Rethinking Alcoholism

[sfgirl]

I have been thinking about this for awhile. I got really into thinking about it ever since that prohibition thread. But it was also motivated by the hard drinker vs. real alcoholic argument. Basically, I am a big nerd and I read a lot of research about addiction and alcoholism. A lot. I am more and more overwhelmed by the differences in research about treatment and how treatment is carried out. I basically think the alcoholism field needs to grow amply. I think currently it only serves people who have reached the most acute stage. I think that prevention and catching people earlier is possible. I also think alcoholism comes in different shades than we talk about here. I believe my family is full of high functioning alcoholics who are not going to get worse. I don't think this means they don't have alcohol problems. But whatever, I can go off on rants and probably this isn't the place. However, I do think that we should try and think of things on all sides of the coin. I want to share a really interesting article. If anything it will get you thinking.

Source Citation:Willenbring, Mark L. "New research is redefining alcohol disorders; Does the treatment field have the courage to change?." Addiction Professional 6.5 (Sept-Oct 2008): 12(7). General OneFile. Gale. San Francisco Public Library. 22 June 2009

New research is redefining alcohol disorders; Does the treatment field have the courage to change?

In the treatment community, it is common knowledge that many people with alcohol dependence never receive specialty addiction treatment, and that those who do receive treatment have the most severe form of the disorder together with substantial co-existing mental, physical, and social disability. Among treatment professionals, one common explanation is lack of access due to practical barriers such as distance or lack of insurance. Stigma also is frequently mentioned. But are those the biggest problems?

This article proposes an alternative explanation: that the type, location, and style of treatments currently available are based on outmoded views of the nature and variability of alcohol dependence and the types of treatment that should be available to address it. I also will argue that fundamental changes are needed in the configuration of services and service providers (the continuum of care) to make effective treatments sufficiently attractive, accessible, and affordable to reach more than the one in eight of those who need and currently receive specialty addiction treatment.

Although access, cost, and stigma are important, treatment avoiders are more likely to assert, "I'm not that bad yet," or "I can handle it myself." Accordingly, many professionals view those assertions as evidence of "denial" (i.e., that people do not realize that they are ill). I believe that explanation to be simplistic and self-serving. Like the famous cartoon character Pogo, I believe instead that "we have met the enemy, and he is us." Unless we open ourselves to new ideas, I don't think we will make progress. In fact, we may expend precious time and resources in search of the wrong solution.

A continuum of need

In a recent National Institute on Alcohol Abuse and Alcoholism (NIAAA) Web conference titled "Alcoholism Isn't What It Used to Be: New Findings on the Nature and Course of Alcohol Use Disorders" (available at https://webmeeting.nih.gov/p27471408), I presented evidence that our view of alcohol use disorders (AUDs; abuse and dependence) has been distorted by focusing on people attending treatment programs. This is not uncommon in healthcare: We focus first on the people presenting for care, who have the most severe, treatment-resistant form of the disorder and who often also have other unrelated disorders that make managing any one of them more difficult. Only in time does a different picture emerge: The disorder exists in a much more varied form in the community at large, and those entering treatment do not represent the typical person who has it.

For example, at first breast cancer was identified only when a tumor became large and unavoidable; now mammograms identify tiny tumors undetectable even by careful examination. Once it was thought that schizophrenia was inevitably severe and totally disabling, requiring long-term hospitalization; but then studies of community populations revealed many milder cases in which people improved over time and were able to work and have relatively normal lives.

In the general population, there is a continuum of alcohol use and disorders ranging from abstinence to low-risk drinking, risk drinking, harmful drinking, and dependence to chronic, relapsing dependence (see Figure). There is no sharp delineation between categories; instead, they blend one into another, and category definitions involve tradeoffs between being too sensitive or missing "cases."

For example, a diagnosis of alcohol dependence requires that three of seven DSM-IV criteria be met, but why not two, or four? Most heavy drinkers (four or more drinks per day for women, five or more for men) do not have and never develop any AUD or other adverse consequences. Most people who become dependent have milder forms of the disorder and meet only three or four DSM-IV criteria. Almost three-quarters of persons with dependence experience a single episode that lasts three or four years, after which they get and stay well. In contrast, most people in treatment programs meet six or seven criteria and have repeated episodes over the course of years to decades. Whereas most people with dependence have no observable disability (i.e., job, relationship, or legal problems) and remain quite functional even though symptomatic, most people in treatment are significantly disabled and have multiple co-existing conditions.

Thus, our understanding of AUDs and related judgments about how they should be treated are limited by our exposure to only the sickest 10%--that is, those in our treatment programs. Unfortunately, this incomplete understanding leads in turn to many false beliefs: Recovery is not possible without treatment...; alcoholism is inevitably a severe, chronic, progressive disorder; people are either alcoholic or not; heavy drinking always leads to bad consequences, and so forth.

JPEGF

If we (incorrectly) assume that non-treatment seekers care, our attempts to address the treatment gap will fail. And although almost all would agree that strategies based on the best and most current research are most likely to succeed, recent findings suggest very different directions from those to which we are accustomed. Rather than being a threat to the treatment professional, however, decisions based on these new findings can lead ultimately to a stronger, more effective, and more satisfying specialty treatment sector that complements other elements to address persons who are less severely affected.

Structural barriers

The peculiar way that treatment developed in the United States also presents a barrier to innovation. The dominant treatment paradigm, the Minnesota Model, developed outside the mainstream of professional care and initially was staffed by recovering counselors with little or no professional education. Even now, in some states, only a high school education is required. The "28-day program" was a noble initial attempt to address alcohol dependence, but it has not kept pace with advances in knowledge.

For example, only about 5% of current patients are treated with available, research-tested medications, even though they are about as effective as treatments for depression. According to recent research, we must admit that we have been attempting to treat a chronic, relapsing form of alcohol dependence in a few weeks or months. Yet, if a client doesn't achieve recovery with a run through "the program," we have little to offer except another run through "the program." In addition, we are only beginning to consider appropriate treatments for the large numbers of non-treatment seekers who have milder forms of the illness and are more functional than treatment-seekers.

Further, most of our clients today are overtly coerced into treatment by the criminal justice system, employers, or family members. Among treatment professionals, this situation divides loyalties (e.g., are we serving the court or the individual?) and fosters complacency, since programs need not attract clients based on understanding what customers want and providing good service. Instead, we can do what we please and our clients must accept it. At present, more than 90% of treatment programs offer group counseling.... If instead our clients had a choice, would we be forced to innovate?

Of course, the "up" side of the current situation is that there is a huge untapped market for the entrepreneurial among us: a new model of consumer-oriented treatment. Non-treatment seekers who have AUDs tell us that they are not coming to treatment because they are not yet so bad off they have no other choice. What if we offered them treatments that they found attractive, affordable, accessible, and effective? Since most people with AUDs never achieve a degree of severity so great that they have no choice, I propose that we offer them treatments that they will choose to receive without coercive interventions.

Before Prozac was approved for treatment of depression, very few people received treatment. Only the sickest people, who were usually hospitalized, were treated and then only by psychiatrists. In a foreshadowing of today's controversies, psychoanalysts argued that we should not use medications to treat depression, because then people would not be motivated to change (never mind that subsequent research showed that psychoanalysis was not effective for treating depression). In 1987, Prozac was approved as the first of many second-generation medication treatments, and the field changed rapidly. Now, most depression treatment occurs in primary care, about two-thirds of depression episodes are treated, and mental health specialists provide more intensive treatment for those with more severe and complex disorders. The time is right for a similar development in addressing heavy drinking and AUDs.

A broader service mix

What are the elements of an expanded continuum? From a public health perspective, we need first to address nondependent heavy drinking (risk drinking). Because 21% of U.S. adults engage in risk drinking, they account for more excess morbidity and mortality than dependent drinkers, who constitute only 4% of the population in any given year. Because they are non-dependent, risk drinkers often respond to facilitated self-change or brief counseling and advice, which could be made widely available at relatively low cost. Some harmful and dependent drinkers will respond to the same modalities, but many will need additional services.

The only way to reach so many people is through existing systems with a broad reach, such as primary medical care and general mental healthcare. (If everyone with a diagnosis of dependence showed up at specialty treatment programs, we would be quickly overwhelmed.) Since most of them have milder forms of dependence, are functional, and have more resources available to them, they may respond well to either outpatient behavioral treatment (such as 4 to 10 sessions over a few weeks) or medication with brief behavioral support, or both. In the COMBINE (Combining Medications and Behavioral Interventions) trial, for example, behavioral treatment and naltrexone plus brief behavioral treatment were equally effective.

For this continuum to work, however, the addiction specialty treatment sector needs considerable development. Intensive abstinence-oriented behavioral treatment would continue, but with greater resourcing to improve efficacy. Over time, the minimum requirements for providing specialty treatment would need to increase to approximate those for treating mental health disorders. Since no one behavioral approach has better overall outcomes than others, clients should have a choice of available, effective treatments.

Because most people in need of specialty treatment (about one-quarter of all dependent persons) have chronic, relapsing dependence as well as co-existing physical and mental disorders, specialty addiction treatment should seamlessly integrate addiction, primary medical, and psychiatric treatments. In addition, for those unable to achieve or sustain full remission, chronic care models (such as those available for other chronic illnesses) should provide intermittent or continuous treatment and management over years to decades.

New research has shown us that the disorder that we treat is more varied and complex than we had imagined. Yes, these findings challenge what has become conventional wisdom among addiction professionals. Will we view them as a threat or as an opportunity? How we respond is up to us and will determine the future of our field.

[stone]

I don't think my alcoholism could have been caught earlier because at that stage I was drinking because I wanted to and didn't want to stop. It is only after a line had been crossed and it becomes a problem that a person will want to do anything about it. A person drinks, at first, because they like it and because of this the comparison between drinking and depression or breast cancer doesn't hold up. I do think it would be a good idea for GPs to be more aware of problem drinking and maybe offer help before it is asked for though. Might help?

[Zencat]

I think that there many people that have problems with alcohol and resist the idea of having a label. I believe that alone keeps many away from seeking help.

[sfgirl]

Originally Posted by stone

I don't think my alcoholism could have been caught earlier because at that stage I was drinking because I wanted to and didn't want to stop. It is only after a line had been crossed and it becomes a problem that a person will want to do anything about it. A person drinks, at first, because they like it and because of this the comparison between drinking and depression or breast cancer doesn't hold up. I do think it would be a good idea for GPs to be more aware of problem drinking and maybe offer help before it is asked for though. Might help?

I wonder about that to because there has to be motivation for change and if it is still working and fun why would you want to? For me I started drinking at 14 and I had these horrible panic attacks daily that set in at 18. I had them every day without warning. The initial panic attack I had was brought on by coming off a bender. Then I stopped drinking for those months because it was aggravating them. I never could understand what those panic attacks were about. Now that I finally am sober, sober I am understanding myself a lot better and realize that they were a sign of a problem and that if I had gotten sober then, by which I mean worked on recovery, I think it would have nipped the problem in the butt. Of course, the SSRIs which finally saved me and allowed me to go back to drinking helped immensely. The other thing is my alcohol consumption started with sexual abuse which I think is all too common. However, what happened is that I was a victim of tons of other sexual abuse and inappropriate behavior over my formative years because of alcohol. That has been extremely damaging. This is something that is so common for people who start drinking young. If someone or better if there was a culture where these consequences of alcohol use were talked about and if a professional had approached me when I was having those daily panic attacks, when I was probably not quite in the deep clutches of attachment to alcohol but I was willing to do ANYTHING to save myself from the panic, and explained to me the serious consequences that the alcohol had taken on my life until then and would take later things might have changed. So I think in a way if there was more education, it could be easier to motivate people before they deepen their attachment to booze too far. It has just been such a painful and lonely journey for the last 4 years trying to finally kick this alcohol thing. And that is relatively a short time— but again who knows if it is over? I wish there were other options for the next generation.

But yeah motivation for change is a difficult issue. However, the deeper in you get probably the more motivation you need. I mean I started crying when I realized I was actually going to have to stop for real. Alcohol was my life. My best friend. It was true. Sad. You probably need less motivation when it is just your acquaintance but then again it might not seem like an issue.

[Eroica]

People have different degrees of alcohol problems.. I'm still don't consider people who can function to be alcoholics, because i think for some people the problem is so bad that they cant function at all-they lose their job, family, or what have you. Its seems not fair to put a person who abuses alcohol, even on long benders, in the same category as someone who drinks night and day and can exercise no control at all. But that's just me. Obviously, both groups suffer and addicts cross both groups as well.

My image of an alcoholic is different from others.. that's because there is no such thing as alcoholism. Addiction and dependence are broad enough to count all degrees of alcohol problems. The label "alcoholic" is not based on any kind of science at all.

The treatment industry has brainwashed us into thinking that alcoholism is a progressive incurable illness. Rehabs would go out of business if alcoholism was no longer considered a disease...or if they only catered to people in the acute stages of a problem.

[mistycshore]

I think it is a continuum rather than black & white. I knew a man who drank insanely for his entire life, lost his home, family, career, survived a drunken shoot out with the sheriffs and continued to live in various states of drunkedness until he was diagnosed with cancer in his late 60s. Then he cut back to one beer a day - boom, just like that. One beer a day is not something I would want to try (sounds rather hellish), but it goes to show that recovery lore is based on bad assumptions and imaginary categories (heavy drinker vs. alcoholic, etc.).

Practically though, I doubt the health insurance industry is going to want to ante up for treatment of people who are not in very bad shape. And I'm guessing most family doctors working under HMO guidelines would prefer prescribing meds and recommending support groups, especially for patients who are high-functioning.

[Freepath]

Of course, the "up" side of the current situation is that there is a huge untapped market for the entrepreneurial among us: a new model of consumer-oriented treatment. Non-treatment seekers who have AUDs tell us that they are not coming to treatment because they are not yet so bad off they have no other choice. What if we offered them treatments that they found attractive, affordable, accessible, and effective? Since most people with AUDs never achieve a degree of severity so great that they have no choice, I propose that we offer them treatments that they will choose to receive without coercive interventions.

I hate to be a naysayer, because this sounds really good, but how on earth do we do this? I absolutely will not grow a cell in my brain unless it grows directly from an arrow in my a$$. I mean, the world already has a treatment solution like this it’s called Disneyland. Isn’t this the entire problem? Alcohol and drugs are SEDUCTIVE. It’s fun. Everybody’s partying, having a good time getting loaded. I specifically remember being drunk and stoned out of my mind and turning to one of my fellow partiers and saying “doesn’t this get old after a while? Sure, were all sketchy with music and mojo, but doesn’t it get old?" He didn’t think so, and his lifestyle since that time has reflected this fact. I’m finally coming clean and sober and I feel good about it. It seems to me that going places, meeting people and doing things is fun, and generally when one is snookered out of one’s mind these activities turn a little more challenging. I think what the author is really referring to amounts to nothing short of a cultural revolution where people simply don’t place such a cause and effect relationship between getting wasted and having fun.

For this continuum to work, however, the addiction specialty treatment sector needs considerable development. Intensive abstinence-oriented behavioral treatment would continue, but with greater resourcing to improve efficacy. Over time, the minimum requirements for providing specialty treatment would need to increase to approximate those for treating mental health disorders. Since no one behavioral approach has better overall outcomes than others, clients should have a choice of available, effective treatments.

I’m having a hard time picturing what this would look like, especially for the “non-treatment seekers.” This reminds me of missionaries going into hunter gatherer tribes and trying to convince the populations that they need to find god. If someone is a “non-treatment seeker” and they “never develop adverse consequences,” why would they even be interested in quitting? It’s not a problem.

I guess I see where the author is going with this article, and I absolutely agree that current recovery paradigms are not evidence based, but turning the whole thing into some kind of health care guinea pig phenomena seems absurd. It just seems to me that if enough people reject drugs and alcohol and clearly have happy lives as a result, that would be a much more powerful reason for anyone to make a decision to quit.

[lunarise]

Really interesting thread...
thanks

[sfgirl]

Originally Posted by mistycshore

I think it is a continuum rather than black & white.

There was a graphic that didn't come through when I copied the article showing the continuum of care proposed. Here it is:




Here is the link to the article on the Addiction Professional website: New research is redefining alcohol disorders | Articles & Archives | ArtIcles/News | Addiction Professional

Also, I didn't realize this until now, but the author, Dr. Mark Willenbring is the Director of the Division of Treatment and Recovery Research at the National Institute on Alcohol Abuse and Alcoholism.

[jamdls]

Interesting thread. It was obvious I had a problem with alcohol from the first time I got drunk when I ws around 12, the stuff tasted horrendous (it was straight gin!) but yet I drank and drank and there is nothing anyone could have done to change my behaviour. One of my sisters used to refer to me as the 'family lush' when I was just in my 20s, so I just avoided seeing her and the rest of my family for many many years. I think the only early education that can be successful comes from within the family. 2 of my 4 siblings have never touched a drop of alcohol because they saw what it did to my father and in turn the effect his drunkenness had on our mother; of the other 3, 2 of us definetly drink or drank wayyyyyyyy too much and 1 seems to be able to drink responsibly. My 12 year drinking binge started when my daughter was 12 but even before that I always talked to her about the fact that alcoholism ran in our family and the negatives it had, then of course she continued to live with while I tried to drink myself to death, I always made alcohol available to her told her if she wanted to drink she could with me and she did once or twice--she saw all the negative effects of uncontrollable drinking in me and she is now 28 and has never developed a taste nor desire for much drinking.

[Freepath]

Sfgirl,

I thought quite a bit about this today and I read some more of your threads. You have made some fantastic points. It seems disappointing that kids graduating from high school know everything from how to solve geometry and algebra problems, to how to speak a foreign language, to how to make something in woodshop, but culturally, we mention disappointingly little about alcohol.

I do remember quite a bit of attention being given to drugs and drunk driving, but never to the addictive dangers of alcohol. Couldn’t they say that alcohol could very well cause you to die at about half the age that you should? If someone did stand up in the front of a high school rally or health class and explained the dangers of alcohol, would anyone listen? Especially the way our culture is today?

I remember starting when I was very young. Alcohol was around when I was young, and alcohol addiction has occurred in my ancestors. I don’t see much credence in the semantics that people like to argue about. From my perspective, it all seems like the inability to control when you drink, and how much you drink.

So, promotion of health and prevention of alcoholism are wonderful ideas. I believe that this involves changing the way that our entire culture views alcohol. But that’s not so crazy, right? 70 years ago the United States military gave free cigarettes to anyone serving in the military who wanted them. You can’t even smoke while you are walking down the sidewalk in some cities today.

I believe that you should go ahead and rant. Maybe that’s just what our culture needs is more people pointing out the problems which result from the addiction to alcohol. We sure do seem to have quite a few people in denial on the other side of the argument.

Thank you for remaining an avid reader and a constant inspiration.

[SugarScars]

Thank you for providing this viewpoint. I agree with much of what it proposes and feel that I am a good example of the type of person who has been most neglected by the current system. As a young professional, I am often not welcome in traditional settings. I receive contradictory messages from many health professionals: I am not severe enough to have a real problem and should be able to "fix" myself on my own (too successful); I am too severe (too deviant) to be served by the current system: there is no place for me within today's addiction treatment model.

I am an IV drug user who has been considered conversely too severe for traditional treatment and not severe enough, as the traditional treatments do not meet my needs - nor do I meet theirs.

I, for one, believe that change within the system is definitely in order and believe that had treatment been ATTRACTIVE to me as a college student, I would have chosen a much different path. I knew that I had a problem, but believed that my only options were traditional treatment (giving up, believing that I had an incurable disease and needed to sell all of my dreams for a better life in order to recover) or to continue to try to use successfully with a minimal amount of consequence (which has grown quite old - I'm over it!).

It appears that I have slipped through the cracks, and continue to do so. My current Suboxone doctor considers me a peer, and often forgets that I have a deadly condition.

I was also rejected for treatment by another Suboxone clinic who deemed me "too high-risk", meaning that they refused to treat me because they thought that I was too severe. I could have ruined their numbers and what treatment center wants that?

The mixed messages of our current treatment model are extremely unattractive indeed. Individualized attention is in order. This is truly about saving individual lives and not about forcing individuals to conform to models that do not serve their unique needs, but rather the needs of the facility to prove SHEER VOLUME. This quantity over quality mindset is causing many people to needlessly die.

Each of us is unique like everybody else! Forcing us to conform because it makes treatment centers' jobs easier is nothing other than negligence.

[sfgirl]

Thank you so much for your comments SugarScars.

It is really complicated.

I just started drug and alcohol counseling classes last week. I went to an information session about a month ago and they were talking about how it was a growing field— trying in a way to attract people in this dwindling economy. They talked about how the number of people diverted from jail to treatment programs was increasing and there needed to be places to put them because of prop 36 here in California. All placements for the internships were in prop 36 places or community non-profit type clinics. There was a definite emphasis on the traditional "underserved" population. When I went to therapy a few days later I was talking about prop 36 and the like because I used to work at a criminal defense law firm and the emphasis on the "underserved" population and I suddenly realized that in this field, I actually am the "underserved" population. While I may have the financial and other resources to get health care (minus the fact that it was extremely difficult for me to get health insurance but that is a whole different story...) in terms of my alcoholism I have been missed so many times. And like you talk about— when I started to take it seriously, the health professionals did not take me seriously. I remember telling my primary care doctor that I really wanted to work on my drinking, that I thought it was a problem. Her response was that was a good idea because she sees people who are high functioning my parents age who struggle with it. Ok, that was it. Wait, now that I think about it, she is a doctor should she not have pointed me in some sort of direction, not just told me "good idea!" Exactly, she treated me like a peer. That conversation was five years ago. Conversely, if I had been arrested for some sort of drug or alcohol related issue maybe prop 36 would have taken me seriously but one of my top priorities was not driving at all. I had enough money to support my habit. The likelihood of my arrest was very, very low. In a way the only option I knew about were those fancy malibu overpriced rehabs that seemed like a joke and part of me didn't feel that far gone. What I really needed was someone that knew about addiction to talk to me, to be pointed to a counselor who specialized in alcoholism. I feel like I did my part more than enough. I realized I had a problem. It was the health professionals who did not quite know what to do with me.

I see people my parents age who are extremely high functioning alcoholics. I just feel in a way there are so many different presentations of the disease and that to not allow those different presentations to exist keeps people in the emotional pain. That makes me so sad. I didn't link the emotional pain I was in to my alcoholism until I got sober and I just want everyone to have that chance.

[agrippa]

The professionals have two categories: alcohol abuse and alcohol dependent.
There is no physical test for either; no cat scan, x ray, blood test for physical lesion or antibodies. Both are in the DSM.
I prefer these two categories.

It is far easier to quit when it is early days; when the habit is far less developed. It is far easier to quit when the drinking and mental health issues are not involved. Put the two together -- people get confused about the description of the problem and the solution.
It is far easier to quit when you have very strong reasons to quit.

It is a continuum; it is not either/or.
This means that humans are individuals and do not fit into a mold.

I used RR, but I did not know that I did until after I read the book.

After I quit, I went to SMART Recovery on line.

[agrippa]

This is coming on to four years after abuse was over and done with; so, there is some perspective here [ I think]. I was on the line between risk drinking and harmful drinking. early days. It was a bad pattern that I had gotten into. It had gone on for a about a year. And, was in the way of me putting life back together. Which had come apart and precipitated the abuse.

I think that some self awareness is needed; a realization of the connection between behavior and consequences; a strong incentive to change; the determination to do so; real support from others; etc.
I had all save the last one; at the least, it had the smallest effect upon me.

I would say that there are real limits to safe drinking -- long term limits and short term limits. Be aware of the risks and donnot challenge the odds.

[Freepath]

Here's another interesting article related to this subject:

Addiction Is a Brain Disease, and It Matters -- Leshner 1 (2): 190 -- Focus

This addresses the disease versus decision argument.