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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-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 a really 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 percent. 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 these 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
severely afflicted: abstinence. Any other strategy, they
feel, is too risky. "Every alcoholic would like to
drink moderately," says Douglas Talbott, 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 (box, Page 62) 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 ambivalence 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 urged 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
held 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
altar," says Frederick Glaser, 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 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 psychotherapy, 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
Audrey 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 of 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, paralleling 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
two 15-minute sessions, one month apart, with their
physicians, discussed their current health behavior and the
effects of alcohol, and signed a prescriptionlike 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 Elisa 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.
With Laura Tangley
Should you worry?
No questionnaire can tell you for sure if you're a
problem drinker. But many alcohol-abuse experts use the
following test.
1. How often do you have a drink containing
alcohol?
0--Never
1--Monthly or less
2--2-4 times a month
3--2-3 times a week
4--4 or more times a week
2. How many drinks containing alcohol do you have on a
typical day when you are drinking?
0--1 or 2
1--3 or 4
2--5 or 6
3--7 to 9
4--10 or more
3. How often do you have six or more drinks on one
occasion?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
4. How often during the past year have you been unable
to stop drinking once you started?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
5. How often during the past year have you failed to
do what was normally expected of you because of drinking?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
6. How often during the past year have you needed a
drink in the morning to get going after a heavy drinking
session?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
7. How often during the past year have you had a
feeling of guilt or remorse after drinking?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
8. How often during the past year have you been unable
to remember what happened the night before because of
drinking?
0--Never
1--Less than monthly
2--Monthly
3--Weekly
4--Daily or almost daily
9. Have you or someone else been injured as a result
of your drinking?
0--No
1--
2--Yes, but not in the past year
3--
4--Yes. During the past year
10. Has a relative, friend, doctor, or other health
worker been concerned about your drinking or suggested you
cut down?
0--No
1--
2--Yes, but not in the past year
3
4--Yes. During the past year
TOTAL
Scoring: A total score of 8-15 may indicate a
problem with alcohol use. You may want to ask your physician
about cutting down or becoming abstinent. A total score of
16 or more suggests a more serious problem. You should
contact your physician or an alcohol-treatment program for
help.
Source: Alcohol Use Disorder Inventory Test, World
Health Organization, 1987
Cutting back
These organizations and people offer help to those
who want to reduce their drinking.
DrinkWise.
Brief intervention in person or by phone. At the University
of Michigan Medical Center, 800-222-5145; At East Carolina
University Medical School, 888-816-2736; E-mail: tedmondson@brody.med.ecu.edu
Moderation Management.
Self-help group with meetings, an Internet discussion group,
and Audrey Kishline's book, Moderate Drinking (Crown,
$14): 612-512-1484;
Counselors. New Mexico psychologist Reid
Hester's Web page lists behavioral counselors and links
to other resources.
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