Photo of Mark Willenbring by Bill Branson, National Institutes of Health
In the treatment community, it is common knowledge that many people with alcohol dependence never receive specialty addiction treatment, and that those who do receive treatment have the most severe form of the disorder together with substantial co-existing mental, physical, and social disability. Among treatment professionals, one common explanation is lack of access due to practical barriers such as distance or lack of insurance. Stigma also is frequently mentioned. But are those the biggest problems?
This article proposes an alternative explanation: that the type, location, and style of treatments currently available are based on outmoded views of the nature and variability of alcohol dependence and the types of treatment that should be available to address it. I also will argue that fundamental changes are needed in the configuration of services and service providers (the continuum of care) to make effective treatments sufficiently attractive, accessible, and affordable to reach more than the one in eight of those who need and currently receive specialty addiction treatment.
Although access, cost, and stigma are important, treatment avoiders are more likely to assert, “I'm not that bad yet,” or “I can handle it myself.” Accordingly, many professionals view those assertions as evidence of “denial” (i.e., that people do not realize that they are ill). I believe that explanation to be simplistic and self-serving. Like the famous cartoon character Pogo, I believe instead that “we have met the enemy, and he is us.” Unless we open ourselves to new ideas, I don't think we will make progress. In fact, we may expend precious time and resources in search of the wrong solution.
A continuum of need
In a recent National Institute on Alcohol Abuse and Alcoholism (NIAAA) Web conference titled “Alcoholism Isn't What It Used to Be: New Findings on the Nature and Course of Alcohol Use Disorders” (available at http://https://webmeeting.nih.gov/p27471408), I presented evidence that our view of alcohol use disorders (AUDs; abuse and dependence) has been distorted by focusing on people attending treatment programs. This is not uncommon in healthcare: We focus first on the people presenting for care, who have the most severe, treatment-resistant form of the disorder and who often also have other unrelated disorders that make managing any one of them more difficult. Only in time does a different picture emerge: The disorder exists in a much more varied form in the community at large, and those entering treatment do not represent the typical person who has it.
For example, at first breast cancer was identified only when a tumor became large and unavoidable; now mammograms identify tiny tumors undetectable even by careful examination. Once it was thought that schizophrenia was inevitably severe and totally disabling, requiring long-term hospitalization; but then studies of community populations revealed many milder cases in which people improved over time and were able to work and have relatively normal lives.
In the general population, there is a continuum of alcohol use and disorders ranging from abstinence to low-risk drinking, risk drinking, harmful drinking, and dependence to chronic, relapsing dependence (see Figure). There is no sharp delineation between categories; instead, they blend one into another, and category definitions involve tradeoffs between being too sensitive or missing “cases.”
Figure. Continuum of care for excessive drinking and alcohol use disorders. (Percentages represent the approximate proportion of the U.S. population age 18 and older in each category in any given year.)
For example, a diagnosis of alcohol dependence requires that three of seven DSM-IV criteria be met, but why not two, or four? Most heavy drinkers (four or more drinks per day for women, five or more for men) do not have and never develop any AUD or other adverse consequences. Most people who become dependent have milder forms of the disorder and meet only three or four DSM-IV criteria. Almost three-quarters of persons with dependence experience a single episode that lasts three or four years, after which they get and stay well. In contrast, most people in treatment programs meet six or seven criteria and have repeated episodes over the course of years to decades. Whereas most people with dependence have no observable disability (i.e., job, relationship, or legal problems) and remain quite functional even though symptomatic, most people in treatment are significantly disabled and have multiple co-existing conditions.
Thus, our understanding of AUDs and related judgments about how they should be treated are limited by our exposure to only the sickest 10%—that is, those in our treatment programs. Unfortunately, this incomplete understanding leads in turn to many false beliefs: Recovery is not possible without treatment or Alcoholics Anonymous (AA); alcoholism is inevitably a severe, chronic, progressive disorder; people are either alcoholic or not; heavy drinking always leads to bad consequences, and so forth.