quote: If we could eliminate all alcohol from our society (and I know that such a thing is likely impossible but if it weren't impossible) and in doing so we could prevent all the deaths by drunk drivers, all the crimes committed by binge drinkers, all the premature deaths from alcohol abuse, all the divorces caused by alcoholism, all the children born with fetal alcohol syndrome, all the fights between drunks all the child and spouse abuse done by drunks and all the societal problems caused by excessive alcohol use would you want to do it even though it would mean also giving up all the pleasure experienced by moderate drinkers and any health benefits incurred by moderate drinkers?
Hrm. I think eliminating alcohol would almost immediately cause millions of people to begin experimenting with other mood-altering substances. The initial social stigma against those other intoxicants would, I suspect, wear off fairly rapidly.
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What about when I buy unpasteurized OJ and stick it in the fridge for a few days, and it turns to alcohol? Under such a system, would I be prosecuted for
-allowing it to happen -drinking it, since it's safe -letting someone else have a sip, such as a neighbor?
Prohibition sure as heck didn't work.
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Tom: that's why we need to find aliens from Jupiter or something, to see if they can enjoy our music, and if they drink alcohol. It would answer a lot of questions.
We would be able to see how messed up we (humans) really are, or are not.
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Speaking of music, my music therapy student friends in college were always doing research on how music affects one's state. I don't have any of their research, but I know from personal experience that listening to different types of music DEFINITELY changes my state, and I often listen to certain types of music with an "altered state" being my motive.
It's the best of the drugs.
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Note that you may be conflating "problem drinking" with just "alcoholism" (usually medically tied to "alcohol dependence," although used in a highly variable way colloquially). Most problem drinking is from binge drinking, not alcohol dependence, and that is where the primary burden of morbidity and mortality from alcohol lies.
Most people referred to Alcoholics Anonymous are not dependent on alcohol in the medical sense, and yet they may be problem drinkers. Brief Intervention is established as an effective tool for problem drinking without dependence (again, most cases of problem drinking), and it is being studied for use in dependent populations (e.g., those admitted for hospital treatment of alcohol dependence).
CT - first, thanks so much for the links. I will read through in great detail.
Secondly, I would like to say I think in AA we do acknowledge the difference between the physical-dependent alcoholics (daily drinkers) and the binge-drinkers (what you are terming "problem drinkers" as opposed to what you consider to be true "alcoholics") We pretty much say the program works for both (obviously) and still consider binge-drinkers to be alcoholics if they have no control over their decisions to binge drink It is still dependence.
So this is what I have a hard time with in understanding how a non-abstinence program works for binge drinkers like myself (I was never a daily alcoholic, or dependent drunk, but would binge for several days and then be totally dry for a few months, depending on when opportunity would arise again).
When I came into AA, because I wasn't a daily, dependent drinker, I for awhile convinced myself that I was NOT an alcoholic and didn't need the program. So another drunk put me to "the test", so to speak. (I think I've told this story here before, so forgive me for repeating) He said, "Fine. If you can walk into a bar every night this week, and CHOOSE to only have one drink, and walk out of that bar after that one drink, and go home, then you don't need this program."
So I went to the bar each night that week. I ordered one drink (I always ordered Black Russian). I drank it. Immediately I would be hit will an overwhelming crave for alcohol, and I had an immediate physical buzz that impaired me from having the slightest inclination to even THINK about walking out of there with only one drink. I really had my mind made up when I went in, that I would pass this challenge. But I failed each and every night.
To me, that was a pretty sure sign of alcohol dependency, even if I didn't turn to it daily.
So as a binge drinker, total abstinence is still the best way to go; (for me); so that is why I have a hard time seeing the benefits of teaching them "controlled" drinking.
(Yes, I have sometimes been tempted to see if now, 20 years later, I could have a drink or glass of wine and control my decisions beyond the first one. But I have decided it just isn't worth it to test myself).
(Understand that why I'm an alcoholic myself, I have absolutely nothing against people who choose to drink, and have no problems with it. It no longer ever bothers me if they drink around me, for the most part. I just realize there is something in my physiology that makes it impossible for me to drink responsibly.)
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A point of clarification: "problem drinking" in the technical literature refers to both binge drinking and alcohol dependence (i.e., "alcohol abuse," "alcohol misuse," and "alcohol dependence"). It is not just binge drinking. For example, most college students with problem drinking are binge drinkers but are not dependent on the substance. Still, some of them who exhibit "problem drinking" are dependent.
Similarly, we may mean different things when we use the term dependent. I am using it in the strictly technical sense, as defined in the DSM-IV manual, and that is how it is used in the scientific literature. It's (of course) fine to use it otherwise, but it is useful to be aware of the difference.
[Edited to add: By the way, you do fit the technical criteria for "substance dependence" regardless, and BI isn't established for those who are dependent -- this may be why BI doesn't feel right for you. On the other hand, there are some non-abstinence/non-12-step programs which appear to be just as effective for most problem drinkers -- see next edit below and followup post afterward.]
quote:DSM-IV Criteria for the Substance Dependence
A maladaptive pattern of substance (alcohol) use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:
(1) tolerance, as defined by either of the following:
....(a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect
....(b) markedly diminished effect with continued use of the same amount of the substance
(2) withdrawal, as manifested by either of the following:
....(a) the characteristic withdrawal syndrome for the substance
........Criterion A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.
........Criterion B. Two or more of the following, developing within several hours to a few days after Criterion A:
............(1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100)
............((2) increased hand tremor
............((3) insomnia
............((4) nausea or vomiting
............((5) transient visual, tactile, or auditory hallucinations or illusions
............((6) psychomotor agitation
............((7) anxiety
............((8) grand mal seizures
....(b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
(3) the substance is often taken in larger amounts or over a longer period than was intended
(4) there is a persistent desire or unsuccessful efforts to cut down or control substance use
(5) a great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance, or recover from its effects
(6) important social, occupational, or recreational activities are given up or reduced because of substance use
(7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g. continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
[bolding added or emphasis]
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I understand that you are describing your experience and what has been related to you for other individuals' experiences, and I am fully in support of the choices you have made. Obviously, what you have done works well for you. (Look at your beautiful family! And we have you as a strong and stable friend.)
When assessing what to do to benefit a large population, it is necessary to work not from anecdote, but from outcomes studies over large groups of people. Many people with problem drinking come to one or two AA meetings, but then don't come back.
If the people you talk with about drinking are mainly those who you met through and have stayed with AA, then it is entirely likely that everyone you talk with will have found AA to be the only successful program. If something worked before AA, they wouldn't have tried AA; if AA works, then they would have no reason to try anything else.
The problem for using anecdotal evidence is one of extreme selection bias. That doesn't mean it doesn't work for you, just that the odds of it working for a randomly selected problem drinker are less for this program than for others.
It doesn't matter how intense and heartfelt (and true and important) one or two (or ten, or twenty) individuals' personal experiences are, not at the level of broad policy *** -- what matters is that when given a large (hundreds to thousands or more) group of people randomly assigned to different treatments, after a good bit of time has passed, which treatment approach was more successful overall? Was the difference significant? If it was, then a more effective approach for standard protocols is to use the more effective treatment. Of course, there can be multiple things offered, but the goal is to be as efficient at the first step as possible and have backup plans in place. But it doesn't make sense to start with a program that is less successful overall for most people, even if that is the program some people will end up using.
[Also edited to add: In your case, at this point, a family physician shouldn't have considered you a candidate for BI, since you fit the criteria for dependence. Nonetheless, there is strong evidence that other, non-12-step programs may have worked -- see followup post below. 12-step programs, cognitive behavioral therapy, and motivational enhancement therapy (a longer-term version of BI) all seem to be equally effective.]
It may be that people who stick with AA longterm have a good outcome, but also that most people can't or don't stick with it, but may well stick with what they learn in BI. Assessing the effectiveness of a standard protocol has to take into account the dropout rate, too -- so even if very effective for a small number, if most drop out, then it isn't going to be effective overall. In this case, something else is.
And just as you cannot imagine anything else working for you but AA, there are many many people who have tried 12-step programs and cannot imagine how this would ever work for them. For many of these people, BI [or its longer-term cousin, Motivational Enhancement Therapy] does work -- and as hard as it may be for a given person to accept this, the longterm studies show that these people do exist. A lot of them. And their stories are just as heartfelt, poignant, relevant, and important.
Look, I would never criticize your decision to stop drinking, or argue with your decision to talk about AA and what it means to you. I also am still going to talk about other programs which have validation in the research, because the scientific evidence is that AA is not the only way to control drinking for most problem drinkers (maybe not you! maybe not the people you know at AA! but yes, a bigger percentage of people out at large with problem drinking; and even those who are dependent have other options than AA, with outcomes just as good), and people need to know that, too for all sorts of reasons. They need to know about other options for themselves and those they know, and they need to know about it for the purposes of forming public policy.
Hopefully we can continue to talk about the subject side by side, even if we are focused on different aspects of it.
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Thanks for the interest and information, Rabbit! Dave is not only aware of this population and the studies, but has already made recommendations in that area. Given that this section of the population is a small percentage, it won't have much bearing on the thrust of the national effort, but it is included. Most family physicians won't have someone from this population in their practice, but they will have many problem drinkers -- and genetic testing is expensive -- so this issue is further down the list.
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Edited to add: *** Of course, it goes without saying that in other contexts, such stories are deeply important and more relevant than national policy issues. Different contexts, different relevance. In this thread, I think both are relevant side-by-side.
posted
As for treatment of people with alcohol dependence, the most cited study is Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) -- you can find more details here -- which compared the longterm outcomes in 1700+ people dependent on alcohol assigned to one of the following:
quote:1) a 12-step facilitation therapy (based on the principles of Alcoholics Anonymous but an independent treatment designed to familiarize patients with the AA philosophy and to encourage participation)
2) cognitive-behavioral therapy (based on social learning theory and designed to provide skills for avoiding relapse)
3) motivational enhancement therapy (based on motivational psychology and designed to help patients mobilize personal resources to effect change)
All three were equally effective.
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Edited to add: By the way, CBT and MET don't rule out abstinence -- they just don't assume that abstinence is the only option on the table. Many people who go through CBT or MET come to accept that abstinence is right for them, after having worked through the various options with a trained person. A major difference from AA is that it isn't a necessicity to agree to abstinence as the only viable goal in order to continue to progress through the program.
That doesn't mean that abstinence doesn't end up being right for a given person -- and for some of these people, having to commit to abstinence early on may be why they did or would have dropped out of a 12-step program, even though a different approach may lead them in that direction anyway.]
posted
Oh, CT! Please never take what I said as a critcism of the other programs of which you speak. I was speaking on purely a personal level as to how I personally could not understand some of the other programs. I take that as a failure on my part in comprehension and understanding, not at all as a negating of the benefits of those programs. Whatever it takes to help the people.
Actually I had a very close friend of mine (also an M.D., by the way) who worked a few years back in a hospital that had an alcoholic treatment program/wing. He and I talked about how AA doesn't work for everyone, and he was exploring other possibilities at that time. He move away before I ever found out if they found something that worked better for some of their repeat clients - especially those who seem to dislike the AA approach. (the whole "higher power" thing). I certainly realize the AA approach does not work for everyone.
On the same note, however, those of us in AA (and I say this loosely, as I haven't attended meetings in a couple years now or more); talked often about how the whole composition and make-up of AA has changed from the way it was originally designed to be. When Bill W and others wrote the Big Book, they were reaching out to alcoholics who WANTED to quit, who were struggling to find a way.
Sometime a long the way, the U.S. Court system pounced on AA as being the "cure all" for those getting DUI's and started sending masses of people to AA meetings who had absolutely no desire to be there, no desire to stop their behaviors at all, and generally totally changed how the program operated at the local level. You lost a lot of the close-knit camaraderie because there were new random strangers every single meeting who just wanted you to "sign off on their paper" so they could leave and tell the judge they had done what they needed to.
Because of this, it has overall hurt the "validity" of the program, and has practically forced everyone involved with substance abuse to look a new ways of thinking and treating and dealing with alcoholism.
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CT, do you think future research will make selecting the proper therapy based on patient characteristics more accurate in the future?
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quote:Originally posted by Farmgirl: Sometime a long the way, the U.S. Court system pounced on AA as being the "cure all" for those getting DUI's and started sending masses of people to AA meetings who had absolutely no desire to be there, no desire to stop their behaviors at all, and generally totally changed how the program operated at the local level. You lost a lot of the close-knit camaraderie because there were new random strangers every single meeting who just wanted you to "sign off on their paper" so they could leave and tell the judge they had done what they needed to.
Because of this, it has overall hurt the "validity" of the program, and has practically forced everyone involved with substance abuse to look a new ways of thinking and treating and dealing with alcoholism.
That's it exactly!
((((Farmgirl)))) [edited for your privacy!]
I didn't want you to feel I had invalidated your experience, or that I didn't care about you. I'm just so frfustrated at seeing people automatically referred to AA by police, ER workers, the court system, family docs -- that isn't going to work most of the time. As you rightly said, it is for people who are in a particular state of readiness.
Actually, as I've hunched over the screen this morning, writing and rewriting these posts, I think I may have pinpointed the diconnect you feel (maybe, who knows) -- abstinence is often where people dependent on alcohol end up, if they are going to be successful in making their lives work for them. It's just that AA is founded on the readiness-for-change, and the other programs usually seem to work better for people not ready to change yet.
For some of them, getting through to the ready-to-change state is facillitated by the sessions, and then -- for many -- it becomes apparent that the best thing is to abstain from drinking. But abstinence isn't the only option on the table, and I think that may be one reason people find working through the other programs more useful, especially at first.
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quote:Originally posted by Dagonee: CT, do you think future research will make selecting the proper therapy based on patient characteristics more accurate in the future?
Oh, sure. Project MATCH was set up particularly to find out what characteristics predicted the best outcomes in given forms of treatment (thus the MATCH acronynym, Matching Alcoholism Treatments to Client Heterogeneity). More is in the works.
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quote:Originally posted by Dagonee: Thanks for the info, CT.
I've heard of what Rabbit just wrote about, including the greater chance of alcoholism in such people.
But, I've also heard that an unnaturally high tolerance to alcohol (before one would normally develop a high tolerance through heavy drinking over time) can indicate a greater likelihood of alcoholism. Anecdotally I've found this to be true, although I obviously don't know a statistically relevant sample.
Any thoughts on why both extremely low and extremely high tolerances seem to indicate such a greater likelihood? The dichotomy never struck me until today.
The biochemistry of alcoholism is quite complex and not fully understood. There are at least two different types of genetic factors that can lead to alcoholism. The first one, which I talked about before, results from differences in the enzymes that break down alcohol (alcohol and aldehyde dehydrogenases). There is enormous genetic variability in these enzymes which can affect how long alcohol stays in your system as well as build up of intermediates in the break down process. If your body is bad at breaking down alcohol, it will take you less alcohol to achieve the same blood alcohol level and you will maintain that level longer. The theory is that since the alcohol stays in your system longer you are more likely to become addicted.
The second biochemical factor that predisposes people to alcohol results from a difference in the seretonin pathways in the brain. These are much more complicated than the breakdown of the alcohol and they aren't nearly as well understood. What is known is that changes in these pathways that are associate with a high tolerance for alcohol are also associated with a desire for alcohol. Exactly how this leads to alcohol addiction isn't exactly clear (although I'm not up to date on research in this area so I'm sure more is known by leaders in this field than by me).
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