How Many People Are Actually "Alcoholics"

It's estimated that there are about four times as many people in the United States who are problem drinkers, people who have less severe alcohol problems than there are alcoholics. Well, I mean, it's good to know that, but it's unfortunate that the majority of addiction treatment programs in the United States are for the people with the most severe problems. 95% of the programs in the United States are abstinence-based programs that are modeled within the AA framework and programs for so-called problem drinkers.

People with less severe problems have been scarce and hard to find. For decades, the uh addiction treatment field has been dominated by uh the traditional abstinenceonly approach based on the disease model of addiction of alcoholics anonymous. The disease model says that if you have developed a serious problem with alcohol that you are somebody who is quote constitutionally incapable of controlling or moderating your drinking within safe limits and that if you've already developed that problem it's a one-way street. The best thing for you

is to stop drinking and stop drinking for good ideally for the rest of your life. So AA and the 12step program is an abstinence-based program which started in the 1930s by the way and uh the early treatment programs that developed on the heels of that of course naturally became abstinence-based programs based on the AA model of alcoholism as a disease. That is alcoholism was seen like pregnancy. You either have it or you

don't and there's no in between. There were no shades of gray. The idea that there would be a program to try to teach people how to moderate their drinking was out of the question. It was um

abstinence or nothing, all or nothing. In recent years, uh another model of treatment uh has developed, another model of addiction, actually a way of looking at alcohol and drug problems, and it's known as the harm reduction model. And the harm reduction model says that uh there are many different types of drinking problems that they are problems that lie on a spectrum from mild to moderate to more severe problems. They don't all neatly fall

into one category. The harm reduction philosophy, which is really now just starting to build up some steam, says that any steps taken to reduce the risk of of harms or the actual harms caused by a person's alcohol or drug use, any steps taken are steps in the right direction should be supported and applauded. And that treatment programs really need to start where the person is, not where others think they ought to be. And so treatment does not have to

start with completely giving up alcohol as step number one. You can start by trying to help people see whether or not with some professional guidance and help they can learn how to pull back on their drinking and cut down reduce the consequences and anything done to reduce the harm associated with their drinking is is worthwhile. And people with less severe problems in particular may be people who don't necessarily have the disease of addiction. It may not be an

all or nothing matter for them. They may be able to learn how to cut back on their drinking, drink responsibly, and drink in ways that don't cause problems. It's been a long time coming, and this model has taken a long time to gain traction because the traditional uh 12step approach of abstinence only has gained a very strong foothold in the addiction community, in the recovering community, and in the treatment community. I mean, for good reason. and

millions of people have been helped by AA around the world. It's a great program. The biggest problem is its low level of acceptance among people who don't see themselves as alcoholics who will in fact never set foot in an AA meeting. Many people who go to an AA

meeting and don't come back and people who feel like the treatment programs that they've made contact with require them to accept an identity as being an addict or an alcoholic embrace the 12step philosophy, stop drinking immediately and get involved in a program to change their relationship with alcohol and in fact to change the way they're living their life. And for people who take to that program and uh are able to make use of it, it's a it's a wonderful program. And among the people who do participate in a meaningfully meaningful way, the success rates are good. The problem is that it's

a program that's acceptable to only a very small fraction of the population of people who have alcohol problems. Uh, of course, abstinence is the safest goal by far. There's no question about that. And

in fact, if you offer people the option to um help them learn how to moderate their drinking and they have difficulty with that, they can't seem to master the skills required to reliably moderate their drinking. Significant numbers of them, at least 25% of those individuals will switch to abstinence on their own. They will come to see through their own experience that they can't reliably control their alcohol use. They don't

have a reliable off switch. That is once they start drinking, their intention to limit their drinking dissolves along the way in the alcohol. By the time they're at their third or fourth drink, their original intention to limit it there has all but disappeared and uh they're likely to go on and then consume significantly more alcohol on that occasion. People learning that through

their own experience come to realize that abstinence is probably the better course. So I see moderation offering people the harm reduction approach for many of them as a stepping stone an unavoidable stepping stone that brings them to the conclusion that abstinence may be the better course and that's extremely valuable. These are people who probably would have never come into treatment in the first place if uh they were told that a requirement of coming into treatment is that they have to agree to abstinence as their goal and immediate abstinence if at all possible.