Home » Columns

Cold turkey better than dead drunk

31 October 2009 4,186 views One Comment

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.

One Comment »

  • John Wallace said:

    To Ross Fitzgerald

    Hi Ross

    I have a professional interest in addiction rehabilitation, and I agree with your two fold evaluation of harm minimisation in the Weekend Australian today – HM is good where it is effective, but abstinence beats “controlled use” hands down.

    Recently I came across a number of websites that promote abstinence using peer encouragement, but without the spirituality of AA. e.g. http://www.seekingsafety.org among others.

    A practicing Christian myself, I nevertheless believe that AA does not provide the most accurate or effective analysis of addiction. That honour, in my opinion, goes to the late Allan Carr, who discovered it first in regard to smoking and then applied it to other issues, including alcohol use and over-eating. How one defines a problem, will decide how one must treat it, so to have a good understanding of addiction is vital for successful treatment.

    If you don’t know Carr’s method (called “The Easy Way” because it doesn’t focus on so-called will power), I recommend you buy one of his books on quitting alcohol. e.g. http://www.amazon.co.uk/Allen-Carrs-Easy-Control-Alcohol/dp/0572028504 . It could be argued that this book’s title “The easy was to control Alcohol” is a red-herring as it seems to imply that “controlled use” is possible. In fact, Carr’s logical arguments lead to abstinence – that is, to having a good time at parties, unwinding after work, able to let your hair down, renew your confidence, cope with grief and stress, become talkative, etc, etc in more effective ways than using alcohol.

    In a nutshell, Carr’s analysis challenges the almost universal belief even among non-users –

    that nicotine or alcohol (and I would add speed, and heroin), despite all the damage they do you, do also provide some benefits to the user. Otherwise there would be no point at all to using them, would there??!

    Carr’s approach is unique in that he argues very persuasively that all the Advantages are no more real than a magician’s trick! (Given how extremely profitable the trick is for suppliers of alcohol and other psycho-active drugs, we can understand the motivation and refinement that has gone into the exquisitely clever propaganda.) Carr says that only the Disadvantages of use (often very serious, slow-developing problems) are real. He argues very persuasively that the so-called Advantages (usually involving a guaranteed and rapid mood change) are either:

    * effects produced by something other than the addictive substance (e.g. alcohol is not refreshing, it is the water in the beer that refreshes),
    * not really advantages (e.g. losing awareness of your feelings when intoxicated), or
    * else rely on the placebo effect (e.g. the belief that that the alcohol is relaxing you as soon as you put your feet up after a hard day’s work and take your first guzzle your favourite beer – in fact your feelings of relaxation have nothing to do with alcohol, as shown by the fact that the alcohol won’t actually hit your brain for 20 minutes after than first guzzle, yet you are feeling relaxed as soon as you sit down).

    Typically, when we have an addiction (be it gambling, sex, shopping, workaholism, drugs, etc ) and are again caught in the urge to use (because we are experiencing unpleasant feelings which we don’t confidently know how to manage constructively), it is an excruciating experience – we feel we are between a rock and a hard place. Carr’s approach dissolves the double-mindedness for all who are able to really see that the addiction’s once-believed benefits are actually not real, whilst remaining mindful that the addiction’s disadvantages are real.

    Add to this approach Donald Nathanson’s Affect Theory – that unpleasant emotions exist to focus our attention on threats to our wellbeing, which threats we will be able to adapt to or overcome with some well-considered decision-making – and we become happier, better integrated, better-behaved people, free of addictions.

    Any feedback appreciated,

    John Wallace