Acamprosate Approval in the News

Recent approval by the Food and Drug Adminstration of Acamprosate to treat alcohol dependence is making its way around the media.

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.

And, from Business Week’s coverage by Amy Tsao:

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.

Answers for Amber

Hey, Amber…

Are your ears burning? I’ve been talking about you and your appearance on Oprah several months ago. I thought you asked a great question:

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

And it seemed to me the answer you got was muddy.

I’m not a professional, but I’ve got some relevant experience, and somehow I’ve become an alcohol-issues geek. For what it’s worth (take it or leave it as you wish), I’ll take a shot at clearer answers to your question.

Abuse and dependence

First of all, there are two broad categories of problems folks run into with their drinking: Abuse and dependence.

Alcohol abuse

describes folks who continue drinking despite having recurring problems (legal, health, social, family, relationship) or despite the fact that their drinking creates hazards to themselves or to others. The problems caused by alcohol abuse can occur without us being addicted or dependent, and in fact, there are four problem drinkers for every alcoholic.

Alcohol dependence

is problem drinking plus either high tolerance or withdrawal symptoms. That is what you heard a lot about on the Oprah show. It’s real, it sometimes sneaks up on folks, but I disagree with those who suggest that it is never possible to see it coming.

Does abuse lead to addiction?

It can, but this large 5-year study (580K PDF) suggests it generally doesn’t.

Drinking by the numbers

Is it OK to have 3 drinks, but not 4? Actually, you’re in the ball park with those numbers, but as an intelligent woman you won’t be surprised to hear it’s not quite that simple.

If you want to be very safe,

the USDA

recommends that you have no more than one (233K PDF, pg 40) drink per day (the limit is two for guys).

In Britain,

the recommended guideline is about twice that (360K PDF, pg 3) for women and slightly higher for men.

A 1995 study

found that problem-free drinking occurred at levels of up to 3 drinks per day for women, with a max of 12 per week (4/day, 14/week for guys), with some non-drinking days each week, and

Moderation Management

(MM), a group of folks concerned about their drinking, also recommends 3/day but 9/week. Guidelines set by government ministries in

Italy, Denmark, Spain, and Japan

are closer to the 3/day mark; other countries are closer to the one/day limit suggested by the USDA.

Tailoring drinking to life

Maybe the bigger question for each of us than “What is a problem?” or the scientific stuff surrounding the various numbers is “What is important to me?” We each must answer that question for ourselves, but we may find it helpful to ask, “Why not have alcohol-free days?” “What matters most to me?” “How is my drinking contributing to my quality of life?” “Subtracting from it?”

The answers that work best for you aren’t going to be the answers that work best for me. No surprise there; it’s a matter of examining our values and shaping our lives to fit them.

Making changes

It’s not unusual for us to take a look at our lives and decide we want to make things different. Typically, though, we don’t make the big changes by snap decision, just because they make sense to us intellectually. Sustained change tends to come from working through healthy ambivalence as we navigate recognizable stages of change. The MM folks recommend trying out periods of abstinence as one way to explore change, but they also point to the benefits of reducing harm, which I’ve found helpful at times when optimal solutions were temporarily beyond reach.

I couldn’t really tell where things were at for you (not that it matters, given that I’m a layperson in this area), but from the bit that I heard, I’m guessing I’ve got you beat when it comes to not-so-smart drinking habits. The thing is, you and I know that we’re both responsible for and capable of doing what’s necessary to live sensibly. That means being willing to admit that we sometimes get off-track (or at least, I do) and have to adjust our course.

Summing up

I gotta admit, Amber, I feel a little silly dumping all of this to somebody who showed up on the TV several months ago. Is this a geeky thing to do, or just plain dorky?

Ah, well, you can probably tell from my website that I care about these kinds of issues, a bunch. You raised a simple, very valid, question that I’ll bet millions of other folks watching that day would have liked answered, and a golden opportunity was missed to put solid information in people’s hands.

I hope you are well, and I’d love to hear from you or anyone else on the show that day.

—Steve

Joe Six Pack in the News

Keith Emerich has bounced in and out of the news in recent weeks. His physician contacted the Pennsylvania Department of Transportation (PennDOT) to identify Emerich as having a condition that could impair his ability to drive safely. Radley Balko has also tracked the story.

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.

The chronology:

• 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.

Odds-n-Ends in the News

Drying out stigma for problem drinkers:

Researchers say drugs that handle alcoholism as a medical condition will encourage people to seek help.

Dr. Henry R. Kranzler, professor of psychiatry and an alcoholism researcher at the University of Connecticut Health Center in Farmington Connecticut

…said he would like alcoholism and diabetes to be regarded in the same manner — as conditions in which genes, lifestyle choices and biochemistry play a role in causing disease.

Researchers agreed that medications alone cannot cure alcoholism. But they can be a boost to 12-step programs such as Alcoholics Anonymous and to traditional psychotherapy, which for generations have been the backbones of treatment for heavy drinkers.

Note to reporter Hilary Waldman: Other future trends in alcohol-related care will be growing awareness of alternatives to 12-step programs, alternatives to abstinence, and harm reduction.

Dr. Stanton Peele interviewed by Jeffrey Taylor at wsRadio.com

Jeffrey Taylor is a thoughtful 12-stepper. His bio includes a 40-year span of heavy drinking, ending less than two years ago. He kicked off a weekly internet radio show in June, Cocktails at 5. Just four weeks into this new venture, he interviewed AA alternatives champion Dr. Marc Kern, co-author of Responsible Drinking, the latest guide to the Moderation Management approach. This week, for his seventh show, he snagged Dr. Stanton Peele.

Head on over and listen in. Jeff and Stanton had fun together. Jeffrey’s also written his story, A Gentleman Drunk, the first 7 chapters of which are available online.

Teen drinking problem not improving, despite prevention efforts

Media coverage of drinking issues often doesn’t include getting input directly from drinkers, much less letting teens speak for themselves. Here is an exception:

Drinking is usually a big part of a teenager’s social life…

Getting the alcohol isn’t a problem either, with older friends, and knowing the places that don’t card. One teen says her group of friends go into smaller towns to drink, because it’s safer.”It’s more fun to go to a smaller town cause no one knows who you are , it’s easier to drink than your own hometown,” said the teen drinker…

For many area teens, drinking is a very normal part of their lives, and stopping drinking isn’t an option, so they try to be safe and not get caught.”Kids seem to be careful nowadays, they’re becoming smart about it cause they know cops will pull them over,” said the teen drinker.

If we think we’re going to effect changes in underage drinking, we’re going to have to reconcile with simple observations like these.

Getting Real About Alcohol:

I have a problem with drinking, but I can’t stop. What can I do?

Michele asked (in part):

I have a problem with alcohol. I am a diabetic and should not be drinking.

Frederica Mathewes-Green, whose site lists no counseling credentials and includes no discussion of substance abuse issues, replies:

…you are no longer able to control your consumption of alcohol. This is a serious sin, as well as a serious illness…

You have to stop drinking, and never drink again for the rest of your life. This is the only solution… You need to choose to hold yourself accountable to others, perhaps in an Alcoholics Anonymous group…

Pssst… Ms. Mathewes-Green… perhaps Michele should be encouraged to speak with a medical doctor for evaluation, diagnosis, and treatment recommendations.

114-Year-Old Ukranian female still drinks strongest alcohol beverages

Yevdokiya … does not suffer from any diseases - she has never been to hospitals, she has never asked for doctors’ help…

Extremely strong drinks do not show negative influence on the woman - she is not an alcoholic at all. She says one should have a very good substantial appetizer after a strong drink Yevdokiya prefers Siberian pelmeni (meat dumplings).

Oprah Questions Denial

I caught an intriguing verbal exchange on the topic of denial a couple months back on Oprah. The episode was called Moms Who Drink Too Much.

The expert featured that day was Debra Jay, who is an addiction specialist, a professional interventionist, and author. She and Jeff Jay published Love First: A New Approach to Intervention for Alcoholism and Drug Addiction, in 2000.

They had talked earlier with:

• Sarah, who identified as an alcoholic for the first time and agreed that treatment was necessary.
• Amber, who had spoken about drinking wine nightly, generally not more than 2 glasses while her children were awake.

During the “After The Show” featuring the same folks, after Amber mentioned taking responsibility for herself (as she had done during the main show, as well), the conversation turned to denial:

Debra: [T]his is what’s hard for people to get: You’ll never see [alcoholism] coming. You’ll never see it coming. People always say, “I’m watching it,” and I’m thinking, “What are you watching? What are you waiting for? What do you think you’re going to see?”

Oprah: See, now I don’t get that…

Amber: So, would it be irresponsible…

Oprah: I don’t get that, I don’t get that, Debra, because…

Debra (to Sarah): Did you see it coming?

Oprah: You would see it coming…

Debra: No, you don’t. Did you see it coming?

Oprah: You would see it coming if you blacked out.

Debra: No.

Oprah: You would see it coming if you get to the point where you’re …

Debra: No.

Oprah: …confrontational, your personality is altered. You would see…

Debra: Remember what I said earlier was, the first thing that goes is your ability to be self-aware. That’s the first part of the brain that the alcohol hits.

Oprah: You would see it coming if your husband is saying, “Look, you’ve got a problem.”

Debra: You and I, listen, you and I would see it coming, but an alcoholic cannot see it coming. Can’t see it. Cannot see it. I’ll tell you, I just worked with somebody, got him into treatment, and his first assignment was, “Tell us how your personality changed,” and he said, “Not at all,” and then they said, “Well, call your family.” And, boy was he surprised at what he heard…

Oprah: OK.

Debra: …totally different story.

Oprah: OK, I’m not, I’m not buying it, Debra.

Debra: It is tough. No, it is a tough one.

Oprah (to Sarah): You didn’t see this coming?

Sarah: I knew blacking out wasn’t normal, but still couldn’t think I was an alcoholic. I just kept trying to find a way to control it - eat a little more, switch to this drink, I just kept trying. But, I mean yeah, there were huge, huge red flags. My family said from the very beginning, “You drink alcohol and your personality changes.” Well, everyone thought that but me.

Debra: The word for it is denial. That’s the hallmark of addiction: Denial.

This intrigues me. Ostensibly, the show was reaching out to mothers with a word of warning about drinking problems, and yet Debra Jay seemed to be suggesting that it is impossible for folks to see a problem developing and be proactive about circumventing it.

She makes it clear that she’s referring to alcoholics here, and had just said to Amber, “I’m not telling you, ‘You have an alcohol problem.’” At the same time, daily drinking and detailed rule-making, both of which described Amber, had been named as potential red flags, signs that alcoholism could be developing even though external consequences were not yet occuring.

Update: August 7, 2004

I used an email address at the site hosted by Debra and Jeff Jay to contact Debra to ask if she’d be interested in clarifying things or adding to the conversation:

From: Bose [bose@sensibly.org]
Sent: Tuesday, July 27, 2004 6:55 AM
To: [The contact address offered at LoveFirst.net]
Subject: Ms. Debra Jay: Question

Dear Ms. Jay,

Hi. I’m a freelance writer focusing on wellness and substance abuse issues.

I got to see the Oprah show titled “Moms Who Drink Too Much” a couple months back. I hope things came together for Sarah in terms of treatment and recovery.

I got confused, though, in the “After The Show” segment when you spoke of alcoholics’ inability to see addiction coming. I wrote about it a bit at my alcohol-related website, and I was wondering if you’d be interested in clarifying your thoughts.

The piece is here:
http://live.sensibly.org/2004/07/27/oprah/

Feel free to respond at your convenience by email, or by posting a comment at my site.

Thanks, so much, for your assistance. Have a great day!

Sincerely,

Steve Boese
bose@sensibly.org
Washington DC

To date, I haven’t heard anything back from her. The offer is still open — I welcome her comments here or direct reply by email. If there is anything she would like to add to the conversation, it’s important to me that she have that opportunity.

And, to be clear, I am not going to single any one person out. Everything I see tells me Ms. Jay is an accomplished professional whose focus appears to be folks who are struggling at the severe end of the alcohol issues spectrum, and I have no doubt that she has served her clients well.

Preempting Harm Reduction

Last year, the Naperville Illinois City Council attached penalties to an ordinance prohibiting under-21 folks from attending parties where alcohol was served. From an article by Anna Johnson in the Chicago Sun-Times:

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.”

It’s not making sense to Rob at the Say Anything Blog.

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.”

Town Square Intro

In this category, I’ll track trends and public policy related to alcohol.

Where is the Line?

In April, The Oprah Show broadcast a episode called Moms Who Drink Too Much. Oprah opened the show with:

It’s estimated that, for millions of moms across the country, the need to escape with a little alcohol has now crossed the line. Have you crossed the line? How many drinks is considered normal? What should have you worried?

The first segment of the show tracked Sarah, a 30-year-old mom who had been filmed at home and created a video diary about her drinking problem. Sarah appears to have worked through the first two stages of change — precontemplation and contemplation — and is now poised to move from preparation into action. The bulk of her ambivalence has been resolved and she is looking forward to life without alcohol. (Oprah says later that the show is going to help Sarah get the help she needs and follow up later on her progress.)

Great stuff. So, Sarah’s frequent heavy drinking, hiding it from her kids, blackouts, and using alcohol to numb her feelings is an example of being way over the line.

Oprah throws out this teaser before going to commercial:

Next, three moms, who like to unwind with cocktails at night, who want to know where they stand. Where is the line? Do they have a drinking problem?

When the show returns, a video montage has the three moms talking briefly about their drinking patterns. One of them is Amber, a 28-year-old mother of two. Her comments include:

I pretty much drink every night, anywhere from on average about 2 glasses of wine a night… I drink because I’m bored. It makes me a better mom, especially when I’m really edgy… I try not to drink before 5, and I try not to drink more than 1-2 glasses when my children are awake.

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

Amber is just rephrasing Oprah’s opener — Where’s the line? What is normal, and at what point should a reasonable person worry?

Oprah and the show’s expert for the day, author and interventionist Debra Jay, discuss:

Oprah: OK, Debra says women who don’t have a problem don’t have to make up rules about drinking.

Debra: That’s right. If you don’t have a problem, you never even think about making up a rule, but when you do you start setting up little rules for yourself so it can look like you’re drinking like everybody else, that your drinking is normal. And what happens, is you find that you keep breaking your own rules.

Oprah: OK, and I see you’re frowning because of that. You don’t like that?

Amber: No, I totally disagree. I think anybody who’s going to be responsible, whether it be with prescription drugs or alcohol or anything different, I think that any responsible parent — or person — needs to have a boundary up, or it’s a free-for-all.

Debra: You know, it isn’t really, not with somebody who doesn’t have a problem. They don’t even have to think about it. They just really can use it responsibly. What I’m talking about is internally, inside of yourself. It’s 2 o’clock and I’m thinking, “Boy, I really want that glass of wine,” and I’m looking at my clock, and I’m thinking I’ve got 3 hours until five. And, I’ve got to hold on, I’ve got to hold on. That’s something completely different. Now I’m feeling all this emotional unmanageability inside of myself, trying to keep that rule. Somebody who [doesn’t have a problem], they’re not going to be thinking at 2 o’clock about what they’re going to be drinking at 5 o’clock if they don’t have a problem. That’s what I’m talking about.

OK, so the anwer to “Where’s the line?” seems to be “when we have to set rules for ourselves,” or perhaps more precisely, “when we set rules which we find emotionally unmanageable and end up breaking.”

A little later, Oprah and Debra come back to the five-o-clock-rule issue:

Oprah: You’re saying, the fact that you have to say, “I’m going to only do it after five”…

Debra: Right.

Oprah: …means that it could be a problem.

Debra: Yeah, and usually it’s not just going to be that rule, there are going to be lots of little rules around when I’m with my kids, and this, and that, you know, I’m going to have lots of little rules.

Oprah: Are you an alcoholic…

OK, now we’re getting down to the root of the question, or at least the root of the answers being given to the “Where is the line? question.

Amber is asking whether a problem is occuring at a certain point, and the answers coming back are about the specific problem of alcoholism. Amber seems to be concerned about crossing a line from use of alcohol to abuse, and in response she’s hearing about dependence (alcoholism). But, I’ve interrupted. Let’s hear the rest of the conversation:

Oprah: Are you an alcoholic… You are an alcoholic because your body has a predisposition for the way it handles alcohol.

Debra: Um hmm.

Oprah: Is it alcoholism if it hasn’t hurt anybody yet?

Debra: No, very, very early on, we can’t… it’s probably not going to hurt anybody. It’s progressive and there are certain stages, so as it moves forward it starts hurting people.

Oprah: So, I’m saying, you’re still functioning…

Debra: Yeah. We’re not going to see it, no, we’re not going to see it…

Oprah: OK, everybody’s doing fine…

Debra: No one will know it’s there yet.

Oprah: But you can still be an alcoholic…

Debra: You can still be an alcoholic and usually before anyone notices on the outside, you start having changes in how you feel about it on the inside.

Oprah: Really. Like what?

Debra: Well, again, preoccupation with it. Really thinking about it a lot.

Oprah: Uh huh.

Debra: Most people aren’t preoccupied with alcohol. They’re not thinking about it.

Oprah: Uh huh.

Debra: But people early on, they might look normal on the outside, but boy, they really like those drinking events a lot better than the dry events, for instance. That would be a little bit of a red flag. Does it mean you’re an alcoholic? Not necessarily, but it’s a red flag.

Taking stock thus far, crossing the line can include:

• Daily heavy drinking, hiding it, blackouts, numbing feelings with alcohol.
• Setting rules which are emotionally unmanageable and seldom kept.
• Lots of little rules about, and growing preoccupation with, drinking.

A later segment introduces the audience to Belinda, whose daily drinking is triggering marital tension. Here is part of the ensuing discussion:

Debra: One of the first rules is, if somebody thinks you have a problem with alcohol, you probably do. One of the things we say to people is, “If you don’t know if you have a problem, look around you. Is somebody close to you having a problem [with your drinking]?” It’s the first place it’s going to hit home. It’s not going to hit your job for a long time after it hits your marriage.

Oprah: Can you just have a glass of wine, though, and not have a problem?

Debra: Absolutely.

Oprah: OK.

Debra: Absolutely.

Oprah: If you have to have — this is the thing — if you have to have the glass of wine every night, is that a sign of a problem?

Debra: I think there are people who have a glass of wine every night, and they don’t have a problem, most definitely. It’s never recommended to drink every single day. That is a slippery slope.

Oprah: So, anything you have to do every day, then you should be worrying.

Debra: I’m not saying you’re an alcoholic, but you might be on that slippery slope.

The discussion continues on “After The Show,” a half-hour piece which airs on the Oxygen cable network. Amber sounds less than convinced that her question has been answered when she says:

Amber: I just keep thinking, I’ve never been much of a drinker, was always a good student, always working and being responsible.

Oprah: But the point we made earlier and I think everybody needs to know, [is that] you can …be [not] much of a drinker — as Debra said to Sarah at the very beginning of the show, Sarah had told us that her first drinking experience after graduation, she blacked out — that blacking out is not a normal relationship with alcohol.

Debra: No, no.

Oprah: You don’t have to be much of a drinker if you have the gene.

I recounted what happened next in Oprah Questions Denial. The bottom line from that exchange was that the brains of alcoholics have a malfunction which makes it impossible for them to see their alcoholism developing.

As the end of the “After The Show” show approaches, they take a last stab at answering the question which opened it:

Oprah: Let’s talk about “What is crossing the line?” which I think is a question you guys wanted answered, and I don’t know if you got it answered. What is crossing the line?

Debra: There’s a simple question you can ask: “Is alcohol creating repeated problems in any area of my life, and I continue to drink anyway. If you can answer “yes” to that, you probably have a problem. It’s simple as that. If you can answer “yes” to that question, you probably have a problem, you probably should take a good, hard look, and I would say if you answer “yes” to that and you think, “Well, maybe I don’t have a problem,” you know what? Change your drinking behavior, cut way back … [committing that:]

• I’m going to drink when I’m not around my kids,
• I’m going to only drink with other people,
• I’m going to drink once or twice a week,
• I’m going to have one or two glasses of wine,
• And, it’s a permanent change in my life.

If you can do it, you don’t have a problem. If you can’t, you’ve got a problem.

So, recapping one last time, signs that one has crossed the line may include:

• Daily heavy drinking, hiding it, blackouts, numbing feelings with alcohol.
• Setting rules which are emotionally unmanageable and seldom kept.
• Lots of little rules about, and growing preoccupation with, drinking.
• A loved one believes there is a drinking problem.
• Drinking at all, for those whose bodies are predisposed to alcoholism.
• Inability to cut back dramatically, instantly, and permanently in the face of recurring alcohol-related problems.

Remember Amber’s question?

I am hoping that someone can tell me, if I have 3 drinks, you’re OK, if I have 4 drinks, you’re not OK. I want somebody to tell me exactly where that line is.

Being fair to Oprah and Debra Jay, let’s recognize that:

• An accurate answer in the format Amber asked about — drinking X glasses of wine is OK, but X+1 is over the line — doesn’t exist.
• The answers given were consistent with those that other addiction specialists may have offered.
• The over-the-line characteristics accurately describe folks who have had alcohol dependence.
• Given time and format constraints, producers of the show may have elected to focus on alcohol dependence, to the inadvertant or necessary overshadowing of alcohol abuse issues.

I can’t help but imagine Amber walking away from that show more frustrated than she walked in. She brought valid questions, particularly for folks not having significant problems with or because of their drinking. She repeatedly insisted on taking personal responsibility and asked for guidelines for being proactive about preventing problems.

Had it been me, I might have left the show with a sense of dark foreboding about a cloudy gloom gathering on the horizon, maybe soon, which I probably wouldn’t see coming, nor be able to push back. I might have felt cowed into cutting my drinking back to negligible amounts for a week or two, but fear generally isn’t a good long-term motivator for me. Anyway, since no daily or weekly drink limits were suggested (the one or two drink, once or twice a week thing was for someone with recurring alcohol-related problems, which I honestly don’t have) having 3-5 drinks four or five times a week will probably be fine.

Some line, eh?

(See also: Answers for Amber.)

(p.s., I welcome first-person reflection and responses from Amber, Debra Jay, Oprah producers, or anyone who participated in the show. I’d much rather let y’all speak for yourselves; feel free to contact me here, and I’ll publish your thoughts to whatever extent you choose.)