My brain is often binary. It is either off, or on. Hyperfocused on one thing, or taking an expansive astrological/anthropological view of everything. Dissecting tiny details, or painting visions of grand vistas.

A year ago, while creating this web space, I floated between the grand visions — what I wanted Live Sensibly to be — and the nuts-n-bolts details of building a website.

I’d hoped to leverage this venture into one that would add income soon, but that turned out to be much a more complex process than I envisioned, so I branched out. I got lucky, landing on a couple of quirky but uniquely fitting opportunities to cover the rent, though not immediately.

That stuff is starting to play out… a little more income is flowing in, and I’m gradually inching my way out of crisis management and into ordinary living.

My passion for wellness, harm reduction, and thoughtful, evidence-based approaches to dealing with compelling, compulsive, and addictive behaviors remains. I wish I had all sorts of time and energy to dig into those kinds of topics TODAY, but of course this is my real life, not the Cinderalla version of it.

Stay tuned, if you wish… the most important part of any journey is its future, not its past, and I’m committed to making this part of my journey meaningful.

You have inspired me, though…

I just want to encourage to to keep on keeping on… I promise that I will do the same. It’s not a perfect world, nor do I want it to be, but I wish you just one moment which feels perfect to you in the next week. You’ve already given me my moment, so wishing you the same is the least I can do.

…former President Clinton, whose addiction to fast food is well known…

One more sign of cultural schizophrenia about enjoying the simple pleasures of life, eh? The disease model: Coming soon to whatever you enjoy most!

He has mentioned his drinking history prior to getting inpatient treatment in June 2002, but not dwelt not on it. Dire circumstances precipitated the hospitalization, which led to 10 weeks of sobriety.

True to his introductory words about living with alcoholism being a battle, the early journal entries recounted 4-10 drinking episodes in each month from November 2002 through March 2003. Sometimes he journaled while sipping the first glass of wine; other times he recounted having drunk 2 bottles (occasionally more) a day or two afterward. Some drinking incidents, like the single glass during Christmas lunch, were less substantial and others, like those in March, were heavier and occurred on consecutive days.

Throughout it all Martin seems grounded in the need to get good care. He talks about staying in touch with his GP to coordinate anti-depressant dosage and monitor side effects, and about having a good relationship with his company doctor. When drinking incidents seemed to accelerate in March 2003, he got back in touch with the treatment facility and returned for a 3-week inpatient stay ending in early April, and continued with its aftercare program.

A full spectrum: Good life amidst the challenges

By his own account, he has sustained a rich, productive life along the way. He and his partner have had a new home built, moving in a year ago. His young daughters are the light and joy of his life. His employer has adapted, if begrudgingly at times, to his health care needs. The relationship with his partner has seen ups and downs, yet some of its dark moments have turned out to be not as severe as they first seemed to him.

The stresses have been real, as well. The relationship with his ex-wife can be contentious, turning life upside-down on top of the trials that come with being a noncustodial parent. The drinking strains the relationship with his partner, whose career-related challenges have surged at times. Conflicts with members of the extended families, familiar to many gay couples, tend to spike around holidays and celebrations of milestones.

Turning point: Second round of treatment?

The second treatment episode, ending in early April 2003, seems to mark a turning point. Prior to it there were fairly regular cravings, little mention of aftercare at the treatment facility, regular attendance at AA meetings, and 4-10 days in each of the five preceding months during which he drank. For the year beginning in late March 2003, there was only one day on which drinking occurred (a single glass of wine), heavy involvement in aftercare at the facility, fewer mentions of cravings, and a tapering back of anti-depressant dosage for a while in the fall.

Things got a little more challenging in April of this year, with 3 drinking days, and drinking has come into the picture on 6 days total from May through August.

Overall trend: Up

There appears to be a positive trend over the past two years:

Martin still describes a significant gap between where he is and where he intends to be. Keeping 95% of his days alcohol-free is noticeably better his past, but the drinking days remain disruptive to his health, his relationships, and his peace of mind. The fact remains, though, that the 17 months since April 2003 have been 98% alcohol-free.

October 2003: One glass

Seven months after the start of the second inpatient treatment, Martin bought wine and drank a glass. Finding the experience to be very distressing, he consulted the folks at the facility and elected to get relapse-related care from them on an outpatient basis over the next 10 weeks or so. Also working closely with his GP, his antidepressant dosage was adjusted, and he followed his doctor’s orders to focus on self-care, away from work, for two weeks in December.

Many phases, multiple choices and solutions

The powerful thing about Martin’s story, to me, is the reminder that dealing with alcohol-related issues is a dynamic affair. From the outside, it may look like a lot of folks find recovery through an awakening that puts life on an entirely new plane, but even for those whose recovery journeys appear placid and peaceful the path has often been rocky.

His path has included working with treatment folks, peer support from AA, and leaning on sponsors for guidance. He’s worked with Acamprosate and tried out dietary options. Some aspects of the disease concept have appeared baffling at times, but he also has asked questions (about powerlessness, for example) and gotten answers that have been helpful.

The battle remains for him. Cravings spike, and frustrations sprout on good days and bad. Being a work in progress isn’t just an addiction thing, though, it’s a life thing. For so many issues, resolution comes from a process instead of a one-time result.

Martin’s journal shows a lot of tenacity — a steadiness about continuing to engage in the recovery journey amidst questions and challenges — as well as in choosing to do so publicly. Week in, week out, he has kept coming back to talk a little bit more about where things are at. Sometimes it draws feedback that may feel a bit intrusive, but he keeps listening.

It could have been a lot easier to give it up when questions came up about his family reading it, or when things have not gone well. I admire him tremendously for sticking with it, for giving voice to a recovery path that seems to be headed in a positive direction.

This is a good guy, a fighter, a thoughtful dad, a real person. There is much for me to learn from him.

Police in eastern Latvia were trying to determine Wednesday what charges to bring against a drunken horse-and-buggy driver who caused a drunken motorist to crash into a ditch, flipping his car.

Nobody hurt, the car driver fined and license revoked, but Latvian law doesn’t criminalize taking the reins while intoxicated.

Via Sarpy Sam at Thoughts from the Middle of Nowhere.

One of the drugs, Naltrexone (Nal), has shown promise both for folks seeking to abstain permanently as well as those who are drinking moderately or working toward a moderate drinking goal. Julie R., a Moderation Management member, has journaled vividly about her recent experience with it and has graciously agreed to let me share a bit of it with you.

Her experience with it strikes me as similar to that of folks using antidepressants — some trial and error is necessary to find the best dosage, results can vary from day to day, and the drug supports, not replaces, insight and effort — and you’ll see that she describes trade-offs in using Naltrexone, as well.

Dr. Alexander DeLuca, M.D. is a great online source for papers on this topic, updated regularly as new stuff is published.

I didn’t have a drink last night. It was my first abs night in months, I think. And it may be the beginning of an indefinite abs.

I preceded it the way so many abs periods start, with heavy drinking, which is actually not a very pleasant experience when you’re taking naltrexone. You keep reaching for that high, and reaching, and instead, all you get is stoned, stupid, dehydrated, and hungover. When I finally couldn’t hold anymore, I poured the rest out. When I woke up yesterday morning, I talked into a tape recorder for a while about how awful an experience it was and how much I wanted my freedom from what has become an unpleasant habit.

Thanks to naltrexone, alcohol has lost its value as a recreational drug. It took a while (I started taking it six weeks ago), and it is not an easy process, but it bloody well works if you take it as directed and have effective help for the issues underlying the drinking (sleeping, depression, neurotic fears).

I can’t remember what it feels to drink without nal. Those memories have been replaced by how it feels to drink with nal. Which ain’t all that great. I mean, it’s something — it gets you to sleep, it makes you forget, it relieves anxiety. But if you’re getting adequate support for the sleep and the anxiety and whatever, as I am, booze is a relatively poor self-medication, if you subtract the endorphin high, which nal does.

I suspect that the way it feels for me to drink on nal is the same as it feels for a non-drinker without any endorphin deficiencies or sensitivities to drink. You know, non-drinkers honestly just don’t like drinking as much as we do. If they did, they’d be drinking, by golly.

July 29 2004

I was watching a movie last night, and at some point three characters have reached the cocktail hour at the end of a long day and one of them says, “Harry, could you organize some drinks for us?” And I suddenly remembered what it feels like to drink without naltrexone. Of course I know it’s different, but I generally can’t remember what it was like to drink without naltrexone. Watching others do it on the screen reminded me — all the relaxing and forgetting of the first cocktail. “Let the healing begin!” as the guy in the New Yorker cartoon says as he order his first double martini, dry.

I wonder how long it will be before I have that feeling again. It is entirely my choice when I do or do not.

In the meantime, I’m more interested in figuring out what it is like to live without alcohol again.

I don’t much want a drink, because it would be a drink with naltrexone, which is not all that pleasant. I think I’d like to just stay the way I am for a while, give my liver a break, think things through with a clear head, do my job.

August 19 2004

I regret to report that my drinking is back up to my pre-naltrexone levels. My psychiatrist says, however, that I’ve got so much going on right now hormonally and neurochemically that it’s too soon to call the experiment a failure, and he has encouraged me to keep taking it and see what happens, so I will.

Update

Ooops, it was actually Joe Gandelman, who also writes at The Moderate Voice, who posted the link at Dean’s site. Dean weighed in with a comment shortly after.

The condition which the law requires the doctor to report is alcohol misuse — which Pennsylvania legal code doesn’t define any further — not addiction or dependence.

Let’s take a look at the sequence of events, how Emerich stacks up against the criteria for alcoholism, then sensible drinking, treatment options, and finally ethical perspectives.

• 1960s: PA passes a law requiring doctors to report patients with impairments that could compromise their ability to drive safely such as seizure disorders and Alzheimer’s; licenses are recalled indefinitely until the driver proves competency to drive.
• 1976: PA legislature creates the Medical Advisory Board to decide which conditions warrant license suspension.
• February 2004: Emerich seeks medical care for an irregular heartbeat. Asked about his drinking, he says 6-10 beers nightly is typical. Alcohol is identified as damaging his heart, and he is advised to cut back.
• 01-April: Emerich receives a notice from PennDOT saying that his driver’s license will be recalled in a month for medical reasons related to substance abuse. A physician has followed PennDOT instructions (20K PDF), which encourage the doc to report and protect him/her from being sued.
• 06-May: Emerich’s license is recalled by the PennDOT.
• July: The PennDOT Medical Advisory Board reviews criteria for license suspension; no changes made.
• 29-July: Emerich appears at hearing to appeal the suspension. “It’s the law that’s wrong,” not his doctor, he says.
• 18-August: County Judge Bradford Charles rules that PennDOT should not suspend driving privileges indefinitely, but citing doubt about Emerich’s claim to have dramatically reduced his drinking, orders him to install an ignition interlock (a $1,100 annual expense) if he wishes to resume driving.

Does Emerich have alcohol dependence (alcoholism)?

Philly.com, 20-Aug: Psychiatrist Charles O’Brien, a University of Pennsylvania addiction-treatment expert and head of mental health research at the Philadelphia Veterans Medical Center. “Anyone who has 10 beers at a sitting is, by definition, an alcoholic.”

That definition doesn’t exactly square with the DSM-IV criteria for alcohol abuse and dependence. The abuse criteria looks for continued use despite failure to meet obligations, causing physical hazards, legal or interpersonal problems. The threshold for dependence is any of that plus high tolerance, withdrawal symptoms, or inability to cut back despite knowing the consequences. But, no negative impacts on his job or family relationships have been reported from his drinking, and on July 29^th:

Philly.com, 08-Aug: At the hearing, he said his Bud habit was all but gone, reduced to a six-pack a week, tops.

“I’m not saying that just to get my license back,” he said afterward. “It’s for my health.”

At the lower end of his 6-10 beer range, Emerich probably doesn’t meet the latest NIAAA definition of binge drinking, for which the threshold is a BAC of 0.08:

Philly.com, 08-Aug: At six feet tall, 250 pounds, he is a big enough man to drink six Buds in two hours and keep his blood-alcohol level within the legal limit of 0.08 percent, by the National Highway Traffic Safety Administration’s formula.

I’ve found no indications that his doctor told him specifically to quit, or that a clinical evaluation has resulted in a diagnosis; he reports that he has cut back significantly without a lot of distress, and seems to be taking personal responsibility for improving his health.

The judge didn’t see it that way, and it’s not clear what evidence he was relying on when he made these comments:

Philly.com, 18-Aug: “If Emerich’s alcohol addiction had progressed to the point where he could not stop drinking even though it was killing him, how could we reasonably expect Emerich to forgo alcohol simply to ensure safe driving?” wrote Charles in his ruling.

LDNews.com 19-Aug: The judge also wrote: “… the abyss of Emerich’s alcoholism was so cavernous that he would and/or could not moderate his alcohol consumption so that he could safely drive.”

Was he drinking sensibly?

Not by any of the standard yardsticks. He was somewhere in the range of 40-70 drinks weekly, pretty similar to where I was at in 2000. Among his U.S. peers, 6-10 beers per day put him in with a lot of men who drink, but only a few at that daily level:

So, he was well into the 90^th percentile in drinking quantity and frequency, not something that many folks can sustain for decades and yet remain healthy. His drinking was starting to cause him problems, as mine did, and continuing with the same pattern was likely to accelerate the consequences.

In one study, a small group of 40-year-old men had an average of 4 drinks daily for 20 years without consequences, while their peers who averaged 5 or more daily generally ran into problems. That evidence doesn’t tell us that 28 drinks weekly is wise or healthy generally (there’s evidence to the contrary), but it suggests that some guys in Emerich’s age range have sustained that pattern for decades without major consequences.

It’s not unusual for us to find ourselves in places like this in our 40s. It’s also fairly common for us to mature out of heavy or addictive drinking patterns — most often without professional treatment — as described by Dr. Stanton Peele.

Is some sort of treatment or support warranted?

Keith Emerich sounds like he’s in good shape to answer that question himself.

If I were him, I’d be getting follow-up care on the irregular heartbeat that started this in February. I’d want to keep track of whether the heart issue is stable and have my doc tell me about the risks and/or benefits of continuing to drink moderately.

Sometimes folks get shocked into abrupt behavior changes, and maybe the heart problem was everything he needed to accomplish that. More often, we end up working through stages of change, so it wouldn’t surprise me if cutting back his drinking has been more of a struggle than he’s mentioned publicly. Sometimes a little bit of the right help moves the change process along more quickly.

If his heart problems were to escalate, his doc is sure to ramp up treatment and/or get specialists involved. The drinking can be handled the same way — if self-care ends up not getting the job done, it would be worth his while to try some sort of peer support or get professional care.

Bottom line, assessment and choices of treatment reside with him and the experts he chooses to consult.

Is treatment available that would fit him?

CentreDaily.com, 14-July: “They want me to go to counseling to prove that I’m OK,” Emerich said. “I tried to go to a place … and they wanted $250 for a three-month program.”

Hmmmm… harm reduction therapy can be done in pieces much shorter than 3 months. Services offered by folks like Tamara Grams in St. Paul and the RRCI in Cincinnati (from Friday’s article) aren’t blocked off that way, either. Perhaps he was talking to folks oriented to doing 12-step work.

Thus far Emerich sounds determined and conscious, not much given to powerlessness, but perhaps still working through some ambivalence. Long-term abstinence could still be on the horizon as a good option, but chances are good that A.A. is either not a good fit, or not a good fit yet.

The chances are also pretty good that somebody like Psychiatrist Charles O’Brien, quoted above, would not hold Emerich’s attention or respect for long. Dr. O’Brien’s complete thoughts might be more nuanced, but the quote used by Philly.com suggests that he’s working from a broader disease model than the DSM-IV that would require clients with substance abuse to admit denial and would discount the evidence that drinking problems often don’t lead to addiction.

Finding client-centered care that meets us where we’re at is still a challenge in most areas. A few cursory web searches for alternatives to 12-step support in Emerich’s area didn’t produce anything promising.

What about the ethical issues?

Radley Balko: DWI Insanity

The guy did nothing that’s against the law. Yet if he wants to drive, he’s now required to pay an extra $1,100 … for the privilege.

The case also puts a chill on doctor-patient privilege. What Emerich admitted to — drinking — isn’t even illegal. Guess if you’re a Pennsylvanian, you’ll now need to think twice before telling your doctor everything he needs to know — even if that means an inaccurate diagnosis.

Doctors’ Responsibilities, Patients Rights Debated:

For many doctors, the crux of the reporting dilemma is maintaining trust with patients.

David Axelrod, an internal medicine doctor at Thomas Jefferson University, confronted that quandary yesterday when a patient who had read about Emerich refused to answer a routine question about alcohol consumption.

“He did not want to answer that question at all because of the fear that what he says can be used against him,” Axelrod said. “I didn’t press it.”

Lebanon Daily News Editorial:

Penalizing an innocent person based on the “likelihood” he will commit an offense DUI, in this case is a slippery slope. … There is language in Charles’ opinion that suggests a strong bias against alcohol use of any kind. … One must wonder whether the judge thinks anybody who consumes alcohol is ever fit to drive…

“Likelihood” is indeed a slippery slope. In this case, it led to a presumption of future guilt. We find that troubling.

The Robesonian: Oh, (Big) Brother

The odds just got shorter that the attending doctor will be aware of his client’s fondness for a cold one. And that could be a dangerous mix.

Fessing Up to Doctor Costs Drinker His License:

Edmund G. Howe calls it “a crapshoot.”

“What one doc considers abuse might not seem as severe to another doc,” said the editor-in-chief of the Journal of Clinical Ethics and a psychiatry professor at the Uniformed Services University at Bethesda, the U.S. military’s medical school.

“I tend to think docs can’t do two jobs and do them both well,” Howe said. “They can’t be adjuncts to the police force and at the same time form trusting relationships with patients.”

Say Anything blog: Pre-Emptive Revocation

What a joke. In most states they even let you drive after you get a couple of DWI’s. What’s with Pennsylvania? This is akin to requiring child-abuse victims to register as sex offenders because they might become pedophiles themselves.

Jay Stahl hears that from time to time as an addictions counselor, but his clients learn it’s no way to bond with him.

“Be specific” is his reply. “Let’s talk about what works or doesn’t work for you about A.A.”

If the client has attended A.A. meetings where the group members seemed out of touch with his/her concerns, Stahl points out that any peer support group will have its own character, strengths and weaknesses. If the personality mix at a meeting wasn’t a good fit for the client, Stahl may recommend other A.A. meetings that could fit better.

“I’m not powerless.” “I’m not an alcoholic.”

Stahl welcomes these sorts of specifics. They are conversation-starters, not symptoms, in his work as a clinician.

So, Sharon feels responsible and empowered, but wants help asserting herself to quit drinking. Or, Shawn shuns the “alcoholism” label, but is ready to talk about solving the problems his drinking is causing. And, Mike resists committing to much of anything, but promised his wife he would talk to somebody.

Stahl is the Executive Director of the Recovery Resource Center, Inc. (RRCI), which provides abstinence-focused care and support in Cincinnati. The RRCI is the brainchild of John Salter, a social worker and addictions care expert who is also an advocate for Rational Recovery, a self-directed approach. He told a bit of his recovery story to Cincinnati weekly CityBeat in January 2003.

Salter envisioned using a mental health model consistent with his social work background in which a Sharon, a Shawn, or a Mike would get help that would:

• Meet them where they’re at.
• Treat them as whole beings, not single problems.
• Place the severity of their drinking on a scale from use to abuse to dependence.
• Identify mental health, relationship, and any other issues or concerns without presuming that addiction is always the cause of the others.
• Empower clients to make informed treatment choices, which might include any of:
  • 12-step meetings,
  • psychotherapy,
  • relationship counseling,
  • Women For Sobriety,
  • SMART Recovery®,
  • LifeRing Secular Recovery,
  • personal practice of Rational Recovery, or
  • other self-directed recovery.

Salter spent 5 years providing services from his basement, in addition to his full-time social work job, starting in 1996. He also spent that time collecting support and funding to open the Recovery Resource Center.

The alternative recovery community in Cincinnati helped Salter build a coalition along the way. Local affiliates of SMART, Women For Sobriety, and LifeRing were already active in the area, and leaders from each stepped forward to serve on the RRCI board. (The RRCI website includes a side-by-side breakout of the high-level distinctions between AA and these alternatives.)

Stahl was brought on board as director in November 2001. The center opened in December, offering a resource library, office space for one-on-one services, and a conference room to host meetings. Early in 2002, the RRCI hosted author Anne Fletcher, as told by the Cincinnati Post, to deliver a couple of lectures.

Jay Stahl’s recovery: Outside the box

The email message I got from RRCI director Jay Stahl in response to my request for a phone interview was friendly:

    From: Jay
    Sent: Monday, August 16, 2004 10:31 AM
      To: Steve Boese
 Subject: Re: Kudos on your services and your website

---

Steve,
Thank you for the kind words — and the link. Please call me … I’ll answer all your questions and maybe even share tidbits of my own (17-year) recovery story. Jay

And yet, to be honest, the whole sharing-our-recovery-stories thang is a little unnerving to me. I can appreciate that Amazing Grace-style “‘twas drunk but now I’m sober” testimonies are heartfelt and real for a lot of folks, but the implicit “you are lost and need to be found” message that often follows them is a turn-off.

It turns out I needn’t have worried. As his September 2003 remarks show, Stahl has seen tough times yet leaves melodramatic hitting-bottom and recovery-as-redemption allusions behind when telling his story.

He chose to quit because drinking was getting in the way of making other changes that mattered to him. A therapist helped him work through issues related to troublesome family dynamics that had preceded and perhaps catalyzed the drinking problems. An avid reader, he dug through books on addictions, relationships, and coping skills. He leaned on friends who modeled the type of person he wanted to be. He also dealt with shades of panic and obsessive-compulsive issues along the way, in each case finding answers from a mix of professional care, peer support, looking at the evidence, and taking responsibility for his mental health.

In the 2003 remarks, he expressed gratitude for friends who supported him:

Their qualities — unconditional love, empathy and understanding, validation and acceptance — nurtured in me the needs of my soul — human dignity, personal liberty, hope and empowerment.

This in turn has allowed me to construct the core of my character — a core which includes responsibility, self-reliance, authenticity, and integrity.

Not yet credible after 17 years?

When he speaks to groups about recovering outside the 12 Steps without relying on a disease model of alcoholism, the pushback has become familiar to Stahl.

“You must not have been an alcoholic” is one of the responses that frustrates him, not so much because of the challenge to his former drinking problems — few alcoholics hit bottom homeless-in-the-gutter style anyway — but because it marginalizes his recovery.

The RRCI doesn’t teach its clients that alcohol itself is an inherently cunning beast, and Stahl doesn’t find a one-size-fits-all disease model of alcoholism to be necessary in his own recovery.

“Then why don’t you just drink?” is a common response when he explains this.

If he chose to cap off a hot day of lawn mowing with a single beer, he isn’t convinced it would catapult him into personal ruin or begin a steady progression to insanity or death. The basic issue with addictions, he notes, is that an attachment to a habit persists despite repeated negative consequences. If he chose to drink, being responsible would need to include consciousness of potential attachments and consequences. While there is no sure way for him to know whether moderate drinking would be viable for him apart from testing it, he doesn’t seem to be interested in finding out.

As he talks about it, his relaxed confidence speaks to a sense of contentment that abstinence is his genuine choice, a proven and joyful path for him, more than his only redemption from dire consequences of the alternatives. That choice also put him squarely in sync with the first of the fundamental principles driving the formation of the Recovery Resource Center: “Abstinence is the best route to recovery.”

And, it bothers him that recovery outside a 12-step model often isn’t accepted as valid or credible, even for a clinician like himself with 17 years of continuous sobriety.

“An incredible uphill battle” for recognition

The Recovery Resource Center’s struggle for recognition and referrals mirrors Stahl’s personal attempts to be integrated and included in communities of recovering folks.

Stahl and Salter have worked to build bridges between the RRCI and public and private addictions policy, education, and treatment groups. Despite making themselves known, they receive few referrals from local agencies, even from those supported by public funds. They have developed their own networks with peers to publicize and promote the RRCI’s educational seminars for addictions professionals after finding that many of the existing communication channels are not receptive to them.

John Salter noted to a CityBeat reporter in 2003:

The four non-traditional programs supported by RRCI have existed for about 15 years, but many of the most influential people in the field of addiction care don’t want to hear about alternatives.

Even the Addiction Studies program at the University of Cincinnati seems to tread lightly, if at all, into the topic of Women For Sobriety and other alternatives to 12-step programs.

It can be bewildering. SMART Recovery and Women for Sobriety have been recognized by the American Academy of Family Physicians. The National Institute on Drug Abuse (NIDA) cites SMART side-by-side with 12-step programs as a valid self-help option, and, after being proven effective with adolescents and in correctional settings, SMART has been adapted for those uses, drawing federal funding in seven digits. It’s hard to make sense of the gap between credentials like those and the barriers to getting the word out about them.

Creating their own system

When it opened, the Recovery Resource Center hosted 3 support meetings per week: One each for Women For Sobriety, SMART Recovery, and LifeRing. Today they’re up to nine.

Stahl says they started out with a vision of becoming an integral part of the addictions care system in southern Ohio, collaborating with local agencies and building up referral traffic between themselves and outpatient and inpatient treatment providers.

The model has evolved, though. Frustrated with limited results after working within the existing system so far, the RRCI is staking out a more assertive role for themselves. They have recently achieved state certification as an outpatient treatment provider and are increasing the availability of certified staff to work one-on-one and in groups with their clients.

They intend to get their options listed with the courts so that clients required to seek alcohol-related care in the wake of being arrested or convicted of driving under the influence will have options.

The plan is to deliver solid, evidence-based treatment and measure its outcomes. Stahl is confident about demonstrating the RRCI’s effectiveness and substantially expanding its base of satisfied clients.

Common recovery processes, but distinct barriers

One of the intriguing things Stahl sees in the addictions field is that core recovery concepts and language are shared by most professionals, peer support groups, and programs: Each promotes getting well, giving up bad habits, examining values, developing healthy coping skills, and getting whatever help, support, and information is needed.

However, the distinctions between disciplines create most of the barriers to folks getting help. That is where he sees the power of offering options. As a clinician, Stahl’s approach doesn’t vary much toward clients who choose 12-step, SMART Recovery, Women For Sobriety, or self-directed approaches.

The program-to-program differences lie not in language nor effectiveness, it seems to him, but in the individual clients’ levels of resistance.

Resistance drops when empowered options are offered to folks who are ready to change but opposed to powerlessness. Progress is made sooner by skeptics of the disease concept when dismantling their objections is no longer a prerequisite. Barriers to treatment soften when questions about the risks of heavy drinking lead to direct answers and encouragement to change based on an internal locus of control. Evidence draws critical thinkers into self-identifying their problems and making informed choices about health care, habits, peer support and professional treatment.

Too often, Stahl points out, treatment providers and well-meaning laypeople “miss it” when given an opportunity to make a positive difference. He’s not immune from missing the target himself. A year into their marriage, he offered his wife the “perfect” solutions to a personal challenge that mirrored one that he had faced earlier: Read these books, write a journal, meditate, and get some physical activity.

“I missed it,” he tells folks when describing the advice he offered her. Her problem-solving style doesn’t include digesting books-full of evidence; introspective journaling was his thing, not hers.

Too often, he says, addictions professionals do the same when they don’t spend time getting to the bottom of their clients’ built-in coping styles and match them to corresponding treatment approaches: Presented with an opportunity to reach a client with workable solutions, they miss it.

As the Recovery Resource Center has proved by reaching over a thousand folks in under three years, the options matter. Empowering their clients to make informed choices works.

Scene: A smoky pool room at a local neighborhood bar. Cigarette, Bourbon, Beer and Sinatra Tunes are shooting a game of doubles

Cigarette: (oddly enough, smoking a cigarette) Hey guys! How long has Coffee been missing? There were five of us here, even though you guys, Beer and Bourbon, are related. Now there’s only four of us!

Bourbon: (looks up from the pool table, where he is lining up a shot) Who cares? We were never that close anyway - he was the natural one to leave the group, damn stimulants. It was always the two of you in the morning - no one ever heard of Coffee and Bourbon hangin’ out.

Go read the rest. Really. It’s quirkygood.

Naperville … already prohibited minors from attending drinking parties, but last year the City Council changed the wording to create a specific ordinance to ticket minors at the parties who aren’t drinking.

City officials say the strict rule is meant to protect minors by targeting unsupervised teen parties.

”We’re trying to be involved in the situation and recognize the tragic and sometimes horrific outcomes of these underage parties,” said Naperville Police Lt. Dave Hilderbrand. ”We’re trying to take a bit more of an ambitious step.”

At The Right Spin, Adam noted in June that the ordinance inadvertantly targets designated drivers:

Nineteen year old Julie Beata has received two citations from the city police. Both times she was not drinking but she was picking up her friends who [had] been drinking…

I guess now, the only way for underage drinkers to get home is to either walk (public drunkenness) or drive (DUI).

Vouchey at the Chicagoist also pointed out in June:

Naperville, a town that seems to have little for their police to do, is acting a bit silly, we think. And we wonder if there are better ways to combat underage drinking other than issuing college and high school kids fines.

These are the difficult, but necessary, sorts of conflicting interests we face when considering the use of harm reduction: How to reduce risks and direct harms through pragmatic balancing of costs and benefits.

The sometimes horrific outcomes are real and devastating to families. In a perfect world, harm might be eliminated by preventing under-21 folks from drinking, but effective enforcement mechanisms for that are simply not available. Given that harm-free solutions are not viable, harm reduction principles encourage us to strike a balance for protecting health and life, like:

• Encouraging under-21 folks not to drink regardless of what their friends are doing (like those that have been ticketed already).
• Setting firm never-drink-and-drive standards.
• Teaching adults and under-21 folks about alcohol safety and the thresholds of safe, risky, and dangerous drinking.

The city has called for a public hearing on the issue next month. Questions have been raised about the constitutionality of penalizing being present where drinking occurs. Some parents are upset that their young adult children are punished despite being responsible; one city official blames parents for not controlling their kids through age 20:

”We don’t want them in the presence of others committing crimes,” [Naperville’s city attorney Frank] Cuneo said. ”If parents did their jobs, we wouldn’t need this ordinance.”

This weekend, another MM member put that principle to work. He wrote to the group just before heading out for the weekend and again after his return, and was good enough to let me share his thoughts here.

From: MNE
To: MM Email List
Sent: Friday, August 13, 2004 10:29 AM
Subject: [MM]Weekend challenge

---

Hi all who wants to read!
This weekend will be a challenge for me.

I am traveling somewhere and will meet a lot of people and can’t really escape the situation. It will be expected to celebrate and having a great party. But at this very moment I DON’T WANT to drink at all. Not even moderate or even taste anything with alcohol in it. It’s a little hard to deal with because I am dealing with following:

1. If I say to everyone that I won’t drink or I’m cutting down, maybe they will think I am a drunk and I will get into the situation to explain why I don’t want to drink. Especially since I usually never really say no.
2. I just can’t see the point of drinking at this time. I have purchased a new membership at a gym, and after slipping 1½ weeks ago into one night of heavy drinking, only to go back into the gym after that and feel GREAT! At this point I feel absolutely healthy and great!
3. I have naturally started a completely new life after moving to a city about a month ago. After arriving here it’s been more natural to break or at least identify old patterns of not being healthy. I do have better sleeping and eating patterns and as a matter of fact, I do drink less! I even got myself a new girlfriend and she doesn’t drink especially much. But when we do share a bottle of wine, those moments of drinking at all I want to have with her. The rest of the time I don’t really want to drink “by habit”.

But I want to move to the next “health” - level. I want to continue going to the gym. I want to do a 30 day abs and just stay healthy with eating and sleeping patterns. I feel so damn much better.

Ok, I should go. First off to the gym. Then having a lunch, then getting away to see a lot of relatives and other people seeing how this weekend turns out to be.

Thanks for listening

MNE

But, listen to the difference a weekend makes:

From: MNE
Sent: Monday, August 16, 2004 2:11 AM
To: MM Email List
Subject: Re: [MM]Weekend challenge - YES, YES!!!

---

Hi all you who replied to my original posting!

It was great to come home to read mail on late Sunday night. I appreciate each one of the replies, and each one is something to keep in mind!

And the weekend…? Well;

Friday: Writing here to MM-list about the fear of the weekend. Then heading off for the gym. Then into the car getting off, driving for 5 hours. Did I drink on Friday night? Nooooo! Did I want to drink on Friday night? Nooooo. Did anyone mind me not drinking or even questioning it? Nooooo! Did I feel great? Yessssss! Did I have a great time? Yesssss!

Saturday: There was a ceremony in church during the day and in the evening the beer, wine and food was a fact. Did I drink? Well yes; 1½ beers during the entire evening! Which was exactly the amount of beer I enjoyed, then I said no to any more. Did anyone get bothered? Nooooo.

Sunday: No hang-over. Just feeling great! Then driving home, meeting up with my new girlfriend. Enjoying the evening together and ending up having great sex. Still very sober and no wishes to drink (didn’t really think of alcohol..)!

After all, the weekend challenge wasn’t that hard. It was very easy! But that is because of being able to lean on you people on this list while being off. When traveling off on Friday I just knew that there are others out there getting similar challenges - I am not alone. And for now this is the third major break of pattern within two weeks!

THANK YOU for being there!!!!!!!

MNE

Feeling reticent about talking through drinking problems is not unusual in any peer support group. The reluctance to open up is reinforced, for a lot of MM folks, by the suggestion that detailed planning or rule-setting is a problem, not a solution.

Obsessing publicly about diet, exercise, weight, physique, and an assortment of other health-related habits is widely accepted. The leading tabloids’ tracking of Oprah Winfrey’s weight is echoed by Oprah’s comments about how the discipline of daily workouts can be a struggle, not something that happens naturally. When it comes to drinking, though, folks in MM often have to reconcile with a curious cultural paradox — that putting forth the effort to create healthy habits might be considered suspect, or at the extremes, a “selfish, weak excuse to avoid the ugly face of alcoholism.”

Against that backdrop, online community-building often delivers the simplest, yet most profound result: Convinced that we are not going it alone, we empower ourselves to take small but decisive steps forward.

I started 30 days of abstinence. With the support of folks in MM, it turned out that having alcohol-free days was kind of freeing, not the burden I had anticipated.

Taking my abstinence past the 30-day mark began to appeal to me by the half-way point. I was figuring some stuff out about myself and adding new habits and skills. All of that would be helpful once I was drinking (but moderately this time) in the future, and I figured a longer period of abstinence would probably be good for me.

Rather than commit to another specific timeframe, I set this framework in place: I could choose to have my next beer (or whatever) at any time, but the decision had to be made a week ahead of time. No moral significance was attached to the timing — I could do it the next week or the next year — but the timeclock was available, and seven days after hitting it I would be free to crack open a cold one or pour myself a glass of wine.

In mid-November of 2000,

less than a month past the 110-day abs, I lost my best friend and partner to suicide. I didn’t drink much, generally staying within MM’s moderate limits for the first couple of weeks. By the second week of December, though, buffeted by cheery holiday decor and songs about the most joyous time of the year, the only achievable goal I could imagine was conscious harm reduction.

For the rest of December, I didn’t set hard limits on how much I drank. I looked forward to the first beer of the evening, but also planned a good meal to eat with it. No stigma was attached to specific numbers, but free of self-judgment, I set drinking slowly and enjoying it fully as the priority. In January, with the holidays done and the edgiest of my grief softening, I did a 21-day abs followed by more moderation.

On March 1^st of 2002,

I kicked off a year of abstinence.

I had just lost another great friend, this time to alcoholism. I sent him off with a helluva eulogy, celebrating the gifts he’d given as well as the challenges he had brought to all of us who had cherished him. I wanted to do more than a bang-up eulogy, though. I wanted his death to spark something deeper in me, and a year’s abs felt just right.

It turned out to be a tumultuous year, moving from Iowa to upstate New York, starting a new job, and facing down an assortment of changes and crises.

Again, sticking with the choice to abstain worked. Some facets of it felt organic and natural, like the symmetry between not spending money on beer and my often paper-thin budget, and there were other times when it felt somewhat artificial, but manageable, to be celebrating, relaxing, or stressing in alcohol-free mode.

In October,

half-way through the abstinent year, I was hanging out with new neighbors at their Halloween party. Not drinking was not working for me in that situation. I needed to either skip out of there to catch a movie (something removed from the noise that would continue for a few hours directly above my place) or have a couple beers with them. Either choice was valid and viable for me, I realized, offering its own benefits and drawbacks. I elected to stay, and I elected to drink on three other days over the next few weeks.

December 2002 brought a markedly different decision from December 2000. I was comfortable with my choice to drink on the four days, but wanted the 80-some days remaining in the year to be alcohol-free. The commitment wasn’t difficult to make. It was the home stretch, and a couple months of being DAFT didn’t sound long.

The year ended up being 99% abstinent — 361 out of 365 days. I was happy with it. The four days were the perfect reminder that my choices on all 365 days were genuine and conscious.

Sticking with (not stuck with) my choices

Some folks are good at making a sudden change in their behavior solely because it makes rational sense. “Since my doc gave me my cholesterol levels and told me to change my diet, I’m stuck with eating low-fat food. I’m not happy with it, but I’m living with it.”

Most of us, though, need more than intellectual awareness about the wisdom of a particular behavior change in order alter ingrained habits. We have mixed feelings about giving up something familiar, and that ambivalence, like grief, is a natural human state. Neither responds well to being shamed, mocked, or short-circuited, but both will generally give way to peace, health, and productivity when accorded the respect, time, and energy they deserve.

Working vigorously with my ambivalence helps me to mold an “I’m stuck with…” into an “I am sticking with…” statement. Here are the distinctions, for me, between the two:

The specific goal doesn’t control whether I’m in the stuck or sticking category. If it had turned out that moderate drinking wasn’t viable for me, I might have started out feeling stuck with abstinence. It would have been crucial, though, for me to figure out how I could best own and embrace my commitment to being alcohol-free.

It doesn’t matter that some solutions work beautifully for millions of other folks; in order to integrate a new skill or habit, I have to tailor it to my unique values, coping styles, and experience.

So, it’s as good a time as any to do a quick review of some of the solidly abstinence-based support out there which follows something other than the 12 steps. Along with that, a request to my readers: I’m looking for individuals who are talking about their experiences in these different groups at their personal websites. If you know of any, please drop links into a comment or an email message.

So, here’s a list of empowered alternatives:

There are also faith-based groups which adapt the 12 steps to their needs. There are professionals who support a wide range of alternatives. Look closely, and you’ll even find folks on the God squad talk about spiritual empowerment and having an adult relationship with God. Find ‘em in the side bar here, or let me know who’s not there yet and needs to be added.

2004.08.15 Update:

The Recovery Resource Center in Cincinnati Ohio has a great page which takes a high-level look at the distinctions between these groups: The Recovery Spectrum.

One of the concepts I worked through while abstaining was my fear that I’d slip right back into bad habits after the abs period finished, or even see my drinking escalate beyond where it had been before. It’s a pretty common sentiment; an MM member who is 10 days into his first 30 expressed a similar fear, and I responded:

From: Steve Boese
Sent: Wednesday, August 11, 2004 9:14 PM
To: MM
Subject: RE: [MM]abstinence

> Maybe I am a natural worrier, but it
> seems like things are going too easy
> right now. Like it is just a matter
> of time before I cave in and have that
> bender that will put me over the edge
> and set me back again….

That was me, exactly, four years ago.

Over time I decided that I had been framing my drinking as something mystical, something that could rise up like a beast and erase all of my progress, and that such framing was neither helpful nor accurate. I started DE-mystifying it, and the more I demystified my drinking, the more effective I became at marshalling some control over it as a simple habit.

OK, so it was a habit with a compelling edge — the allure of alcohol is stronger for me than, say, Play-Doh or broccoli, after all — but demoting my old drinking patterns to simple habits also got me thinking about healthier patterns as tuned-up, very do-able habits.

Another way I framed things: I reminded myself that every day of abstinence (as well as moderation and harm reduction) changed me. Once I added those experiences to my life, nothing could erase them, nothing could take me back to where I was in June, 2000. Even if I went back to nonproductive drinking patterns exactly like before, the new experiences told me unequivocally that I would never be content again living in the old ways.

So, I’d encourage you to trust that these 10 days have changed you. They are not a magic bullet, of course, but you are not going to erase these experiences from your consciousness. You are proving yourself able and powerful, self-reliant and wise. You will — all of us will — take what we learn from the good days and make better days, better lives, with them.

—Steve

That’s different from concepts that many A.A. members find helpful, that alcohol is “cunning, baffling, and powerful” and the path to better health includes accepting powerlessness, eh? We each need to figure out what works best for ourselves.

The Washington Post runs a short piece by Alicia Ault (free registration required) which includes:

Campral appears to work by restoring the balance between excitation and inhibition in nerve signals, a balance that gets altered by alcohol abuse. An older drug, Antabuse (disulfiram), makes people violently ill if they drink alcohol. Another, naltrexone, works by making people want to drink less, said Litten.

Only 5 to 10 percent of people treated for alcoholism are prescribed naltrexone or Antabuse, which don’t work for everyone and are not widely marketed, said Litten. Forest aims to market Campral broadly to addiction centers and physicians, said company president Ken Goodman, and persuade insurers to pay for the drug.He would not comment on price.

The U.S. is well behind other nations in using drugs to help battle alcoholism. Including Campral, only three anti-alcoholism drugs have earned FDA approval — and Campral is the first new one in almost a decade. Moreover, fewer than 5% of the nation’s 14 million alcoholics are being treated with drugs, with the vast majority relying on behavioral therapy and support groups like Alcoholics Anonymous to help them quit. Though alcoholism is increasingly viewed in the U.S. as a disease, the predominant belief is that “you don’t treat a sin with medication,” says A. Tom McLellan, professor of psychiatry at the University of Pennsylvania and director of the Treatment Research Institute, a nonprofit group that evaluates addiction therapies.

Many American alcoholics are starting to demand more help in achieving what for most is the greatest challenge: Long-term abstinence.

Tsao notes that Campral has been available in Europe since 1989.

The five percent number doesn’t surprise me. By the time by buddy Brian’s drinking finally killed him in 2002, he had at least a decade of treatment, 12-step support, sponsorship, and one-on-one therapy. His care came mostly from one of the leading hospital-based chemical dependency treatment facilities in Iowa. At age 44, his last year included several close calls laden with all of the standard -itises and -opathies.

A month before his death, he and I talked about alternatives like Naltrexone and harm reduction therapy. Thoughtful, intelligent guy that he was, the value of options struck a chord with him. After all of his years working within that system — and being trained as a peer support group facilitator — he said the only possible outcome of asking about the options would be earning a merit badge for denial, making it out of the question for him.

Maybe his medical condition (such as liver damage at the end) would have precluded the use of Naltrexone at that point. It seemed clear, though, despite being available since 1995, not only was the option not on the table, his caregivers had convinced him that merely asking questions was also strictly verboten. It struck me as a classic case of insanity defined as doing the same thing repeatedly, yet expecting a different result.

Anyway, it’s good to see that more research is in progress:

Researchers are also wrapping up a large, multicenter trial of Campral, Naltrexone, and both drugs combined. That study, for which 1,380 patients took the drugs in conjunction with various behavioral therapies as well as without any additional therapy, should help elucidate what combination of therapies works best.

Hopefully we’re on a path toward treating the truly life-threatening forms of addiction more like cancer and HIV: No single approach is going to work for everyone, but information about any approach which shows promise ought to be in the hands of the folks who could benefit so they can make fully-informed decisions about their preferred course of treatment.