Tuesday, 24 July 2018

Binges, bouts and gaps in treatment

I’m going to suggest in this post that the approach of alcohol policy and treatment in the past few decades has had a crucial blind spot.  As ever, it’s not peer-reviewed research, so what you’ll find is the usual mix of personal and professional experience, in this instance prompted by literature.

This is a relatively short piece and isn’t meant to be watertight or academic.  It doesn’t go into the full debates around definitions of dependency, addiction, alcoholism, substance use disorder, etc.  I just hope it’s useful and can be judged on its merits (or lack of them).

I’ve written before about how definitions of problems associated with alcohol change over time.  The characteristic drinker seen as having a problem in the nineteenth century wasn’t doing the same things as someone we might see as having a problem in the 21st century.

I have to confess I get most of my feeling for this from fiction.  I say ‘confess’ as if I feel guilty about this.  I don’t.  (Though I will be making a reference to a proper confession in a minute.)  There’s plenty of histories of the concept of ‘alcoholism’ or ‘addiction’, and I’m not the person to write more on that; I’m certainly no historian of medicine.  But I have read my fair share of scientific definitions of problem drinking.  In fact, those studies have set for the scene for my thinking based on fiction.

When I was starting out studying ‘binge’ drinking (as defined by the media – i.e. getting drunk on the night-time high street), I naturally wanted to know if there was a ‘real’, ‘scientific’ definition of a ‘binge’.  At the time (2006) there was quite a bit being written about how the idea of ‘binge’ had become a ‘confused concept’ in contrast with a time when it had meant something more specific to the likes of Jellinek when discussing a technical definition of ‘alcoholism’.  And perhaps rather than a ‘binge’ we should have been referring to young drinkers as having ‘bouts’ of drinking.

Basically (and here I emphasise again that I’m no scientist, or medic, or medical historian), a ‘binge’ in old-school parlance meant a period of several days when someone fell off the wagon quite spectacularly.

And here’s where the literature comes in.  One of the most famous examples is The Lost Weekend – the drinker goes through periods of sobriety, before going on a binge, which comes to a natural conclusion in a detox (either in hospital or at home) after period of extreme drinking has run its course.  (I’ve never seen the film, only read the book, so apologies if this doesn’t fit.  Interestingly, the Wikipedia page for Charles Jackson refers to ‘his binge drinking’.)

You can see the same sort of theme in nineteenth-century descriptions of ‘drunks’ – who don’t spend all their time drinking, but get drunk with serious consequences.  Think of Joseph Poorgrass in Far From The Madding Crowd, who it seems can go a long time without a drink, but when he does have one, it ends up being more.  He even takes the opportunity to stop while driving a coffin back from town, parking it up outside the pub

I want to suggest that in some ways we’ve lost sight of this form of trouble with alcohol.  Or perhaps just treatment services and policy people have.

At first sight, this references might seem like classic forms of ‘alcoholism’, following the AA definition.  Someone who has, as I once heard it described, ‘got the spots’ can’t have just one drink – though they might go years without any.  One drink always leads to ‘too many’.  And this is how a lot of people who would see themselves as ‘sober’ or ‘in recovery’ would define their problem with alcohol.  Check out Laurie McAllister’s blog, particularly the contributions from a range of other people.

But I don’t think this is quite how professionals and policy people look at the world.  I would suggest that there seem to be two definitions of problem drinking in the UK today – or perhaps England more specifically.

I want to think about how the problem is defined.  First, there’s the idea that lies behind unit guidelines: drinking alcohol increases your risk of certain illnesses like cancer.  This is what means we have stats on low, increasing and higher risk drinking.  This discussion of drinking isn’t about whether people currently have a ‘problem’, or are suffering ill-effects from alcohol; it’s about whether people are putting themselves at risk of developing problems in the future.

Second, it seems that alcohol policy doesn’t really talk about ‘alcoholism’ much any more.  Instead, to convey the idea of a group of particularly heavy drinkers, the statistics talk about ‘dependent’ drinkers.  This means that you’re drinking at a level where your body has become physiologically dependent on alcohol, and withdrawal will have a harmful health impact that probably needs to be managed with medication.

And this isn’t just about the stats.  Consider how we think of an alcohol problem that needs treatment (as opposed to a ‘brief’ or ‘behaviour change’ intervention that groups alcohol with other issues like diet and exercise).  Generally, we’re referring to someone who drinks every day and has a level of dependency.  That classic question in the screening tools of whether you drink every day, or even have drink in the morning to get yourself going.  What’s the treatment available?  Detox.

I’m not saying that everyone who engages with community treatment services could or should have a ‘detox’.  However, there’s no getting away from the fact that that element is the most clearly defined and regulated.  Prescribing for withdrawal is in many ways more straightforward than trying to identify what ‘talking therapies’ or other interventions might foster ‘recovery’.

I don’t have a reference to cite here.  This is my individual reflection on how treatment services are organised today.  There are two prongs of structured treatment, according to the national database: pharmacological (prescribing) and psychosocial (talking therapies).  This is partly the legacy of a system that was set up to capture the work done to treat opioid use disorders, where prescribing is such a central part of the standard model, but it does to some extent reflect how we think about these systems, and how we commission services.

But think back to those accounts on Laurie McAllister’s blog, or Joseph Poorgrass.  They don’t drink every day.  But alcohol is still a problem that needs something more substantial than a ‘have a word’ approach of: ‘have you thought about drinking a bit less?’

So should we be treating people who have ‘binges’ or ‘bouts’ of drinking?  This idea actually makes me feel uncomfortable.

Why?  I think it’s because this drinking to oblivion is often seen as dysfunctional or maladaptive by definition.  Deliberately drinking to drunkenness, whether called a ‘binge’ or a ‘bout’ is indicative of some kind of underlying problem.

My work on ‘binge’ drinking reframed it (as have other people) as ‘carnivalesque’, to try to convey that it is ambivalent for all concerned, whether producers, drinkers or government/regulators.

And this ambivalence struck me again over the weekend, reading Doris Lessing:

Mr Clarke earned fifty pounds a month which was more than he would earn anywhere else.  He was a silent, hardworking man, except when he got drunk, which was not often.  Three or four times in the year he would be off work for a week, and then Mr Macintosh did his work for him till he recovered, when he greeted him with the good-humoured words: ‘Well, laddie, got that off your chest?’  ‘The Antheap’, Five, p.193

He [James] would get really drunk several times a year, but between these indulgences kept to his three whiskies at sundown.  He would toss these back, standing, one after the other, when he came in from work; and then give the bottle a long look, a malevolent look, and put it away where he could not see it.  Then he took his dinner, without pleasure, to feed the drink; and immediately went to bed.  Once Paul found him at a week-end lying sodden and asleep sprawled over the table, and he was sickened; but afterwards James was simple and kindly as always; nor did he apologize, but took it as a matter of course that a man needed to drink himself blind from time to time.  This, oddly enough, reassured the boy.  His own father never drank, and Maggie [his mother] had a puritan horror of it; though she could offer visitors a drink from politeness. It was a problem that had never touched him; and now it was presented crudely to him and seemed no problem at all.  ‘Eldorado’, Five, p.171

In both of these instances, like Paul in the second extract, I find it hard to see that there’s much wrong with these men’s drinking.  Perhaps, given the fact that Mr Clarke has lost other jobs because of his drinking, and James obviously has some kind of ‘malevolent’ feeling towards alcohol, this isn’t an entirely healthy relationship, but then all of us do (or fail to do) things that other people would see as unwise or unhealthy in the long term.  (I’m reminded of the Church of England confession with its call to sobriety: we’re all ‘miserable offenders’.)

And it’s partly this need to distinguish heavy drinking from problematic drinking that’s made the medical model so attractive: dependence is a diagnosis without judgement; it’s about physiology.

And at this point the disease model of alcoholism/addiction is relevant.  A disease is a medical problem, and it feels natural to us to treat a disease with medicine – hence the idea that a physiological detox is the core treatment for alcohol problems.  And it is in fact a highly effective, evidence-based treatment for physiological dependency.  But dependency is not the same thing as ‘alcoholism’, and even if we just talk about ‘the disease concept of alcoholism’, remember that Jellinek stated: ‘The subject of this study represents not more than a small section of the problems of alcohol – a very small section indeed.’

And here’s the rub: we can never have a clear, objective definition of an alcohol ‘problem’ based on actual drinking behaviour unless we’re prepared to group Joseph Poorgrass and Mr Clarke together.  They both drink, occasionally, to oblivion, but one does it in a planned way, as a holiday; the other does it while he’s transporting a coffin, complete with corpse.

It’s true that this could be captured by elements of the DSM definition – the fact that Joseph Poorgrass’ drinking does damage his work, for example.  But I want to suggest that in practice it’s really hard to actually distinguish between this and the drinking by James in Doris Lessing’s ‘Eldorado’.  I know this is the purpose of tools like AUDIT and SAD-Q, but here I just want to question this pseudo-scientific approach, and wonder out loud as to whether this medicalisation of alcohol problems is actually helpful.

That is, we have a tendency to look back in time and think that terms like ‘drunkard’ were unscientific and unhelpful, and even stigmatising.  We now live in a more scientific and less moralistic world with our ideas of disease and dependency.  But my question is: does this comfort of apparent science and objectivity mean that we fail to offer support to everyone who needs it?

As I said at the beginning, this isn’t a peer-reviewed, evidence-based piece.  It’s just some reflections on my recent experiences, prompted by reading for fun.  Maybe I’m wrong about the nature of ideas of disease and dependency and medical models of treatment, and their influence on services today.  I’d love to know what other people’s thoughts and experiences are.

1 comment:

  1. Hi Will, good stuff as always.

    As you'd expect, there's two key points I very much agree with here.

    1. Treatment services don't 'reach' many drinkers who could benefit from behavioural support, particularly 'harmful' drinkers who don't typically self-identify as alcoholic/dependent/problematic etc
    2. This is in part due to the medical model and indeed over-emphasis on physical aspects of dependence.

    When you say you 'struggle to see there's much wrong' with the drinking in the extracts, I wonder if this is the right question. 'Wrong' is of course a binary, and implies a moral aspect. The drinking behaviours described describe a degree of risk or indeed harm. Isn't the overall aim to help people at risk or harm make the best possible choices for their own well-being, while ultimately recognising it is still their choice, so long as they are not harming others?

    That said, I agree there is of course an ongoing and unresolvable conflict in trying to identify and measure inherently complex, individual and fluid 'problems' in attempt to meet these aims. As such, efforts to capture and support or treat alcohol problems will always be an imperfect 'science', thus thought pieces like these having value.