two novels; she toured nationally. She didn’t
feel that her life was unmanageable, just that alcohol was
taking up too much of it. Following Moderation Management
guidelines, she quit drinking for 30 days and now takes
no more than nine drinks a week, no more than three a day,
and never drinks and drives. (The guideline’s limit
for men is 14 drinks a week, four on any given day.) “It’s
really a nice feeling to know I can have a drink and stop
and feel fine the next day,” she says. “It’s
made a tremendous difference. My life is too interesting
to mess it up with a drinking problem.”
DeCArlo’s strategy is, depending on how you look at
it, either the best hope for problem drinking in America
or the most threatening form of self-delusion. She and other
imbibers experimenting with controlled-drinking programs
around the country have innocently stumbled into the most
hotly contested issue in alcohol treatment: whether cutting
back, as opposed to total abstinence, is an option for some
people who drink too much.
Narrow path. There are 40 million problem
drinkers in the United States-people whose drinking causes
economic, physical, or family harm but who are not technically
alcoholic (defined as being physiologically dependent on
alcohol). But for the past six decades, beginning shortly
after Prohibition was repealed in 1933, treatment for drinking
problems in this country has focused almost exclusively
on alcoholics, has offered abstinence as the sole cure for
their problems, and has laid just two paths to that cure:
Alcoholics Anonymous, the spiritual self-help group founded
in 1935; and a variety of related 12-step programs, originally
developed at the Hazelden Foundation and other Minnesota
clinics in the 1950s, which combine psychological and peer
counseling and AA attendance. (AA is the granddaddy of 12-step
programs, but the two approaches are not synonymous. AA
is a self-help group aimed at sobriety and spiritual renewal;
12-step alcohol-treatment programs adopt some of AA’s
tenets but include a wide array of secular treatments, from
psychotherapy to acupuncture.)
A U.S. News reporter, querying a dozen treatment centers
about her options as someone concerned about her drinking,
was offered only abstinence-based programs. The Mayo Clinic
told her she was welcome to try cutting back on her own
and then to come back if she failed. At the Betty Ford center,
a kindly woman answering the phone said, “For people
like us, one drink always leads to another. You may be functional
now, but it’s progressive.”
The problem with that advice is that for many people it’s
not true. For at least the past decade, researchers have
known that the majority of people who drink heavily don’t
become alcoholics; some experts place that number as high
as 75%. Other drinkers may meet the clinical criteria for
alcohol dependence but can sustain controlled drinking for
months, even years, before getting into trouble. And the
majority of people who cut back or quit drinking do so on
their own. Many of those people binge drank in their 20s
at college parties, at after-work happy hours, or during
Sunday afternoon football games, then got a good job, got
married, got busy, and lost interest in getting smashed.
In the researchers’ lingo, they “matured out.”
Moreover, alcoholism cannot be blamed for the majority of
social ills linked to drinking in this country. Misuse of
alcohol costs the nation dearly-$100 billion a year in quantifiable
costs, in addition to untold emotional pain. Yet the bulk
of those costs are incurred not by alcoholics but by problem
drinkers, who are four times more numerous than alcoholics,
are more active in society, and usually reject abstinence
as a solution. Alcohol figures in 41 percent of traffic
crash fatalities and is a factor in 50 percent of homicides,
30 percent of suicides, and 30 percent of accidental deaths.
(Last week, a 20-year-old Louisiana State University student
drank himself to death during fraternity pledge week; three
other students were hospitalized.) Heavy drinking also increases
the risk of cancer, heart disease, and stroke, long before
people have to worry about cirrhosis of the liver, brain
damage, or other skid-row ailments. A 1990 report by the
Institute of Medicine, an arm of the National Academy of
Sciences, concluded that the harmful consequences of alcohol
could not be reduced significantly unless more options were
offered to people with only “mild to moderate”
alcohol problems.
Threats and firings. Public health experts
recognized the social costs of alcohol abuse long ago and
have responded with programs such as free soft drinks for
designated drivers and free taxi rides home on New Year’s
Eve. But because of deeply held beliefs in the American
alcohol-treatment community, this kind of pragmatic, public-health-centered
approach has rarely been applied to individuals with drinking
problems. Europe, Great Britain, and Australia long ago
defined problem drinking as a public health concern and
have established controlled-drinking programs to reduce
its physical harm and social costs. Forty-three percent
of Canadian treatment programs deem moderate drinking acceptable
for some clients.
But in the United States, researchers and counselors who
have championed-or even tried to investigate-moderation
as a treatment strategy have been threatened, sometimes
fired. “We’ve been accused of murder. That we’re
all in denial. That we’re enablers,” says Alan
Marlatt, a professor of psychology and moderate-drinking
proponent who is director of the University of Washington’s
Addictive Behaviors Research Center.
A big part of the problem is that it’s hard to draw
a clear line between alcohol dependency and problem drinking.
According to a 1996 report by the University of Connecticut’s
Alcohol Research Center, 20 percent of American adults are
problem drinkers, compared with 5 percent who are alcohol
dependent. The National Institute on Alcohol Abuse and Alcoholism,
using much stricter criteria, puts the numbers at 3 percent
alcohol abusers, 1.7 percent alcohol dependents, and 2.7
percent drinkers who exhibit characteristics of both. (Discrepancies
in alcohol statistics abound.)
Briefly put, problem drinkers are people who have had problems
because of drinking (a DUI arrest, marital discord, showing
up late to work). But they usually don’t drink steadily
and don’t go through withdrawal when they stop. By
contrast, someone who is alcohol dependent (the medically
preferred term for alcoholic) exhibits at least three of
the following symptoms: tolerance, withdrawal; an inability
to cut down; sacrificing work, family or social events to
drink; devoting a lot of time to finding and consuming alcohol;
or persistence in drinking despite related health problems.
Even so, the distinctions leave plenty of diagnostic wiggle
room. The medical-and alcohol-treatment communities in the
United States have dealt with this ambiguity by applying
to all drinkers the advice appropriate for the most severe
afflicted: abstinence. Any other strategy, they feel, is
too risky. “Every alcoholic would like to drink moderately,”
says Douglas Talbot, a physician and president of the American
Society of Addiction Medicine. “Ninety percent have
tried. This just feeds into the denial of the alcoholic.”
Moderate-drinking proponents concede that some alcoholics
will seize upon controlled drinking as an excuse to avoid
abstinence. But they say that they explicitly warn that
the strategy is not for alcoholics, only for people with
less severe drinking problems; that tests can evaluate the
intensity of difficulties; and that they regularly refer
dependent drinkers to AA. Controlled drinking, says Marc
Kern, a Los Angeles psychologist, can “reduce harm”
by reducing alcohol consumption” and can propel people
who fail at moderation into abstinence.
Medical or moral? America’s ambiva-lence
toward alcohol is long standing. In the early days of the
republic, we were a nation of lushes. Per capita consumption
of alcohol was three times today’s. The first temperance
effort, led by Philadelphia physician Benjamin Rush in the
1780s, prescribed moderation: Rush urges people to switch
from rum and gin to the more salubrious beer and wine.
Temperance soon moved from the doctor’s office to
the church. In 1826, the Rev. Lyman Beecher galvanized the
movement with his Six Sermons on Intemperance, which hold
that alcohol was a poison and that abstinence was the only
answer. “This is the way to death!” Beecher
said of the drinking life. Ever since, the nature of alcohol
abuse has been debated, the arguments often mixing the medical
and the moral. Is it a bad habit, a matter of will, or a
disease?
The medical model that has dominated alcohol treatment for
more than a half century holds that alcohol dependence is
an ailment with biological and genetic roots. Recent research
suggests there is a genetic predisposition toward alcoholism;
identical twins, for instance, are more apt to share a drinking
problem than fraternal twins, and adopted children whose
birth parents were alcoholics are four times likelier than
children adopted from nonalcoholic homes to become alcohol
dependent. This disease approach is challenged by behaviorists,
the primary advocates of controlled drinking, who say alcohol
abuse is a behavior influenced by psychological, cultural,
and environmental forces, not just physiology.
Science has yet to come up with enough information to resolve
the disease vs. behavior argument. Odds are that alcohol
abuse will prove to be a combination of both, the behavioral
factors dominating in problem drinkers and biological factors
weighing more heavily in people who are physically addicted.
But in the meantime, the disease and behavior camps have
been warring as if the evidence were absolute. A 1976 Rand
report saying that a very small number of alcoholics successfully
moderate their drinking was fiercely attacked. “It
was like desecrating the alter,” says Frederick Glasser,
a psychiatrist at East Carolina University School of Medicine
in Greenville, N.C., who was a researcher at the time. Mark
and Linda Sobell, two psychologists who in the 1970s published
similar findings, were accused of faking their results and
were hauled up before a congressional committee. The Sobells
were later vindicated.
Just say whoa! Though most people in the
mainstream treatment community hold tightly to the disease
concept of alcoholism, the treatment they offer is based
on a combination of folklore and personal experience rather
than on science. As Robin Room, a Canadian sociologist who
is critical of American alcohol treatment, asks: “What
kind of field is it that claims [alcoholism is] a disease,
but the treatment is nonmedical?” Enoch Gordis, director
of the NIAAA, wrote in 1987 of the nation’s $3.8 billion
alcohol-treatment effort: “In the case of alcoholism,
our whole treatment system…is founded on hunch, not
evidence, and not on science.”
A decade later, quality still varies widely, and anyone
seeking solid data on what treatments work best is justified
in feeling confused. In a comprehensive 1995 review of the
effectiveness of treatment programs, New Mexico psychologists
Reid Hester and William Miller concluded that, even for
people with severe drinking problems, behavioral treatments
(such as brief interventions, contracts governing drinkers’
conduct, and coping-skills training) worked significantly
better than the fare routinely offered by 12-step programs:
group psycho-therapy, educational lectures, confrontational
counseling, and referral to AA. The gap between those treatments
shown to be effective and those that are widely used, they
found, “Could hardly be larger if one intentionally
constructed treatment programs from those approaches with
the least evidence of efficacy.” But the researchers
cautioned that their analysis was a “first approximation,”
because the quality of the studies surveyed was uneven.
Not for everyone. Analyzing the effectiveness
of Alcoholics Anonymous is even more difficult because of
the nature of the organization. The self-help group keeps
no membership records and does not participate in research.
“We’re not treatment,” says Valerie O.,
an AA member who answered the phone in the group’s
New York office. “We just sit there and tell our stories
to anyone who asks.” Only three trials of AA’s
effectiveness have been performed, and all three used drunk
drivers and others forced to attend the program, which violates
the group’s creed of voluntary membership. None of
these trials rated AA as more effective than alternatives.
In a 1990 survey, 65 percent of AA members said they had
been sober for a year or more; the survey also found that
the majority of people who start AA drop out within a year.
When AA works, it works extraordinarily well: The testimonies
of lives saved by AA are legion. But it’s not for
everyone.
Because alcohol treatment is so unscientific, some of the
most basic and effective standards of care are ignored.
Instead of adhering to the stepped-care protocol employed
in other areas of medicine-where the least invasive treatment
is used first-alcohol treatment starts with its most drastic
remedy: lifetime abstinence, meetings, and, until recently,
a 28-day residential stay in a substance-abuse clinic. As
a result, many people who need help don’t seek it.
Others try AA but feel it doesn’t meet their needs.
That’s what happened to Moderation Management founder
Audry Kishline. In her 20s, she was drinking five or six
glasses of wine a night, drinking alone, drinking and driving.
Diagnosed as an alcoholic, she was sent to detoxification,
to residential treatment, and to AA. But Kishline didn’t
feel she had been alcohol dependent: She had no withdrawal
symptoms, and she found it easy to abstain for months. She
started researching alcohol treatment, and was outraged
to find that alternatives common in Europe were never even
mentioned here. “the public’s not getting the
full story,” Kishline says. Now 40, married and raising
two children, she occasionally has a glass of wine with
dinner. Had she initially been offered less drastic treatment,
Kishline believes, she would have reached this point of
temperance years sooner.
Other veterans of the treatment system object to AA’s
explicitly spiritual focus, a reliance on God or a “higher
power” that permeates many 12-step programs as well.
Last year, the New York State Court of Appeals ruled that
prisoners are constitutionally protected from being forced
to participate in AA because of its religious orientation.
Similar rulings have been made in California and other states.
And several abstinence-based self-help groups, including
Rational Recovery, Secular Organizations for Sobriety, and
SMART Recovery Self-Help Network, have been founded by people
critical either of AA’s spiritual focus or the belief
that they are powerless against alcohol.
Changing times. Gradually, however, the
alcohol-treatment portfolio is diversifying. After expanding
wildly in the 1970s and 1980s, residential 12-step programs
are falling on hard times: Insurers and employers pressed
by rising health care costs, find little benefit to justify
the programs’ considerable expense and are seeking
cheaper, less intensive alternatives. Alcohol-treatment
research is moving slowly toward a more scientific, empirically
based approach. And a national trend away from heavy drinking-alcohol
consumption has fallen by 15 percent since 1980, parallel
declines in smoking and illegal drug use-makes it, oddly
enough, more acceptable to treat those with only mild alcohol
problems, not just Days of Wine and Roses – style
lushes.
Wisconsin offers a sense of what the future may hold. It
is a big drinking state; 25 percent of its residents say
they binge drink. “Every little town has a church
and a bar,” says Michael Fleming, a University of
Wisconsin Medical School family physician. “Most of
the patients in my practice drinking six drinks a day are
not alcoholics. But if we can get them to cut down from
six drinks to two, from a public-health perspective you’ve
made a huge impact.”
In April, Fleming published the first large U.S. study of
brief interventions for problem drinkers in the Journal
of the American Medical Association. The study, patterned
on research over the past 20 years in Great Britain and
Sweden, selected 774 problem drinkers from patients at 17
Wisconsin clinics. Half the patients met for 2 15-minute
sessions, one month apart, with their physicians, discussed
their current health behavior and the effects of alcohol,
and signed a prescription-like drinking contract. A year
later, the men had reduced their alcohol use by 14 percent;
the women by 30 percent. (women are usually more successful
than men at moderating.) The control group also reduced
its drinking, but the brief intervention group was twice
as likely to reduce it by 20 percent or more.
Other promising research is coming from Seattle, where University
of Washington psychologist Marlatt is working with a notoriously
immoderate population-college students. For the past seven
years, he has followed 350 students who were identified
while still in high school as high-risk drinkers. A year
after half the students were given a one-hour, one-on-one
educational session in their freshman year, 80 percent had
reduced binge drinking substantially. Those who didn’t
were given more education and counseling with the intensity
escalating each year. “It’s a harm-reduction
approach,” Marlatt says, using a phrase more often
applied to needle exchanges and other drug-abuse programs.
“With young people, if you only offer abstinence,
they’re not going to sign up.”
Another brief intervention program, offered to adults by
the University of Michigan Medical Center’s DrinkWise
program, is patterned on one developed at Toronto’s
Addiction Research Foundation. DrinkWise offers four one-hour
educational counseling sessions in person or by phone, with
three-and nine-month follow-up calls, for $495. East Carolina
University will launch its own DrinkWise program later this
year.
Many people enter alcohol treatment not by choice but by
court order for drunk driving and other offenses. They,
too, are beginning to gain a few more options. Last year
California ruled that Los Angeles County does not have to
require offenders to attend an abstinence-based self-help
group, making room for Moderation Management as a legal
alternative to AA.
But these groups are still gnats compared to the elephant
of AA. Moderation Management has just 50 volunteer-run groups;
AA has an estimated 1.2 million members in the nation. Only
8 to 10 people show up for the weekly Manhattan meeting
of MM, which Eliza DeCarlo runs. “We’re like
booze revolutionaries,” she says cheerfully.
There’s reason to hope today’s revolutionaries
will get a more open hearing than their predecessors: The
NIAAA, along with other federal agencies, is increasing
funding for different alcohol treatments. Someday, perhaps,
controlled drinking programs will be as commonplace as Weight
Watchers and Smokenders, and problem drinking will be recognized
as a $100 billion public-health problem requiring solutions
as varied and complex as our long, tempestuous relationship
with alcohol.
(Source:
U.S. News & World Report, Sept. 8, 1997)
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