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In Fighting the Harmful Use of Alcohol, Abstinence May Not Be the (Only) Solution

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Ever since our prehistoric ancestors discovered the pleasant psychoactive effects of fermented beverages, alcohol dependency and alcoholism have been drinking’s perennial companions. According to the World Health Organization (WHO), 2.5 million deaths each year result from the harmful use of alcohol, accounting for nearly 4% of all deaths worldwide. And that is not to mention the enormous burden of morbidity from the negative health effects, violence and injuries associated with alcohol consumption.

However, such worldwide statistics conceal extreme geographic variations. In Hungary, for instance, an estimated 15% of males are suffering from alcohol use disorder, and in Russia the rate is over 16%. In countries with strong cultural and religious taboos against the consumption of alcohol, such as Kuwait and Saudi Arabia, the rates of alcohol use disorder are near zero.

In an effort to curb the many harms associated with alcohol abuse, countries have experimented with a number of interventions. Among the best known is the U.S. government’s (largely failed) effort to criminalize the sale of alcohol between 1917 and 1931 (see U.S. Constitutional Amendment XVIII). Many other countries have attempted similar prohibitions, which also ultimately failed (e.g. Norway and that of vodka in Russia). Still other countries, such as Bangladesh and Brunei continue to impose a nearly universal prohibition on the sale of alcohol. Moreover, virtually every country in the world places limits on the sale, consumption, price, and other aspects of alcohol distribution and use. Some governments have tried more innovative approaches. For example, Amsterdam recently raised controversy by offering alcoholics beer in exchange for cleaning city streets.

Despite the panoply of available government interventions, alcohol use disorder remains stubbornly persistent. Partly, this is due to many governments not making full use of effective interventions. However, while such interventions have the potential to be effective if properly implemented, it is also clear that government proscriptions alone cannot eliminate the harmful use of alcohol. Short of a Brunei-style prohibition (which experience in the U.S. and elsewhere demonstrates is not possible without near-universal cultural and/or religious buy-in), much of the work of preventing harmful use of alcohol will depend on providing proper treatment and care for alcohol-dependent and alcoholic people.

A recent New York Times op-ed by Gabrielle Glaser calls into question one of the central tenets of treating dependency and alcoholism. As she points out, common belief is that, for those who engage in harmful use of alcohol, the only solution is complete abstention. While “American doctors typically prescribe drugs with the goal of abstinence,” Ms. Glaser argues that this is not the only the solution. She points to a study in which the use of naltrexone (an opioid antagonist) in conjunction with moderate alcohol consumption was 78% effective in reducing alcohol consumption among participants. Moreover, programs such as Moderation Management (M.M.)—an alternative to A.A.—help drinkers to manage their drinking without the need for complete abstinence. Such programs have achieved considerable success, and (unlike A.A.) tend to appeal particularly to women.

As Ms. Glaser herself points out, for some—such as those with severe drinking problems—abstinence may remain the only viable solution. However, for the great majority of problem drinkers, moderation can provide a useful alternative to abstinence. Ultimately, placing a meaningful dent in the tremendous harm associated with the misuse of alcohol will require the combination of innovative government interventions and flexible and novel approaches to behavior modification.

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The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.

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