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Ways of the World

Carol Stone, business economist & active Episcopalian, brings you "Ways of the World". Exploring business & consumers & stewardship, we'll discuss everyday issues: kids & finances, gas prices, & some larger issues: what if foreigners start dumping our debt? And so on. We can provide answers & seek out sources for others. We'll talk about current events & perhaps get different perspectives from what the media says. Write to Carol. Let her know what's important to you:

Tuesday, July 21, 2015

Alcohol Problems and Getting Help

Readers who follow developments in the Episcopal Church may know that resolutions were passed at the recent General Convention calling our attention to the role of alcohol in the church and among its clergy and people.

This is certainly enough on its own to elicit commentary from us.  But we were in fact already checking out issues on alcohol that we might explore in a Ways of the World article, and the General Convention resolutions only add to the timeliness.  Perhaps our information here can serve as one small step in discussion within the church that carries out the mandate of the resolutions calling for all of us to give attention and action to the impact of alcohol in our lives.

We had previously been working on this topic for two reasons.  First, we had lately become acquainted with the Right Rev. Chilton Knudsen, current Assistant Bishop in the Diocese of Long Island.  She visited our home parish, St. Ann and the Holy Trinity in Brooklyn, to conduct the ordination of our deacon into the priesthood.  This indeed took place on June 13 and was a very exciting celebration.  But Bishop Knudsen is about to leave Long Island and move to Maryland; beginning in the fall, she will minister there to people and clergy left quite troubled after their now-former Suffragan Bishop (a kind of associate) was involved in a car accident while driving under the influence of alcohol.  A young bicyclist was killed.  Bishop Knudsen is a strong advocate of recovery programs and a very good, compassionate person to work with the heartbroken people of Maryland at this sensitive time.  Meeting her just when her move was being announced thus brought this tragedy closer to home for us.

Secondly, just over a month ago, results of a brand new government study of alcohol and alcohol use disorders were published on a major AMA journal website.  The work, which we learned about in a brief New York Times feature, presents a substantial body of information on the scope and treatment of alcoholism.  Its major conclusion is that, regardless of the type of treatment, only a modest fraction of people with alcohol use disorders seek out any treatment in the first place.  There remains so much stigma that people continue to hide their situation from themselves and others, so that it continues to plague them, their lives and their companions.  This study, like the General Convention resolutions, urges us to bring this problem out into the open and work on it; it can be managed with constructive effort.  We'll try to do at least a little of that here.

The government study provides important background.  It comes out of a nation-wide survey taken in 2012 and 2013 of more than 36,000 people over age 18.  It shows that during the 12 months before the survey, 13.9% of this adult population experienced some kind of drinking problem and 29.1% had experienced such a problem sometime in their lives.  Recalibrated to the total civilian population, this is equivalent to 33 million in the last year and 68.5 million during their lifetimes.  It is all clearly worth talking about.

What is a "drinking problem"?
"Drinking problem" is our phrase.  It has only partly to do with the total amount of drinking and is also concerned with symptoms that arise as a result.  In terms of drinking amounts alone, lots of people do it; in this survey, some 71% of respondents had done some drinking in the past year, including beer, wine and liquor.  Of those who drink, nearly 40% had occasions when they consumed 5 drinks in a single day, and almost 10% of those who drink had 5 drinks in a day at least once a week.

Alcohol affects people differently, of course, and even moderate drinkers can show reactive symptoms.  They may repeat prolonged drinking sets and suffer the attendant hangovers; the drinking may interfere repeatedly with other activities, including job, school or family relations; the people may believe they can take undue risks while or right after drinking, which might include driving, swimming, or unsafe sex; they may feel repeated cravings or believe they need to drink more before any desired effect is felt.  Alcohol use disorders are defined as the occurrence of two or more of these reactions, out of a total of 11.  Two to three conditions constitute a "mild" alcohol use disorder ("AUD"), four or five make a "moderate" AUD and six or more, a "severe" AUD.  The phrase  "alcohol use disorder" is in fact a medical term and comes from the latest American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5; so these people have a medical condition.

Over the 12 months before the survey, 7.3% of the population had "mild" AUD, 3.2% "moderate" and 3.4% "severe," bringing the total to 13.9%, or the 33 million people we mentioned before.  The mean age at onset for these disorders was 26.2 years, that is, pretty young.  The share of 18-29 year-olds with an AUD was 26.0%, while among 30-44-year-olds, it was 16.2%, and 10.0% of 45-64-year-olds.  Even if you notice that this share goes down with age, it's still unnerving that 10% of upper-middle-age people have had an identifiable "drinking problem" in the last year.  Over their whole adult lifetimes, 37% of 18-29-year-olds have had a problem, 34.4% of 30-44-year-olds and 28.2% of 45-64-year-olds.

What about Treatments?
If this is a medical situation, do people seek treatment for it?  Unfortunately, not a lot.  Of the people with an AUD over the past year, just – just – 7.7% of them have sought help.  Now, maybe you could say that it could take longer than a year to realize there is something amiss that needs treatment.  Sure enough, in the survey, the mean age for seeking help was 29.4 years, that is, three years after the mean age of onset of AUD.  However, the survey still shows that for people with AUD sometime during their lives, only 19.8% have sought help.

This "help" comes in lots of forms.  By far the most prevalent is AA or other 12-step-type approach, in which 15.4% of those with AUD participate.  The next most frequent are rehab programs, 9.1%, followed by physicians or other health-care professionals, 8.7%.  The doctors often prescribe a drug called naltrexone hydrochloride, as well as at least two other widely used medications.  Some doctors also use something called "12-step facilitation."  Various cognitive-behavioral therapies also help.

It's important to be clear that these treatments do help.  Apparently the current survey results do not cover effectiveness of treatment, but other previous surveys do report on it.  Thus the authors of the report we have been citing here make this statement:  ". . . participation in 12-step groups increases the likelihood of recovery, consistent with randomized clinical trials testing the efficacy of 12-step facilitation administered by health care practitioners.  Reviews . . . of randomized trials involving thousands of patients have demonstrated the efficacy of brief screening and intervention in primary care settings among individuals whose alcohol problems are not yet severe."  This discussion goes on to comment on the effectiveness of other treatment forms, including the medications we mentioned above.  In one of the previous surveys of this type, people were interviewed in two rounds, three years apart, and asked in the second round about the extent of any recovery.  Results there showed in particular that attending a 12-step program was distinctly helpful and that it enhanced the outcomes of other treatment programs.

Why People Don't Get Help
This latest survey asks people who didn't go for help, why that was.  A list of 29 reasons was provided, and people could mark all that applied.  Here are some of the most frequently chosen answers, shown as a percentage of people who had thought about going for help, but never did:
            I should be strong enough to this handle alone     37.5%
            Thought it would get better by itself     33.8%
            Stopped on my own or with family help      26.4%
            Didn't think it was serious enough     23.3%
            Too embarrassed to talk about it     23.2%
            Didn't want to go          23.1%

Much less frequently chosen reasons include not knowing where to go or lacking insurance coverage.  A few respondents mention lack of child care, even as others fear that their children will be taken from them if they go for help.  Do note that about a quarter of these people who didn't get help were in fact able to solve the problem by themselves.  But this means that three-quarters of them couldn't or didn't.

So indeed, we all have a ways to go in education and reassurance.

Other Conditions Can Complicate
We've not mentioned another major issue called "comorbidity".  Alcohol problems often accompany other illnesses and the two or more conditions work together.  PTSD, identifiable personality disorders, prolonged depression, drug-abuse and nicotine disorders, among others, are found, complicating the treatment and recovery of people with AUDs.  These added conditions make it all the more important to address the subjective concerns, like those listed above, of people who have "drinking problems" but don't seek help.

Finally, we want to mention AA again.  An article in the April issue of The Atlantic asserts that AA has not been medically proven to be effective, and that writer is critical of the weight given to it as the primary approach to treating AUD.   We are hardly in a position to take an informed position on this topic.  We do know a number of people who are active in another 12-step program and that has certainly worked for them, many of them for many years.  You probably know such people as well.  It is the case that it's hard to conduct scientific, controlled studies of the effectiveness of these programs due to their voluntary and anonymous nature.  What we see in the studies we looked at here is that AA is by far the most widely used source of help and that earlier survey work showed clearly that AA enhanced the recovery prospects of other treatments.  A major point to be made is that there are a number of treatment formats and people can certainly try more than one at any given time.  That earlier survey work also noted that belonging to a religious community is constructive in facing an alcohol problem.  Participating in a community of caring people and regular attendance at services are indeed good things.


We could have broken the text with numerous footnotes throughout, but the material is already complex enough not to break the sentences with the source designation.  So here are the sources.  We call your special attention to the NIAAA treatment guide, the fifth item below:

The "current survey" is the National Epidemiologic Survey on Alcohol and Related Conditions III, often called NESARC-III, conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes of Health.  The survey was taken from April 2012 through June 2013.

The main report of results:
Bridget F. Grant, PhD, Risé B. Goldstein, PhD, MPH, and co-authors, "Epidemiology of DSM-5 Alcohol Use Disorder".  JAMA Psychiatry  Published June 3, 2015.  This article is free to the public; no subscription is necessary to access it, though a simple account identifier must be devised and registered to download the pdf.

We accessed the "General Codebook" of the main survey for various details not cited in the article.  This information is found here:

The New York Times reference is "Problem Drinking Affects 33 Million Adults, Study Finds".  The New York Times, June 3, 2015.  Accessed July 17, 2015.

The National Institute on Alcohol Abuse and Alcoholism has a treatment guide.  One early section of it is a quite readable list of the "Signs of an Alcohol Problem".  Find this guide at .  A 20-page pdf "Print Version" can be accessed right by the title.  The list of symptoms is given on page 3, and the entire guide looks quite helpful.

The "prior survey" we mentioned is NESARC, taken in 2001-2002, with follow-up interviews of many of the same people in 2004-2005.  Information from it on recovery prospects is reported in Deborah A. Dawson, Risé B. Goldstein and others,  "Correlates of Recovery from Alcohol Dependence: A Prospective Study Over a 3-Year Follow-Up Interval".  Alcohol Clinical & Experimental Research.  Vol. 36, No. 7, July 2012.  Pp 1268-1277.

The Atlantic magazine article:  Gabrielle Glaser, "The Irrationality of Alcoholics Anonymous." The Atlantic.  April 2015. .

And the news story about the General Convention resolutions can be found here: Bishop Knudsen is quoted in it, as is the Right Rev. Mark Hollingsworth, Bishop of Ohio.

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