Cold turkey better than dead drunk
IN our society, significant pressure is often applied to those who need to remain abstinent from alcohol and other drugs to stay alive.
This also applies in our prisons, where 80 per cent of inmates have significant problems with alcohol and other drugs.
Yet even within our prison population there is strong pressure from psychologists and other professionals to advocate so-called harm minimisation as opposed to the goal of total abstinence.
In common and often professional usage, the notion of harm minimisation conflates two very different ideas. Only one of these do I support, and that is the idea of preventing avoidable harm by providing safe needle exchanges and supervised injecting rooms to prevent users contracting HIV, hepatitis and other disease.
But the other notion of so-called harm minimisation I cannot support. That is the proposition that alcoholics and addicts can (and should) be taught to somehow moderate or control their usage, as opposed to try to learn to abstain, despite the fundamental fact most drug use in our society is illegal.
How bizarre, then, to be informed by prison psychologists that, while in custody, prisoners X and Y are learning to moderate their drug usage, as though this were somehow praiseworthy.
In Australia there is still deep suspicion about those who do abstain.
As Sir Les Patterson puts it: “Never trust a man who doesn’t drink/Though he may not throw up on your kitchen sink/I’d rather be half-hearted/Than be a blue-nose, wowser bastard/So never trust a man who doesn’t drink.”
Recently at a party at Redfern in Sydney, I overheard someone say “Watch her, she doesn’t drink.” Indeed, at social functions when I drink mineral water or fruit juice I am often asked, “What’s the matter, don’t you drink?” To which I sometimes reply, “What do you think I’m doing, eating a sandwich!?”
Alcoholism and drug addiction among the young is much more prevalent than most people realise. And for alcoholics and other addicts, no matter what age, in the long term (that is, for two to three years) the only safe option is to aim for total abstinence. Yet regretfully, as a therapeutic aim, abstinence is still often regarded askance.
To most people it is obvious, given the damaging, life-threatening consequences of alcoholism and other drug addiction, and the proven inability of alcoholics and addicts to control their drinking or drug use, that the goal of treatment should be total abstinence.
Yet in the past 30 years in Australia, and elsewhere in the West, an anti-abstinence orthodoxy has become entrenched in health department and corrective services practice and policy, with unfortunate results.
What is particularly damaging is that alcoholics and other addicts (and their families) are given the false hope that controlled drinking is a viable option.
Despite continued advocacy by many state and federal health workers and government bureaucrats for alcoholics to be treated by controlled drinking programs, the evidence is very strong that after two years or more the aim of controlled use fails miserably for people with addictions.
Indeed, almost all alcoholics who aim for anything other than complete abstinence return to full-blown addiction. As George Vaillant puts it in his long-term longitudinal study, The Natural History of Alcoholism Revisited: “Despite its prominence 20 years ago, training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage. Hopeful initial reports have not led to replication.”
Initially, in the 1980s, funded by the Rand Foundation, Vaillant supported the controlled use of alcohol and other drugs but, after seeing the results of his long-term follow-up studies, he has moved to advocating abstinence and the 12-step approach of Alcoholics Anonymous, which is by far the most successful agency in helping alcoholics and problem drinkers to stop drinking alcohol and to stop using other drugs as well.
Because it is an unpaid lay movement of men and women who have managed to stay free of alcohol and wish to help other alcoholics achieve sobriety, AA is often undervalued or not valued at all by medical practitioners and health professionals.
Despite overwhelming long-term evidence, in Australia the proponents of controlled usage remain in favour with most government bureaucrats and health professionals, while those who advocate a strategy of abstinence are marginalised or ignored.
As Vaillant’s comprehensive studies of alcohol abusers clearly demonstrate, while five years of abstinence is adequate to predict a stable future, return to controlled drinking is a much less stable state.
To put it another way, after abstinence has been maintained for five years, relapse is rare. In contrast, return to controlled drink without eventual relapse is unlikely. This is not to deny that even severely dependent individuals can occasionally achieve more moderate drinking; the crucial caveat is that this is a relatively unusual occurrence.
Moreover, even staunch advocates of controlled drinking or drug usage acknowledge that a successful outcome becomes less likely as the severity of dependence on alcohol and other drugs increases.
Although, superficially, it may seem a useful strategy to health professionals and government bureaucrats, suggesting that alcoholics and addicts should somehow try to learn to control their drug usage is an enormous waste of human and financial resources that causes, if not death, then often irreparable damage.
The truth is that an alcoholic’s or an addict’s best chance of recovery lies in practising total abstinence.
It is pleasing to report that groups such as the Salvation Army have maintained a commitment to total abstinence via the AA program as the prime therapeutic goal for alcoholics and other addicts. Fortunately, in the past few years we are also beginning to see a return to the abstinence model by a small but increasing number of psychologists and medical practitioners, and to once again valuing AA as the most effective form of long-term therapy for alcoholics.
Although it may be regarded by some as politically incorrect, it is pleasing to report that the NSW government’s Expert Advisory Group on Alcohol and Other Drugs, of which I am a member, has adopted and extended the provisions of the Inebriates Act of 1912, which for decades had not been widely used.
Now, in NSW, whose government has strongly supported this initiative, severely ill alcoholics can once again be subject to an order forcing them into effective, long-term, life-saving treatment.
As a side benefit, this means that, as well as those individuals in the grip of addiction, the families of alcoholics and other addicts can be saved from immense despair and desperation and of physical and psychological injury, and sometimes even death.
At the very least, the revamped Inebriates Act may save the lives of thousands of alcoholics and addicts and, in the process, allow enough time for AA and the Bridge Program to do their highly effective work.
Ross Fitzgerald The Weekend Australian October 31, 2009. Ross Fitzgerald will deliver the keynote address to this year’s International Life Education Conference in Sydney on December 13.