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 and stop and feel fine the next day,” she says. waitress asks Elisa DeCarlo as she plops into a “It’s made a tremendous difference. My life is too chair in an Asian restaurant on Manhattan’s interesting to mess it up with a drinking Upper West Side. DeCarlo, a 37-year-old problem.” actress, would love something to drink. She has DeCArlo’s strategy is, depending on how just finished a performance of her one-woman you look at it, either the best hope for problem show at an off-Broadway theater. Only a dozen drinking in America or the most threatening form people showed up, and they laughed in the of self-delusion. She and other imbibers wrong places. After a show, when she is thirsty experimenting with controlled-drinking programs and wound up, is the time she loves a drink around the country have innocently stumbled most. into the most hotly contested issue in alcohol “Nothing at the moment, thank you,” treatment: whether cutting back, as opposed to DeCarlo says, reaching for a water glass and total abstinence, is an option for some people draining it. She drinks two more glasses of water who drink too much. and waits for the food to arrive before ordering a Narrow path. There are 40 million good French pinot blanc. By the end of the night, problem drinkers in the United States-people she’s had three glasses of wine; more than her whose drinking causes economic, physical, or usual two, but still within the limits of Moderation family harm but who are not technically alcoholic Management, the controlled-drinking self-help (defined as being physiologically dependent on program she has followed for the past 16 alcohol). But for the past six decades, beginning months. A self-described problem drinker who shortly after Prohibition was repealed in 1933, used to pound down so much booze after a treatment for drinking problems in this country show she felt lousy the next morning, she had has focused almost exclusively on alcoholics, checked out Alcoholics Anonymous but was put has offered abstinence as the sole cure for their off by the group’s famous first step: “We problems, and has laid just two paths to that admitted we were powerless over alcohol-that cure: Alcoholics Anonymous, the spiritual selfour lives had become unmanageable.” help group founded in 1935; and a variety of “If you choose to overdrink, you choose related 12-step programs, originally developed to overdrink and you know it,” DeCarlo says. at the Hazelden Foundation and other She was happily married; she had published two Minnesota clinics in the 1950s, which combine novels; she toured nationally. She didn’t feel that psychological and peer counseling and AA her life was unmanageable, just that alcohol was attendance. (AA is the granddaddy of 12-step taking up too much of it. Following Moderation programs, but the two approaches are not Management guidelines, she quit drinking for 30 synonymous. AA is a self-help group aimed at days and now takes no more than nine drinks a sobriety and spiritual renewal; 12-step alcoholweek, no more than three a day, and never treatment programs adopt some of AA’s tenets drinks and drives. (The guideline’s limit for men but include a wide array of secular treatments, is 14 drinks a week, four on any given day.) “It’s from psychotherapy to acupuncture.) really a nice feeling to know I can have a drink

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A U.S. News reporter, querying a dozen were offered to people with only “mild to treatment centers about her options as someone moderate” alcohol problems. concerned about her drinking, was offered only Threats and firings. Public health abstinence-based programs. The Mayo Clinic experts recognized the social costs of alcohol told her she was welcome to try cutting back on abuse long ago and have responded with her own and then to come back if she failed. At programs such as free soft drinks for designated the Betty Ford center, a kindly woman drivers and free taxi rides home on New Year’s answering the phone said, “For people like us, Eve. But because of deeply held beliefs in the one drink always leads to another. You may be American alcohol-treatment community, this kind functional now, but it’s progressive.” of pragmatic, public-health-centered approach The problem with that advice is that for has rarely been applied to individuals with many people it’s not true. For at least the past drinking problems. Europe, Great Britain, and decade, researchers have known that the Australia long ago defined problem drinking as a majority of people who drink heavily don’t public health concern and have established become alcoholics; some experts place that controlled-drinking programs to reduce its number as high as 75%. Other drinkers may physical harm and social costs. Forty-three meet the clinical criteria for alcohol dependence percent of Canadian treatment programs deem but can sustain controlled drinking for months, moderate drinking acceptable for some clients. even years, before getting into trouble. And the But in the United States, researchers and majority of people who cut back or quit drinking counselors who have championed-or even tried do so on their own. Many of those people binge to investigate-moderation as a treatment drank in their 20s at college parties, at after- strategy have been threatened, sometimes fired. work happy hours, or during Sunday afternoon “We’ve been accused of murder. That we’re all football games, then got a good job, got married, in denial. That we’re enablers,” says Alan got busy, and lost interest in getting smashed. In Marlatt, a professor of psychology and the researchers’ lingo, they “matured out.” moderate-drinking proponent who is director of Moreover, alcoholism cannot be blamed the University of Washington’s Addictive for the majority of social ills linked to drinking in Behaviors Research Center. this country. Misuse of alcohol costs the nation A big part of the problem is that it’s hard dearly-$100 billion a year in quantifiable costs, in to draw a clear line between alcohol addition to untold emotional pain. Yet the bulk of dependency and problem drinking. According to those costs are incurred not by alcoholics but by a 1996 report by the University of Connecticut’s problem drinkers, who are four times more Alcohol Research Center, 20 percent of numerous than alcoholics, are more active in American adults are problem drinkers, society, and usually reject abstinence as a compared with 5 percent who are alcohol solution. Alcohol figures in 41 percent of traffic dependent. The National Institute on Alcohol crash fatalities and is a factor in 50 percent of Abuse and Alcoholism, using much stricter homicides, 30 percent of suicides, and 30 criteria, puts the numbers at 3 percent alcohol percent of accidental deaths. (Last week, a 20- abusers, 1.7 percent alcohol dependents, and year-old Louisiana State University student 2.7 percent drinkers who exhibit characteristics drank himself to death during fraternity pledge of both. (Discrepancies in alcohol statistics week; three other students were hospitalized.) abound.) Heavy drinking also increases the risk of cancer, Briefly put, problem drinkers are people heart disease, and stroke, long before people who have had problems because of drinking (a have to worry about cirrhosis of the liver, brain DUI arrest, marital discord, showing up late to damage, or other skid-row ailments. A 1990 work). But they usually don’t drink steadily and report by the Institute of Medicine, an arm of the don’t go through withdrawal when they stop. By National Academy of Sciences, concluded that contrast, someone who is alcohol dependent the harmful consequences of alcohol could not (the medically preferred term for alcoholic) be reduced significantly unless more options exhibits at least three of the following symptoms: tolerance, withdrawal; an inability to cut down;

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sacrificing work, family or social events to drink; biological and genetic roots. Recent research devoting a lot of time to finding and consuming suggests there is a genetic predisposition alcohol; or persistence in drinking despite toward alcoholism; identical twins, for instance, related health problems. are more apt to share a drinking problem than Even so, the distinctions leave plenty of fraternal twins, and adopted children whose birth diagnostic wiggle room. The medical-and parents were alcoholics are four times likelier alcohol-treatment communities in the United than children adopted from nonalcoholic homes States have dealt with this ambiguity by applying to become alcohol dependent. This disease to all drinkers the advice appropriate for the approach is challenged by behaviorists, the most severe afflicted: abstinence. Any other primary advocates of controlled drinking, who strategy, they feel, is too risky. “Every alcoholic say alcohol abuse is a behavior influenced by would like to drink moderately,” says Douglas psychological, cultural, and environmental Talbot, a physician and president of the forces, not just physiology. American Society of Addiction Medicine. “Ninety Science has yet to come up with enough percent have tried. This just feeds into the denial information to resolve the disease vs. behavior of the alcoholic.” argument. Odds are that alcohol abuse will Moderate-drinking proponents concede prove to be a combination of both, the that some alcoholics will seize upon controlled behavioral factors dominating in problem drinking as an excuse to avoid abstinence. But drinkers and biological factors weighing more they say that they explicitly warn that the heavily in people who are physically addicted. strategy is not for alcoholics, only for people with But in the meantime, the disease and behavior less severe drinking problems; that tests can camps have been warring as if the evidence evaluate the intensity of difficulties; and that they were absolute. A 1976 Rand report saying that a regularly refer dependent drinkers to AA. very small number of alcoholics successfully Controlled drinking, says Marc Kern, a Los moderate their drinking was fiercely attacked. “It Angeles psychologist, can “reduce harm” by was like desecrating the alter,” says Frederick reducing alcohol consumption” and can propel Glasser, a psychiatrist at East Carolina people who fail at moderation into abstinence. University School of Medicine in Greenville, Medical or moral? America’s ambiva- N.C., who was a researcher at the time. Mark lence toward alcohol is long standing. In the and Linda Sobell, two psychologists who in the early days of the republic, we were a nation of 1970s published similar findings, were accused lushes. Per capita consumption of alcohol was of faking their results and were hauled up before three times today’s. The first temperance effort, a congressional committee. The Sobells were led by Philadelphia physician Benjamin Rush in later vindicated. the 1780s, prescribed moderation: Rush urges Just say whoa! Though most people in people to switch from rum and gin to the more the mainstream treatment community hold tightly salubrious beer and wine. to the disease concept of alcoholism, the Temperance soon moved from the treatment they offer is based on a combination doctor’s office to the church. In 1826, the Rev. of folklore and personal experience rather than Lyman Beecher galvanized the movement with on science. As Robin Room, a Canadian his Six Sermons on Intemperance, which hold sociologist who is critical of American alcohol that alcohol was a poison and that abstinence treatment, asks: “What kind of field is it that was the only answer. “This is the way to death!” claims [alcoholism is] a disease, but the Beecher said of the drinking life. Ever since, the treatment is nonmedical?” Enoch Gordis, nature of alcohol abuse has been debated, the director of the NIAAA, wrote in 1987 of the arguments often mixing the medical and the nation’s $3.8 billion alcohol-treatment effort: “In moral. Is it a bad habit, a matter of will, or a the case of alcoholism, our whole treatment disease? system…is founded on hunch, not evidence, The medical model that has dominated and not on science.” alcohol treatment for more than a half century A decade later, quality still varies widely, holds that alcohol dependence is an ailment with and anyone seeking solid data on what

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treatments work best is justified in feeling clinic. As a result, many people who need help confused. In a comprehensive 1995 review of don’t seek it. Others try AA but feel it doesn’t the effectiveness of treatment programs, New meet their needs. Mexico psychologists Reid Hester and William That’s what happened to Moderation Miller concluded that, even for people with Management founder Audry Kishline. In her 20s, severe drinking problems, behavioral treatments she was drinking five or six glasses of wine a (such as brief interventions, contracts governing night, drinking alone, drinking and driving. drinkers’ conduct, and coping-skills training) Diagnosed as an alcoholic, she was sent to worked significantly better than the fare routinely detoxification, to residential treatment, and to offered by 12-step programs: group psycho- AA. But Kishline didn’t feel she had been alcohol therapy, educational lectures, confrontational dependent: She had no withdrawal symptoms, counseling, and referral to AA. The gap between and she found it easy to abstain for months. She those treatments shown to be effective and started researching alcohol treatment, and was those that are widely used, they found, “Could outraged to find that alternatives common in hardly be larger if one intentionally constructed Europe were never even mentioned here. “the treatment programs from those approaches with public’s not getting the full story,” Kishline says. the least evidence of efficacy.” But the Now 40, married and raising two children, she researchers cautioned that their analysis was a occasionally has a glass of wine with dinner. “first approximation,” because the quality of the Had she initially been offered less drastic studies surveyed was uneven. treatment, Kishline believes, she would have Not for everyone. Analyzing the reached this point of temperance years sooner. effectiveness of Alcoholics Anonymous is even Other veterans of the treatment system more difficult because of the nature of the object to AA’s explicitly spiritual focus, a reliance organization. The self-help group keeps no on God or a “higher power” that permeates membership records and does not participate in many 12-step programs as well. Last year, the research. “We’re not treatment,” says Valerie O., New York State Court of Appeals ruled that an AA member who answered the phone in the prisoners are constitutionally protected from group’s New York office. “We just sit there and being forced to participate in AA because of its tell our stories to anyone who asks.” Only three religious orientation. Similar rulings have been trials of AA’s effectiveness have been made in California and other states. And several performed, and all three used drunk drivers and abstinence-based self-help groups, including others forced to attend the program, which Rational Recovery, Secular Organizations for violates the group’s creed of voluntary Sobriety, and SMART Recovery Self-Help membership. None of these trials rated AA as Network, have been founded by people critical more effective than alternatives. In a 1990 either of AA’s spiritual focus or the belief that survey, 65 percent of AA members said they they are powerless against alcohol. had been sober for a year or more; the survey Changing times. Gradually, however, also found that the majority of people who start the alcohol-treatment portfolio is diversifying. AA drop out within a year. When AA works, it After expanding wildly in the 1970s and 1980s, works extraordinarily well: The testimonies of residential 12-step programs are falling on hard lives saved by AA are legion. But it’s not for times: Insurers and employers pressed by rising everyone. health care costs, find little benefit to justify the Because alcohol treatment is so programs’ considerable expense and are unscientific, some of the most basic and seeking cheaper, less intensive alternatives. effective standards of care are ignored. Instead Alcohol-treatment research is moving slowly of adhering to the stepped-care protocol toward a more scientific, empirically based employed in other areas of medicine-where the approach. And a national trend away from heavy least invasive treatment is used first-alcohol drinking-alcohol consumption has fallen by 15 treatment starts with its most drastic remedy: percent since 1980, parallel declines in smoking lifetime abstinence, meetings, and, until recently, and illegal drug use-makes it, oddly enough, a 28-day residential stay in a substance-abuse more acceptable to treat those with only mild

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alcohol problems, not just Days of Wine and says, using a phrase more often applied to Roses – style lushes. needle exchanges and other drug-abuse Wisconsin offers a sense of what the programs. “With young people, if you only offer future may hold. It is a big drinking state; 25 abstinence, they’re not going to sign up.” percent of its residents say they binge drink. Another brief intervention program, “Every little town has a church and a bar,” says offered to adults by the University of Michigan Michael Fleming, a University of Wisconsin Medical Center’s DrinkWise program, is Medical School family physician. “Most of the patterned on one developed at Toronto’s patients in my practice drinking six drinks a day Addiction Research Foundation. DrinkWise are not alcoholics. But if we can get them to cut offers four one-hour educational counseling down from six drinks to two, from a public-health sessions in person or by phone, with three-and perspective you’ve made a huge impact.” nine-month follow-up calls, for $495. East In April, Fleming published the first large Carolina University will launch its own DrinkWise U.S. study of brief interventions for problem program later this year. drinkers in the Journal of the American Medical Many people enter alcohol treatment not Association. The study, patterned on research by choice but by court order for drunk driving over the past 20 years in Great Britain and and other offenses. They, too, are beginning to Sweden, selected 774 problem drinkers from gain a few more options. Last year California patients at 17 Wisconsin clinics. Half the ruled that Los Angeles County does not have to patients met for 2 15-minute sessions, one require offenders to attend an abstinence-based month apart, with their physicians, discussed self-help group, making room for Moderation their current health behavior and the effects of Management as a legal alternative to AA. alcohol, and signed a prescription-like drinking But these groups are still gnats contract. A year later, the men had reduced their compared to the elephant of AA. Moderation alcohol use by 14 percent; the women by 30 Management has just 50 volunteer-run groups; percent. (women are usually more successful AA has an estimated 1.2 million members in the than men at moderating.) The control group also nation. Only 8 to 10 people show up for the reduced its drinking, but the brief intervention weekly Manhattan meeting of MM, which Eliza group was twice as likely to reduce it by 20 DeCarlo runs. “We’re like booze revolutionaries,” percent or more. she says cheerfully. Other promising research is coming from There’s reason to hope today’s Seattle, where University of Washington revolutionaries will get a more open hearing than psychologist Marlatt is working with a notoriously their predecessors: The NIAAA, along with other immoderate population-college students. For the federal agencies, is increasing funding for past seven years, he has followed 350 students different alcohol treatments. Someday, perhaps, who were identified while still in high school as controlled drinking programs will be as high-risk drinkers. A year after half the students commonplace as Weight Watchers and were given a one-hour, one-on-one educational Smokenders, and problem drinking will be session in their freshman year, 80 percent had recognized as a $100 billion public-health reduced binge drinking substantially. Those who problem requiring solutions as varied and didn’t were given more education and complex as our long, tempestuous relationship counseling with the intensity escalating each with alcohol. year. “It’s a harm-reduction approach,” Marlatt

Source: U.S. News & World Report, Sept. 8, 1997

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