HAMS: Harm Reduction for Alcohol

To The Health Care Professional

As a health care professional you may have been taught that whenever anyone comes to you with an alcohol problem--no matter how big or how small--that you must refer that person to AA. You may have been told that medicine, religion and psychiatry are of no use in helping an "alcoholic" and that the only thing which has ever proved effective in dealing with an alcohol problem is AA and the 12 steps. You may also have been told that "alcoholism" is an incurable and progressive disease and that your patient is powerless to help himself and will surely die unless you get him/her to AA at once. We are here to tell you that these statements are false.

The fact is that the vast majority of people with an alcohol problem do not progress to life threatening withdrawal syndrome. The NIAAA defines binge drinking as five or more standard drinks in one sitting and warns that this may lead to an Alcohol Use Disorder--the modern term for "Alcoholism". And according to the CDC at least one person in three has an episode of binge drinking at some point in their lifetime 1. Yet only one person in three hundred ever shows life threatening withdrawals 2. In many cases a period of heavy drinking is a temporary reaction to stress or to depression or to anxiety and can go away when the cause is eliminated. In some cases a period of heavy drinking is just an example of youthful excess and goes away with age--a phenomenon referred to as "maturing out" 3.

The simple fact is that the notion that Alcohol Use Disorders are progressive and life threatening diseases is FALSE. The vast majority of people with a diagnosable Alcohol Use Disorder get over their alcohol problem on their own. Only a small minority progress.

Perhaps you feel that no harm could be done by sending someone to AA and that the person may actually benefit from it. Unfortunately this is not necessarily the case. We are certain that you as a physician would not indiscriminately prescribe medications to a patient in the hopes that "something might work". We urge you to take the same attitude when it comes to alcohol problems. If someone objects to going to AA or to a 12 step treatment then the odds are that you will do that person HARM by sending them to AA against their will.

The best and most thorough study of AA and 12 step treatment programs ever conducted was done by Doctor George Vaillant 4 at Yale University. The conclusion of a generation long study was that patients treated with the 12 steps were no more likely to improve than a control group receiving no treatment at all. 12 step treatment proved no more effective than spontaneous remission. Moreover there is a 1980 study by Brandsma 5 and his colleagues which demonstrates that there is significantly more binge drinking (p = .004) among clients treated with a 12 step approach than among a control group receiving no treatment at all.

You may have heard that when a person objects to going to AA or to a 12 step treatment that this is the "disease" talking or the "alcohol" talking. There is not one shred of scientific evidence to support this notion. AA is a spiritual program and as such of necessity entails certain religious assumptions. Some people find the religious structure of AA both offensive to their personal beliefs and harmful to their mental health. It is surely everyone's fundamental right to reject a spiritual program which they find detrimental to their mental health and which violates their fundamental religious beliefs.

There is no question that rates of suicide and depression are very high among AA members. Even during the short time that I attended AA I heard about numerous suicides. Suicide and depression in AA have never been studied scientifically in comparison to a control group, but it seems that such studies are warranted. If suicide is a significant side effect of AA attendance then it is very important that doctors monitor clients for whom they prescribe AA--just as they monitor patients to whom they prescribe antidepressants or Chantix.

One thing which we have learned from experience with hard drug users is that the single most effective intervention for hard drug users is harm reduction. Building abstinence-based treatment centers for heroin users does not affect the incidence of HIV in a community. But building needle exchanges and methadone maintenance programs and heroin maintenance programs drastically reduces the incidence of HIV in a community. We believe that what is true for heroin is true for all drugs--even the legal drug alcohol.

So if someone with an alcohol problem approaches you as a physician and wants to go to AA then by all means send them to AA. If the person wishes to abstain but can't stand the religious nature of AA then perhaps you need to refer them to an abstinence-based secular program such as SMART Recovery. And if the person is unwilling or unable to abstain from alcohol then your best shot at helping this person may well be a harm reduction based-intervention.

Not only may it be your best shot--it may well be your duty under the Hippocratic Oath.


1 Health Behaviors of Adults: United States, 1999-2001

2 Delirium Tremens: Overview - eMedicine

3 Peele S, Brodsky A, and Arnold M. (1992). Truth About Addiction and Recovery. New York, Fireside.

4 Vaillant, G E. (1995).The natural history of alcoholism revisited. Cambridge, Mass. Harvard University Press.

5 Brandsma, J.M., Maultsby, M.C., & Welsh, R.J.. (1980). Outpatient treatment of alcoholism: A review and comparative study. Baltimore: University Park Press.

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