I

Toxic Compulsion 1: Alcohol Abuse

Hawaii enjoys a well-deserved reputation as the vacation and relaxation capital of the United States. Both visitors and residents commonly seek escape from the pressures and stress of “ordinary” life. And that means they spend plenty of time basking in the sunshine, playing on the beach, or relaxing after rounds of golf or boating. I’ve seen this firsthand because I own a home in Hawaii and have spent a lot of time there over the years.

That “play” state of mind may be why our slice of paradise has earned the dubious distinction of being the Drinking Problem Capital of America. Both of the top two U.S. cities with the highest percentage of problem drinkers and binge drinkers are in the Aloha State, according to statistics compiled by the U.S. Centers for Disease Control and Prevention (CDC). Hilo on the big island of Hawaii ranks as the drunkest U.S. city, with 30.7 percent of the population meeting the criteria for binge and problem drinking. Close behind in second place is the town of Kapaa on the island of Kauai, with 30.5 percent of its citizenry admitting to excessive alcohol consumption.

What does heavy drinking or binge drinking look like? The CDC in its 2009 nationwide survey defined “heavy drinking” for men as having more than two alcohol beverages a day and for women more than one; binge drinking for men means downing five or more drinks at a time on one or more occasions during a month, and for women it means consuming four or more at least one or more times in a month.

Montana claims two of the other top five drunkest U.S. cities—Butte-Silver Bow at 29.3 percent of the population and Bozeman at 29.2 percent. This could make sense for a couple of reasons: 1) frigid temperatures might keep people indoors longer with more excuses to drink, though by that reasoning Alaska should have been at the top of the list; and, a more likely reason, 2) Montana has one of the nation’s highest rates of high school binge drinking. Heavy drinking during the teenage years can influence levels of alcohol abuse later in life.

These days, according to the 2009 National Survey on Drug Use and Health, 86 percent of our kids have used alcohol and half of them are binge drinkers by the time they turn 21. Many of the underage binge drinkers will outgrow the habit, but increasing numbers will continue to succumb to their compulsions. Drinking behavior before the age of 16 is a key indicator of future alcohol use. When kids become heavy drinkers before the age of 15, “they are about six times more likely to end up with alcohol problems,” said Peter Delaney, director of the Center for Substance Abuse Treatment at SAMHSA (the Substance Abuse and Mental Health Services Administration).

Pamela Hyde, administrator of SAMHSA, added: “The earlier someone starts using alcohol or drugs, the more likely they are to have an issue in adulthood. And conversely, if you can avoid using alcohol and drugs until you’re 25 years old, your chances of getting addicted are greatly lessened.”

This brings up an interesting question. Should parents be teaching their teenagers how to drink responsibly, just as we are supposed to teach them how to drive a car safely? Or should we be preaching and enforcing strict abstinence?

Though the minimum drinking age is 21 throughout the United States, 31 states allow parents to furnish alcohol to minors in the home. The statistics on use and abuse that I have seen are revealing. According to a 2004 survey of 6,245 U.S. teens, published in the Journal of Adolescent Health, those kids who drank alcohol in moderation with their parents, especially at meals or in religious rituals, were one-third as likely to engage in binge drinking as other teens, and half as likely to become regular drinkers.

There is an additional problem for teen binge drinkers, other than possibly setting a standard for abuse later in life: Alcohol abuse can inflict long-term harm to their developing brains. Using brain scans to study adolescents, university researchers reported in a 2009 issue of the Journal of Clinical EEG and Neuroscience that the frontal cortex and hippocampus of adolescents who have 20 or more alcohol drinks a month begin to change. Guess what those brain areas control—our cognitive and executive functions, our memory, our attention, and spatial skills. In other words, judgment becomes warped and impulse control is diminished. Unfortunately, the frontal cortex and the executive functions it coordinates are not fully developed until our early twenties. Alcohol use in adolescence impairs functions that are not yet fully developed.

By now, you should be getting a glimpse of your own pattern of alcohol behaviors, the ones you established early in life. Reflect on that for a few moments.

What kind of drinker were you as a teenager?

Were either of your parents a problem drinker?

How often did you get inebriated?

Was it a pattern that you continued into adulthood?

How often have you tried to stop drinking and failed?

Are you able to be honest with yourself about your drinking habits, or do you sense denial that needs to be penetrated for the truth to be known?

Indicators of an Alcohol Problem

It’s not always easy to know if you or someone you love has an alcohol problem and is in need of treatment. There are usually layers of denial—both yours and theirs—which must be penetrated, and then there are the social pressures that must be resisted, pressures that tell us drinking alcohol is a “cool” and socially expected behavior, even though more and more there is a stigma attached to its overuse and abuse. Here are the indicators that a personal alcohol problem may exist:

You carry an alcohol-susceptible gene

From Dr. Drew Pinsky, addiction medicine specialist and clinical professor of psychiatry, University of Southern California School of Medicine: One day we will have a genetic spectrum for the disease of alcoholism. The North American Indian version of the gene that makes them susceptible to alcohol will be different from the Irish-Persian, which can be different from the Northern European, and they are going to have different potentials for the disease. When a person’s genetic burden is low, the psychiatric burden or environmental burden has to be high for alcoholism to occur. But fundamentally, in my opinion, the most common issue that precipitates the disease from the genetic potential is something called Emotional Dysregulation. Not just more anxiety, not just more depression, which alcoholics have throughout their history, because they often come from an alcoholic family, but an incapacity to regulate their emotions. So their emotions are too prolonged, too intense, and too negative.

You’re anxious or depressed

From Pamela Hyde, administrator of SAMHSA: If you take people who have a mental disorder, who are depressed, 20 percent also have problems with alcohol or drugs. Almost half of all people with an identifiable addictive disorder also have an identifiable mental illness. These disorders often go hand in hand. We have a tendency to say, “Let’s take care of the depression and that will make the alcohol go away, or let’s take care of the alcohol, and that will take care of the depression.” I think the science tells us that integrated treatment, treating both concurrently, is the better way to go.

You’re overconfident about handling risks

From Dr. Robert DuPont, President of the Institute for Behavior and Health Inc, first director of the National Institute on Drug Abuse, second White House Drug Chief, and clinical professor of psychiatry at Georgetown Medical School: Is it risky to be a social drinker? My answer is yes. I see lots of people who are social drinkers for many years and then become alcoholics, even later in their lives. The addiction switch gets thrown late for these people. Once that switch is on at any age you don’t go back to being a controlled alcohol or drug user.

It’s clear that everybody is vulnerable, but some are a lot more vulnerable than others and usually what you find is the people that have a problem really liked alcohol a lot and tolerated it. If you’re starting to drink and you don’t like it, can’t tolerate it, and you feel terrible afterward and that leads you not to use, you’re protected from becoming an alcoholic. But if the first time you use you say, “Whoa! That was cool. I can drink and I can hold my drinks,” that’s a very bad sign.

So what aspects of a person’s lifestyle contribute to triggering or exacerbating substance use? Willingness to take risks and self-confidence that you can handle risk are very good predictors.

You exhibit these specific behaviors

From Norman G. Hoffmann, PhD, president of Evince Clinical Assessments: We’ve been looking at very detailed diagnostic data from over 7,000 people recently. And what we find is that there are certain things that are cardinal measures that you’re dependent. If you sacrifice activities in order to use, whether its alcohol or other drugs, or if you’ve not fulfilled your normal role obligations. You were supposed to do something and didn’t because you were preoccupied with drinking. You find yourself thinking a lot of about using when you aren’t. That doesn’t tend to happen for those who meet either an abuse (nondependent) criteria or the moderate substance-use disorder criteria.

If you set rules and you don’t follow them, that’s another one that tends to be on the list. If you’ve not fulfilled your role obligations as a homemaker or as an employee or whatever, if you’ve been very preoccupied with use, had a compulsion to use where you just felt you couldn’t not use. If you regularly experience any of these indicators, then you have a serious issue and you’re just not a mild user. If you’re one of the many who do experience these issues, then you need to understand that abstinence is probably your only stable out.

You suffer from multiple health problems

Finally, when assessing unhealthy alcohol or drug use, you should look at levels of use that may risk producing health consequences.

Dr. Richard Saitz, professor of medicine and epidemiology and director of the Clinical Addiction Research and Education (CARE) Unit at the Boston University Schools of Medicine and Public Health, proposes asking one single straightforward question to assess risk: How many times in the last year have you had more than five drinks (for men), or four drinks (for women) in a single day? If your answer is one or more times, you have a risk of health consequences from alcohol. It’s that simple.

Most people know about some of the obvious health consequences of alcohol abuse, from hangovers to chronic conditions such as liver disease and brain damage (yes, chronic use actually damages and shrinks parts of your brain that control judgment, impulses, and memory, along with regulating social and sexual behaviors). But did you also know that the chronic medical condition of alcohol abuse is the third leading cause of death in the United States and has been linked by medical studies to premature aging, high blood pressure, heart attack, stroke, and cancers of the breast, esophagus, stomach, liver, mouth, and throat?

Time to Get Honest with Yourself

We all possess layers of denial and self-deception about aspects of our lives. Whether it’s about our vanity (“I look younger than anyone my age.”) or about our skill levels (“I’m indispensable in this job.”) or our impact on people (“I am universally loved by others.”), our minds have a great capacity to trick us and shield us from unpleasant truths.

When it comes to alcohol and drugs and the other Seven Toxic Compulsions, our capacity to fool ourselves, which ordinarily serves to protect us from the wounding of pride, has much broader and deeper repercussions. These can include exclusion, the loss of one’s job, family, home, self-respect, and freedom, and even death. Substance abuse is a nasty and devious disorder of the mind that further empowers any natural tendency toward denial so that we end up playing complicated games with our thoughts and our rationalizations in ways that smother the truth and inflict harm on ourselves and others.

That’s one reason why it sometimes takes a life trauma such as a spouse leaving or bankruptcy or an unpleasant encounter with the criminal justice system for the layers of denial and the mind games finally to be punctured so that the light of honest self-reflection can shine through.

What sort of denial are you engaging in? What does the echo chamber inside your head sound like? Does any of this feel and sound familiar?

I don’t have a problem.

I’ve never had a problem.

I will never have a problem.

I can always control my drinking.

Okay, occasionally I slip up.

But I can always stop drinking if I really want to.

I enjoy drinking too much to ever stop.

If other people have a problem with my drinking, that’s their problem.

Okay, getting drunk and crashing my car into that tree was a slip up.

It will never happen again. I promise.

I know I can control my drinking.

And the mind games and the endless chatter of delusional thoughts go on and on and on.

It’s time to get real with yourself, and if you’re playing dangerous mind games, it’s time to stop. The following two questionnaires are useful screening tools to help you gauge the severity of your drinking. It’s an opportunity to shed some light on the matter and help you avoid inflicting unnecessary harm to yourself in the future.

Still not convinced you have an accurate insight into your drinking habits? Don’t know if you have an addiction or just a festering bad habit? What follows is a more in-depth series of questions that, if you’re able to be honest with yourself, should dispel any doubts about your drinking status.

AUDIT scores in the 8–15 range represent a medium level of alcohol problems, whereas scores of 16 and above represent a high level of alcohol problems.

The AUDIT (Alcohol-Use Disorders Identification Test) was developed by the World Health Organization (WHO). The test correctly classifies 95 percent of people into either alcoholics or nonalcoholics. It was tested on 2,000 people before being published. The pdf format version of the AUDIT is available through the WHO Web site, where you can also find the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST): www.who.int/substance_abuse/activities/assist/en/index.html.

Percentage of Users Who Become Dependent

This information comes from the only major study that estimates the percentage of persons using a specific substance who will become dependent on that substance. If you think about the number of people who periodically drink alcohol, the 15.4 percent who become “problem” drinkers translates into tens of millions of users with a habit that may be evolving into a dependency.

(Source: “Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey.” Anthony JC, Warner LA, and Kessler RC. Exp Clin Psychopharmacol. 1994 Aug;2(3):244–68. doi: 10.1037/1064-1297. 2.3.244.)

Alcohol Is the Most Dangerous Substance

Here is another collection of comparisons for you to keep in mind. The authors of this study evaluated the relative harm that alcohol, tobacco, and other drugs cause to users and others, whether they be friends, family members, coworkers, the local community, or the broader society. The authors assigned each a harm score on a 100-point scale. The higher the score, the greater the overall harm associated with the substance.

Here is the ranking:

(Source: “Drug harms in the UK: A multicriteria decision analysis.” Nutt DJ, King LA, and Phillips LD. Lancet. 2010 Nov 6;376(9752):1558–65.)

Myth buster: alcoholism is a moral weakness

Public opinion polls conducted in the United States throughout the first decade of the 21st century consistently showed that more than half of all people surveyed consider alcohol abuse and alcoholism to be caused by a “moral weakness” or a “character flaw” that can be cured merely by exercising willpower. Poll results for drug abuse and addiction provide similar results about public attitudes.

Although there is no doubt that willpower is important in any person’s decision to quit drinking and to remain in recovery, the root cause of alcoholism can be found in a person’s genetic predisposition, family history of substance abuse, and underlying psychological triggers such as anxiety and depression. In addition, environment is important. Poverty, social norms, easy access to substances, natural and man-made-disasters—all can contribute to the problem. These are all factors that must be taken into consideration for long-term sobriety to occur.

“There have been about 25 different genes found that are associated with how you respond to alcohol, determining such things as whether you have a tolerance,” pointed out clinical psychologist Norman G. Hoffmann, president of Evince Clinical Assessments, a pioneer in the study of treatments for addictions. That shows how complicated the genetic picture of addiction can be. By contrast, research by the National Institutes of Health determined that mutations in just one gene, the LCT gene, determine whether you have lactose intolerance, a painful digestive condition.

As for alcoholism being a disease process, Pamela Hyde, administrator of the federal government’s Substance Abuse and Mental Health Services Administration (SAMHSA) program, said, “There is no question that [alcohol is] a disease process. There’s also no question that there are some behaviors associated with getting started that tend to be voluntary in the beginning, but very quickly can become the disease process. There are also some behavioral and willpower things associated with remaining in recovery, yet we have to make sure that we stay focused on the disease process of alcoholism, which is not unlike any other disease—diabetes, for example—and it needs to be treated in that way.”

Inconvenient truth—some teenagers can drink like alcoholics

From Dr. Thomas McLellan, CEO of the Treatment Research Institute and former deputy director of the White House Office of National Drug Control Policy: It turns out that some young people, 18 to 25, can drink alcoholically. Go to any college campus, go to any Army base, and you will see regular use that meets any diagnostic criterion for alcoholics. Now if I said these people were 40 years old—and the science supports me on this—they’ll never drink normally again. They won’t be able to.

But it is a fact that some people in that range up to 25, or maybe even a little older, can meet the criteria for alcoholism and later age out of the problem. They can meet criteria for marijuana dependence. And they get out of college, go to work in the financial industry, and can use alcohol only on Friday and Saturday night and stop or greatly reduce marijuana use. Many others in this age group, however, don’t and probably can’t age out of their problem. So, you can’t assume that if you’re under the age of 25 and have an alcohol or drug problem, it will simply go away as you mature or your life circumstances change. We don’t understand what happens between the ages of 25 and 40. But by time you’re 40, your chances of aging out of an alcohol or drug problem are slim to none. You can’t have been drinking alcohol weekly and then suddenly say, “I guess I’ll just start drinking less now.”

A colleague of mine looked at a Drexel University’s freshman class about 10 years ago. He was very concerned about males who had either a father or an uncle with an alcohol problem. So he measured alcohol consumption in groups who didn’t have that first-degree relative and age-matched them with boys going to the same school who did. They were all drinking like fish. They were just drinking way in excess of what was good for them and they were drinking in dangerous fashions.

Here is what he found: Four years after college was over, the sons of the alcoholics were still drinking that way, but the sons of the nonalcoholics had reduced their use substantially.

Why People Quit Drinking

There are myriad reasons why a problem drinker may choose to quit or be pressured into quitting, or at least cutting back on use. Here are six reasons cited by some prominent experts interviewed for this book.

Family health history

From Dr. Leonard Weiss, psychiatrist and “addictionologist,” Atlanta Behavioral Care: There is always that person who wanders in and they’re just getting to be a bit on the abuse side of things and they just actually stop, it’s like a miracle. The main reason they give me is they say, “You know my father, my mother, whoever—they were alcoholic and they died of cirrhosis of the liver and I just—I don’t want to go that way.” That’s the main reason. Usually they somehow get in touch with the fact that they have a genetic proclivity.

Health concerns for the unborn

From Carlton Erickson, Director, Addiction Science Research and Education Center and distinguished professor of pharmacy/toxicology, University of Texas at Austin: Which drugs produce the worst fetal syndrome when the mother uses them during pregnancy? Alcohol by far is the worst drug. It produces the permanent effects: abnormal facial characteristics, and organ developmental defects, including brain underdevelopment. All other recreational drugs (legal or illegal) produce marked, but temporary, effects on the fetus. But the effects of alcohol on the fetus can be lifelong.

Legal consequences

From Pamela Hyde, administrator of SAMHSA: When a person with an alcohol problem is in a criminal situation, such as driving under the influence or something more serious where a person is hurt or dies because of an addiction, sometimes it’s the courts that have to say, “You’re going to suffer the consequences if you don’t get treatment.” Of course, if that person with the alcohol caused something more serious such as another’s injury or death, the courts will lower the boom. Treatment, if any, will occur behind bars. Some people need these kinds of punitive consequences to change. For others, an intervention by family and friends who say, “You have an issue, we love you, and we want to help you change,” is enough. So for some people who need the consequences, try to be supportive. For some people who need the support, the possibility of consequences may be an important part of starting the treatment and recovery process.

Fear of losing something

From Dr. Andrea Barthwell, CEO of the North Carolina treatment center Two Dreams Outer Banks: Some people can make a decision to quit by saying, “I don’t like the way my life is going.” It is really sort of decade driven. If by the end of your 20s, if you haven’t been able to create or maintain healthy relationships, the longing to be connected drives people to seek help. In their 30s, the reality of life sets in. Everything in their 20s is full of promise. And in the 30s, reality sets in and people experience dissatisfaction with where they’ve gotten in life. Sometimes that dissatisfaction accelerates the process of addiction, or sometimes it sets it off.

In their 40s, it’s generally a loss that motivates change. Your parents die, your marriage breaks up, your kids go off to college, you’re not performing well at work. Your health goes and you’re dealing with that. And in the 50s, if you’ve survived to that point, it’s generally about a rebirth, and a lot of the recovery that I see during the 50s is spontaneous. It’s like all the stuff that used to drag me down in a negative way, I don’t tolerate anymore. Then, if you haven’t left something significant or contributed in some way by your 60s, you start longing for that. You start trying to get busy because you know you don’t have much time left and you can’t have substance dependence getting in the way.

A desire to achieve something

From Thomas McLellan, PhD, CEO of the Treatment Research Institute and former deputy director of the White House Office of National Drug Control Policy: Quitting can start with asking, “What do you want in your life? Do you want to graduate? Do you want to get that new job, or meet that new girl? How is alcohol helping? How’s your drinking helping you to achieve what you want?” If it’s not, and usually it isn’t, that’s a sign, and yet, you’re still doing it. Sometimes asking these kinds of questions can bring the person to the point where they’re thinking about their behavior in relation to their own goals and that leads them to say, “It’s not working for me, actually. I need to change.”

When a therapist does this, it’s called a motivational intervention and that enables the individual to see that their own life goals are not being met by their substance use. Next they have an opportunity to try different ways of reducing their use. For people who have lost control over alcohol, they need to have something that’s important to their lives. Without it, without a goal, without a good job, a good religion, a good woman or a good man, it’s very difficult to give up their love affair with that substance.

To end depression

From Dr. Jeffrey D. Roth, addiction psychiatrist, author, editor of Journal of Groups in Addiction Recovery, and medical director, Working Sobriety Chicago: I’ve never had anybody come to talk to me where we didn’t find an addiction or compulsive behavior. If somebody comes in and says they’re depressed, okay, I say, “You’re depressed, are you engaged in any behavior that would be depressing?” And if the answer is, “What do you mean by that?” I say, “Well, for instance, alcohol is a central nervous system depressant. Are you using alcohol?” And the person will say, “Well, I drink recreationally.” And my next question is, “Is there a connection between drinking and getting depressed?”

And in general, if the person is using alcohol and they are depressed, there’s a connection between their use of alcohol and depression. So I’ll say, “Okay, the first thing you might want to consider is, what is your investment in staying depressed based on your continued drinking?” If you continue drinking, you’re taking in a depressant and you’re likely to be depressed. If being depressed is worth continuing to use alcohol, then I guess you’re telling me it’s not a problem.

If being depressed is something you’d like to do something about, you have a few choices. If you want to continue drinking a little bit, my question is, “What is your investment in being a little bit depressed?” So it becomes a question of what are you accomplishing by ingesting alcohol. Sometimes people are tired of being depressed and they come in ready to change their life. So they quit drinking.

Clinical Research Ranks Effective Treatments

Below are the top 20 alcohol treatment approaches based on the cumulative evidence of effectiveness compiled from the results of 381 clinical trial studies. These characterize what has come to be known as medical science’s “evidence-based” treatment options, all of which are available for you to choose if they suit your own treatment needs.

1. Brief intervention
2. Motivational enhancement
3. Acamprosate (a GABA agonist)
4. Community reinforcement
5. Self-change manual
6. Naltrexone (an opiate antagonist)
7. Behavioral self-control training
8. Behavior contracting
9. Social skills training
10. Marital therapy (behavioral)
11. Aversion therapy (nausea)
12. Case management
13. Cognitive therapy
14. Aversion therapy (covert sensitization and apneic)
15. Family therapy
16. Acupuncture
17. Client-centered counseling
18. Aversion therapy (electrical)
19. Exercise
20. Stress management

(Source: Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd ed. Hester RK and Miller WR, eds. [Boston: Allyn & Bacon, 2003], p. 19.)

Top 10 treatments are all relatively brief and can be delivered in an outpatient setting

None of the 10 most effective treatment approaches in the list above requires inpatient care, and most revolve around brief interactions with treatment providers and taking responsibility for the course of your own treatment trajectory. A few, of course, can be applied over extended periods of time and gradually have their effect. Even if the recovery pathway only involves taking one of the two medications, you still have control over your path to recovery. Among these top 10 treatments there is an approach “designed for people all along the continuum of severity, from problem drinkers to severely dependent individuals,” according to Hester and Miller’s Handbook of Alcoholism. Remember, too, for many people a formal treatment plan is not always the pathway to recovery. Community-based not-for-profit organizations and other recovery community organizations—all run by people in recovery—can provide a wide variety of support services that supplement and sometimes even replace treatment.

Some treatments don’t rank because of too few studies

A number of possibly effective treatment approaches for alcohol-use disorders don’t appear in the top 20 list because just two or fewer studies evaluating them had been finished by the time the Hester and Miller handbook was published.

Under-studied treatments include:

• Biofeedback
• Mindfulness
• Transcendental meditation

In the years since the handbook was released, however, numerous studies have been conducted demonstrating the effectiveness of all three of these treatment “tools.” I will discuss those results in Part Two of this book. In Appendix Two various mutual-aid recovery resource options are listed, many of them on the Faces and Voices of Recovery Web site, www.facesandvoicesofrecovery.org.html. And with the explosive growth in new technologies comes additional recovery options, including interactive text-messaging platforms and smart phone GPS apps to map high-risk geographic areas.

Also, as of the handbook’s 2002 release, only four studies had examined hypnosis as a treatment for alcohol problems, and all four reported no long-term positive effect on the drinking behaviors of study subjects.

What is the verdict on medications as treatment?

From the Miller/Hester handbook: “Many medications designed for the treatment of psychological disorders (e.g., anxiety, depression, psychosis) have been tested, and although these can be useful in treating concomitant disorders, they typically have very little direct effect on drinking. There are, however, two medications that now appear to be quite effective aids in the treatment of alcohol dependence: naltrexone and acamprosate.”

Since those comments were published, two more medications have been championed by some treatment centers and addiction experts: Vivitrol and Campral. Vivitrol, is a long-acting (or depot) formulation of naltrexone given by monthly injection. Naltrexone, both in its original pill form and in its newer long-lasting form, blocks the high that alcoholics and persons addicted to opiates such as heroin or oxycodone normally feel. Campral is taken orally and is intended to restore the balance in the brain’s neurotransmitter pathways harmed by alcohol abuse, which also helps to reduce cravings.

Although these medications are an improvement over Antabuse (disulfram), the medicine that has been in use for decades and makes a user sick when alcohol is consumed, there is an inherent limitation in relying upon medications for long-term recovery. They may be helpful in reducing urges so the person can get through the early months of recovery, but they don’t treat the underlying psychological causes for the disorder, teach the skills needed to achieve sustained recovery, or substitute for the necessary lifestyle changes and family and peer group support necessary for successful long-term recovery.

Taking naltrexone, for example, is a bit of a crap shoot. You just don’t know what the response will be. Dr. Thomas McLellan explained why: “If you give naltrexone to alcoholics, you get a pretty modest response. But it turns out if you give naltrexone to those alcoholics who have a particular genetic heritability, you get a really dramatic, almost curative response. If alcoholics don’t have that specific genetic combination, you get very little response.”

Are there more natural ways to reduce cravings?

To successfully stop drinking and remain sober it’s important to limit exposure to the triggers that produce the thoughts that, in turn, release the cravings for alcohol. These triggers can include people, places, memories, emotions, activities—just about anything that connects you to thoughts about alcohol and drinking. Controlling these triggers can be a difficult challenge for anyone. But it’s not impossible and the better you get at it, the less “charge” these triggers will carry for you over time.

“You may not be able to completely eliminate your exposure to triggers, but you always have control over your thoughts,” observed Dr. Harold C. Urschel, CEO of Urschel Recovery Science Institute, chief of medical strategy for www.enterhealth.com, and author of Healing the Addicted Brain (2009, Sourcebooks). “Cravings are common in the recovery process. They are not a sign of weakness or failure. Cravings are like waves in the ocean: They may come in big and strong, but they go out with no strength at all. The startling fact is, people in recovery typically give in to only about 5 percent of their cravings! That means 95 percent of the time, you will not drink or use in response to a craving. That means that you can already resist just about all of your cravings—and with work and time, you can learn to resist the rest and, eventually, they will go away.”

In his book and on his Web site, www.EnterHealth.com/HealingtheAddictedBrain, Urschel described five “craving crusher” techniques that anyone can learn to use:

• Distract yourself. Whether by using a meditation practice, doing yoga or exercise, or listening to music, you can distract yourself from cravings when they arise.
• Use flash cards. By writing a list of the positive benefits of resisting cravings and the negative effects of embracing them—and referring to the cards when cravings arise—you can train your brain to stay focused on sobriety.
• Talk it out. This one is commonly used in 12-Step programs. When you feel a craving, contact someone sober by phone or in person to talk about what you’re feeling in the moment.
• Stress management. Again, whether it’s meditation, yoga, or other stress-managing techniques, or acupuncture, massage, or reflexology performed on you by someone else, it’s important to keep your stress levels low to keep triggers at bay.
• Visualization. A variety of sensory awareness techniques fall under the heading of visualization exercises. What they generally have in common is they distract you from the cravings by keeping your attention focused on a serene, positive, and happy place that you create within your mind’s eye.

For more detailed information about the above techniques and other ways to reduce alcohol cravings, refer to Part Two of this book for a how-to course on a range of effective and easy-to-learn techniques.

What makes brief interventions effective?

It’s important to emphasize that dozens of clinical studies show a significant beneficial effect on a problem drinker can occur when contact with a physician, social worker, or addictions counselor is relatively brief but impactful. Three types of brief interventions rank among the top five most effective evidence-supported treatment approaches.

These approaches contrast sharply with confrontational counseling styles, which, whether delivered in an individual or group setting, “have one of the most dismal track records in outcome research with not a single positive study,” concluded the authors of the handbook’s chapter on treatment research.

One of those authors, William R. Miller, the distinguished professor of psychology and psychiatry at the University of New Mexico, explained his analysis of findings from 30 studies that identified the six important reasons, or elements, that make these brief conversations so effective:

1. Feedback. People get personal information about themselves and their drinking practices. This isn’t a lecture, because lectures have little impact on drinking problems. The information could be the results of a liver function test, showing them where those results put them in relation to the general population; such results usually surprise them because they think their drinking is quite normal.
2. Responsibility. These interventions tell people it is up to them; no one can make the change for them. Their autonomy is being acknowledged.
3. Advice. The advice-giver shows compassion in expressing concern and suggests a change in the drinking behavior.
4. Menu of options. The drinkers are told there is a range of different approaches, if they want help, so the key is to find what works for them. That is empowering.
5. Empathy. The counselor’s style is a listening, compassionate one, rather than an in-your-face authoritarian “I know best” approach.
6. Self-efficacy. Instill optimism: People can and do make changes in their drinking habits.

All of those were mixed together in these 15-minute interventions in the studies analyzed by Prof. Miller. The interventions occurred in a variety of settings, even in places like an emergency room where the alcohol abuser was being stitched up from an injury.

More study results support my optimism. In 2007, British researchers assessed the effectiveness of brief interventions in reducing alcohol consumption by doing a “meta-analysis” of 21 randomized controlled trials involving 7,286 patients in primary care settings. Meta-analysis means statistically comparing the results of multiple studies that address a particular question.

On average, patients who received brief interventions reduced their alcohol consumption by 41 grams a week compared to patients with similar drinking habits who didn’t receive intervention. “Brief interventions consistently produced reductions in alcohol consumption,” wrote the nine University of Newcastle authors of the study. The effect was clearer and more pronounced in male patients than in women after a follow-up one year later. (Source: “Effectiveness of brief alcohol interventions in primary care populations.” Eileen F. Kaner et al. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004148.)

“Motivational interviewing” inspires drinking habit changes

Motivational interviewing is an effective type of brief intervention pioneered by Prof. Miller. It involves a way of talking to people to encourage the emergence of their own internal motivation for change. He explained it this way:

“There is no formula for the questions that can be asked. I would first ask about your drinking habits. I might ask, ‘Tell me about what’s been happening in your life that is negative. What is the downside of your drinking? What would be some advantages about changing your drinking? How would you do it? How would you go about that to succeed? How important do you think it is to be drinking?’

“I listen and ask them to give me their own experience. You get the person talking about their own motivations. They begin to see that the cost of their drinking has gotten to the point where it isn’t worth it anymore. They begin to desire change.”

Can you do a brief intervention on yourself?

Sometimes it’s possible, though admittedly it’s rare, for someone to ask themselves three or so questions, all brief intervention questions that shake loose not only their realization of their alcohol problem, but also lead to a commitment to addressing the problem. Psychiatrist Leonard Weiss provided three questions that might be used by someone attempting a brief self-intervention:

1. What is my potential in the major areas of my life, and how much is my addiction affecting that potential?
2. What do my family and friends think? (Since none of these decisions is made in a vacuum.)
3. What are my options (practically and financially) for treatment if I make a decision to receive treatment?

(To learn more about interventions and how to conduct them, refer to Part Two of this book and the section “I Love an Addict, How Can I Help Myself?”)

Why don’t 12-Step programs appear in the top 20 ranking?

You won’t find Alcoholics Anonymous and the 12-Step structure in the Hester/Miller handbook’s top 20 ranked treatment approaches for three very good reasons: 1) nearly all of the studies done simply tested coerced attendance (court orders or employee assistance mandates by employers) at AA meetings, and it’s common knowledge that the AA program works most effectively for people who are committed to it by choice; 2) 95 percent of the people who attend their first AA meeting end up dropping out and not staying in the program long enough to experience beneficial results, so few studies have focused on or have followed long-term attendees at AA meetings; and 3) AA and other 12-Step programs are not forms of treatment (i.e., they are not clinical services provided by professional practitioners). (See Part Two of this book for more information about 12-Step programs and their effectiveness.)

Can You Become a “Moderate” Drinker?

Between the extremes of uncontrolled problem drinking on the one hand and total abstinence on the other is a type of compromise or middle ground of use called the Moderate Drinking program that seems to work for some people.

For college binge drinkers and adults who feel capable of continuing to drink responsibly but want to reduce their consumption levels, and for people who need to experience an intervention but fear the stigma and shame of doing so with family or friends, computerized and Internet-delivered interventions and drinking-control techniques may be the answer to a prayer.

This evidence-based approach using computers and the Internet has been pioneered by Dr. Reid Hester and his team of clinical researchers at Behavior Therapy Associates in Albuquerque, NM. It involves a cleverly designed series of interlocking components:

• A Drinker’s Check-up, a computer-based motivational intervention, available as both an Internet or Windows application, which gives an assessment of drinking habits. The Drinker’s Check-up has been included in SAMHSA’s National Register of Evidence-based Programs based on clinical study results and the finding that college students reduced their drinking by up to 55 percent in the months following a session.
• For an annual fee of just $59, an interactive Web site, www.moderatedrinking.com, guides alcohol users through steps to control their drinking based on the principles of Behavioral Self-Control Training. Dr. Hester conducted a randomized clinical trial with users of the program and found that their alcohol consumption was cut nearly in half. There is even a Facebook page and evidence-based Web apps for people with alcohol and drug problems.
• To further address the needs of early-stage problem drinkers who do not want to abstain, Moderation Management (MM) can be joined online (www.moderation.org) or by meeting in person at sites around the country. The organization’s goal is management and control of alcohol consumption rather than complete abstinence. About 30 percent of MM members eventually do decide to enter abstinence-based programs after testing whether they could adhere to MM values and goals. One key MM assumption is that alcohol abuse, in contrast to dependence, is a learned habit and not a disease; and that problem drinkers should take responsibility for their own recovery by being offered a choice of behavioral change goals. Dr. Hester is on the board of directors of this program.

A 2006 study of the Moderation Management program in the International Journal of Drug Policy found that the dropout rate for new MM members was 61 percent, compared to 81 percent within one month for Alcoholics Anonymous members. Another interesting difference between the two programs was in the proportion of women in attendance—66 percent of MM members were women compared to AA’s female membership of just 33 percent. This difference may reflect the fear of stigma, a particular barrier to women’s help-seeking. The MM online format combined with the use of pseudonyms, and the fact that MM also encourages a discussion of life problems and emotional issues other than drinking seems to account for the gender disparity between MM and AA.

Study author Ana Kosok of Columbia University reached this conclusion: “Women may have needs unmet by AA, which focuses primarily on alcohol cessation … MM emphasizes balance in all areas of life … MM may be particularly attractive to women because they need not leave home or disclose their help-seeking to family and friends, and because MM may offer more opportunities for attention to personal issues.”

In 2011 Dutch researchers studied Web-based program treatments for problem drinkers and concluded that “Web-based interventions for problem drinkers improve the availability of alcohol treatment services and reach a more diverse segment of the population of problem drinkers … evidence supports the clinical effectiveness of a diversity of Web-based interventions … it seems that the best results are achieved with interventions that use personalized feedback.” (Source: “Attrition in web-based treatment for problem drinkers.” Marloes G. Postel et al. J Med Internet Res. 2011, Dec. 27;13(4):e117.)

Dr. Hester further observed: “When you’re undecided about whether you have a drinking problem and need to change, a 12-Step program or other abstinence-only program may not work at first. Nobody likes to be told what to do. Our Drinker’s Check-up online program helps people answer the questions, ‘Should I be concerned about my drinking, what risks are there, and how bad are my consequences?’ It helps them resolve these questions. There is a lot of data indicating that people are more willing to disclose information about their drug or alcohol use to a computer program than to a person. Anonymity helps to initiate the process of change for many people.”

Here are some links to check out for more information:

Who Needs Inpatient Treatment?

Before you jump to the conclusion that you or someone you care about needs to enter an inpatient treatment facility, which, needless to say, can be very expensive, carefully consider all of the options and what the following two experts have to say.

From Norman G. Hoffman, clinical psychologist and president of Evince Clinical Assessments: Whether you should be in an inpatient or outpatient program needs to be dictated by whether or not your life is stable enough to benefit from the outpatient program, or whether you need some kind of a controlled, safe environment in which treatment can begin its process. So the issue of who needs a residential placement is really more a function of do you have either a chaotic home life, an environment that’s not conducive to recovery, like there’s nobody in the family that’s supportive, or half of the family members are also addicted? Or has your functioning deteriorated to the point where you really should have some kind of a structured environment for a period of time?

We actually did a study and found that people who appeared to be overtreated, who would’ve qualified for an outpatient program but for some reason went to inpatient, actually did worse as inpatient. And I think part of the reason for that was—this was in Minnesota in the 1980s—that the person who was less affected being placed in such a program with people having more serious problems, would look around and say, “Well, I haven’t lost my job yet, and I haven’t lost my spouse yet, and I haven’t been in jail yet, so I don’t have this problem.” And so I think for some of them that would lead to denial and a more serious drinking problem when they left the facility.

From William White, senior research consultant, Chestnut Health Systems: Inpatient and outpatient treatment cannot be adequately compared because they are designed to respond to different levels of problem severity and potentially to different stages of recovery. I would estimate that not more than 20 percent of those meeting diagnostic criteria for a substance-use disorder require inpatient or residential treatment. Inpatient and residential care should be restricted to those with the greatest problem severity and the lowest natural recovery support resources. Inpatient and residential care is particularly appropriate for persons with acute medical/psychological problems who require close monitoring or care during detoxification and early recovery, persons living in a family or social environment that inhibits the initiation of sobriety, and persons for whom past outpatient treatments and community supports have not provided a sufficient framework for achieving recovery stability.

Some Treatment Options

For more information about the self-help oriented treatments mentioned most frequently by the experts interviewed for this book, along with valuable tips about how to utilize these methods and tools, consult the following:

• Acupuncture, Seven Self-Care Tools, p. 264
• Cognitive Behavioral Therapy, Seven Self-Care Tools, p. 235
• Exercise, Seven Self-Care Tools, p. 261
• Group Therapy, Seven Self-Care Tools, p. 240
• Nutrition, Seven Self-Care Tools, p. 256
• 12-Step Programs (including Moderation Management), Seven Self-Care Tools, p. 240
• Journaling, Seven Self-Care Tools, p. 270

Your 30-Day Challenge for Alcohol

(developed by Andrea G. Barthwell, MD, FASAM)

Do you have a bad habit or a dependency? Here is another chance to find out.

You’ve answered the questionnaires for this toxic compulsion. You’ve read through what the experts have to say and thought about the extent to which you exhibit the behaviors associated with either a nondependent use disorder or a dependency.

Do you still have any doubt about whether you have just a bad habit, or whether your behavior meets the criteria for a dependency?

Create a 30-day challenge for yourself.

Your challenge is to have two drinks every day for a solid month, whether you want to or not. But no more than two drinks a day!

That means either:

• two 12-ounce beers a day;
• or two 6-ounce glasses of wine;
• or two 1-ounce shots of hard liquor.

If you’re a nondependent user, you will find it difficult to actually complete a month of daily drinking. Someone with a drinking problem will not only meet the challenge but may well drink more than the two-drink-a-day quota.

Meeting this challenge of drinking every day doesn’t mean that you do or don’t have a problem, but it’s safe to say that if you are unable to drink every day, you probably don’t qualify as a problem drinker.

If at the end of this challenge you sense that you really do have a problem, the next step is up to you. Treatment is probably something you need to consider.