Back From the Drink

The new approach to alcoholism puts practicality before ideology.What works? Keeping motivation high, for starters. And it's not even necessary to admit you are an alcoholic to curb drinking.

Each year it kills 40,000 Americans. It can damage and destroy every organ in the body, scarring and pocking the liver until it looks like a lump of drying lava, laying waste to the heart, pancreas, arteries, throat, and stomach, snuffing out receptors in the brain. Every year alcoholism costs our country over $80 billion, is implicated in 30 percent of suicides and 46 percent of teen suicides, and is a factor in one of four hospital admissions. No wonder it has long been decried as not far removed from original sin.

Yet like the music of Greek sirens, alcohol has also been the hymn song of poets, monks, philosophers, and soldiers. It is a ritual substance in most religions, intimately linked to God and altered consciousness. It is the supreme seductress: "For not even the gates of heaven, opening wide to receive me," wrote author Malcolm Lowry of a bar in Mexico, "could fill me with such celestial complicated and hopeless joy as the iron screen that rolls up with a crash. All mystery, all hope, all disappointment, yes, all disaster, is here." Or, as Rabelais put it: "I drink for the thirst to come. I drink eternally.... The soul can't live in the dry."

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What other substance has so mesmerized and polarized us as alcohol? It has a long and illustrious role in our culture, from social lubricant to lethal intoxicant. There are those who contend that culture itself owes its existence to alcohol -- that the first primitive, agricultural societies sprang up around the farming and ferment of hops. Experts advocate a glass or two of wine daily, citing wine's healthful antioxidants and significant potential to reduce heart disease. Yet the same experts call for an astounding 25 percent reduction in alcohol consumption. Sound confusing? Not surprising. Alcohol is one of the most potent pharmacologic agents around, one whose effects seem as protean as human nature itself.

For that reason, perhaps, it has taken the maturation of neuroscience and psychology to give us a realistic glimpse into alcohol use and abuse -- and the picture is no longer black or white. Researchers are now beginning to ferret out the causes of alcohol addiction, of liquor's fiery path across the cells of the brain, its social underpinnings and cultural power -- as well as new, innovative, and flexible treatments for this condition.

"There's tremendous excitement, a watershed feeling, as if something is just beginning to happen," notes Henry Kranzler, M.D., a psychiatrist at the University of Connecticut who has pioneered new pharmacologic approaches to alcoholism. "This field now is at the same place that the treatment of depression was 30 or 40 years ago. We're really beginning to understand this condition, to develop promising medications and psychosocial interventions."

THE SHIFTS ARE PROFOUND. Perhaps most important, according to Dennis Donovan, M.D., a psychiatrist and director of the Alcohol and Drug Abuse Institute at the University of Washington, is the willingness to look at the goal of treatment for alcoholism as far more than abstinence or the lack of it. "Abstinence is no longer the gold standard, it's simply one standard."

There is a growing understanding among mental health experts that alcohol abuse occurs on a continuum and must be treated thusly. According to Steven Liljegren, Ph.D., clinical director of Child and Adolescent Services at Brookside Hospital in Nashua, New Hampshire, traditional alcohol treatment programs work for less than half of drinkers. An unprecedented multisite study called Project MATCH, involving over 80 therapists, is now underway to match patient characteristics with different kinds of therapy. Researchers are discovering that, while some former alcoholics require unequivocal abstinence, others can drink in moderation.

As the field moves away from an absolutist, all-or-nothing view, the definition of treatment success, too, is widening. Some of the new findings sweeping the field include:

o Alcohol is not, as was long believed, simply a chemical sledgehammer. It seems to act specifically on neurotransmitters and receptors, primarily GABA, the prime inhibitory neurotransmitter in the brain, and one that accounts for much of alcohol's effects. This discovery may lead to new medications for helping drinkers overcome the condition.

o Most alcoholics do not have preexisting psychiatric conditions. However, about 20 percent are suffering from psychiatric disorders that they may be attempting to medicate with alcohol, and which are beginning to be treated with the latest psychotropic drugs.

o Social support -- whether from friends, family, therapists, or self-help groups -- is crucial to recovery. In fact, peer and family support may be the "missing link" that allows some alcoholics to quit on their own, without any formal treatment, according to Donovan. Social support can be provided by contact with recovering people, access to self-help groups, and a family that helps the drinker to readjust to life without substances. Social support does not mean that the family should keep on protecting the alcoholic when he or she is in trouble; it means creating enthusiasm in both the drinker and the family that a life without alcohol is possible.

o In the arena of alcoholism, motivation to quit reigns supreme. The latest research shows that brief, motivationally based interventions, where counselors work with patients for one to four sessions -- to both establish and to reinforce reasons for quitting -- can be as effective as far more intensive therapy.

o The motivation to quit drinking varies considerably among alcoholics. For one, losing job and family isn't enough; for another, an embarrassing moment at a corporate party may change a man's life. It's always subjective.

o One of the key genetic factors in alcoholism is an ability to metabolize liquor too well, because of the presence of the liver enzyme alcohol dehydrogenase. Indeed, a common trait among alcoholics is the early ability to "drink others under the table."

o Twenty percent of all alcoholics can and do quit successfully on their own. Researchers are just beginning to explore what is "special" about them and how to apply it to all alcoholics.

o In sum, no matter where and how an alcoholic recovers, this powerfully complex condition imposes three requirements for recovery: high, sustained motivation for quitting; readjustment to -- and building -- a life without liquor that includes family and peer support; and relapse prevention based on specific, well-rehearsed strategies of "cue" avoidance. These factors are being incorporated into treatment programs around the country.

As the tectonic plates of alcohol treatment shift, with new flexible views sending a shudder through the mental health field, the person who may finally benefit is the alcoholic. New insights into alcoholism are yielding exciting treatment approaches, creative uses of medication, and innovative psychological interventions.

No one can ascertain exactly when man discovered that carbohydrates could be fermented into alcohol, although we know that in 6000 B.C., beer was made from barley in ancient Sumeria. What is clear is that societies have long venerated and feared alcohol. Ancient Egypt and Mesopotamia allowed liquor into temple rites but regulated its general use; the Greeks linked their entire intellectual flowering to grape and olive growing; medieval monks brewed beer.

In the U.S., in turn, alcohol has a history marked by ambivalence that has shaped treatment so powerfully that a singular model has prevailed for nearly a century.

DURING COLONIAL days, alcohol consumption was extremely prevalent -- and there was no concept of the "alcoholic." The dawn of the 19th century brought with it a temperance movement that, according to Harry Levine, Ph.D., professor of sociology at Queens College in New York City, viewed alcohol as an addictive substance as dangerous as today's heroin or crack. Abstinence was the only solution.

Prohibition flowered directly out of the rich soils of the temperance movement, and yet it only set the stage for a very dismal failure: Consumption of hard liquor (which was easier to smuggle) rose, while overall drinking fell. A typical "temperance" culture, the U.S. gave birth to Alcoholics Anonymous, which has flourished in other temperance cultures, such as England, Canada, and Scandinavia. Notes Levine, "AA is really a religious movement that has tremendous continuity with the 19th century temperance movement. And AA's understanding of alcoholism is the central understanding of addiction in American culture overall."

Alcohol consumption, especially hard liquor, has seen a steady decline to 74 percent of its mid-1970s record high. Still, 13 million Americans are alcoholics. As researchers increasingly realize, a society's attitudes about alcohol strongly impact how individuals handle drinking. In Mediterranean, nontemperance cultures, wine is as common as bread, and individuals drink every day without becoming "problem" drinkers. The per capita rate of alcohol consumption is high; cirrhosis is common; but behavioral problems from alcohol are rare, and society does not lay the blame for its ills at alcohol's door.

In sharp and astonishing contrast, a temperance culture is highly ambivalent about "demon" alcohol, which is seen as a significant cause of our society's problems. In America, for instance, addiction is considered a root cause of violence. "In temperance cultures, people drink to get drunk. They tend to drink in short bursts of explosive, hinge drinking. Wine cultures rarely get fall-down drunk," says Levine.

Levine cites the typical European view: "Papa comes in with liver disease, and the doctor calls in the family and says, 'Look, he's got to make life-style changes, stop drinking for a while, eat less fatty food, exercise, and minimize stress, and the whole family needs to work together to help him because these changes are hard.' Apparently this works. Tell these European practitioners that what they really need to do is send their patient to 90 meetings in 90 days and turn themselves over to a higher power and they'll say, 'I've got somebody with health and dietary problems and you've got a religious solution?'"

In a temperance culture where alcoholism is widely -- if incorrectly -- regarded as a disease, the cure until now has been relentless abstinence. Levine calls this model a "useful fiction" that works for some, but by no means all, alcoholics.

For any person, the first step in reducing alcohol intake is to understand alcohol itself. Advances in neuroscience have given us new insight into the actual impact of alcohol on the body -- and the mind.

FROM AN $800 BOTTLE OF DE LA Romance-Conti, vintage 1978, to the crudest, rudest moonshine, alcohol impairs far more than our judgment and coordination. While we absorb the active ingredient of many psychoactive drugs in minuscule quantities -- an ant can carry a few hits of LSD comfortably on its back -- a drinker literally floods the body with alcohol. "Alcohol is problematic in part because it's so impotent," points out John Morgan, M.D., pharmacologist at City University Medical School in New York. "Other mood-altering substances are active in the bloodstream at literally thousands of magnitudes below what is required for alcohol."

As a result, alcohol -- particularly in alcoholics, who can tolerate large amounts of liquor -- exerts its toxic effect on virtually every organ system in the body, says Anthony Verga, M.D., medical director of Long Island's Seafield Center. The repercussions range from W.C. Fields's perpetually red nose to a torqued and failing liver common in alcoholics.

The liver, in fact, is the body's main line of defense against intoxication. But the fight is hardly fair. The organ's supply of alcohol dehydrogenase -- the enzyme that helps break alcohol down into harmless water and carbon dioxide -- can only handle about one drink's worth of alcohol an hour. Worse, the process produces acetaldehyde, a highly toxic chemical that attacks nearby tissues. The result is a variety of disorders. One of the gravest, cirrhosis, kills 26,000 Americans each year. But the liver is by no means the only casualty of alcoholism:

o After a few years of heavy drinking, some alcoholics develop pancreatitis, a painful inflammation of the pancreas.

o The heart wastes away, a condition called alcoholic cardiomyopathy.

o Drinking impairs blood flow. Heavy drinking can increase risk of stroke.

o A pregnant woman who drinks heavily can give birth to a baby with Fetal Alcohol syndrome (FAS), one of the leading causes of mental retardation. FAS occurs in up to 29 out of every 1,000 live births among known alcoholic mothers. Babies suffer lifelong neurological, anatomical, and behavioral problems. Some of them never learn to speak. Recent research indicates the casualty rate may be higher than once thought: Even babies appearing normal in infancy often grow up to manifest FAS disabilities.

o Alcohol takes its greatest toll on the brain. A small percentage of alcoholics may, after years, develop such severe brain damage that they remain permanently confused or become psychotic, suffering from auditory hallucinations. At least 45 percent of alcoholics entering treatment display some difficulty with problem solving, abstract thinking, psychomotor performance, and difficult memory tasks. About one in 10 suffers severe disorders like dementia.

Why can't a drunk brain think? Is there any way to correct the misfiring that chronic alcohol use induces? Alcohol appears to stimulate GABA in the brain: "What GABA does is slow down the firing of the cell on which the receptor is located," says Kranzler. This neuronal inhibition may contribute to the telltale signs of intoxication, from slurred speech to nodding off in mid-sentence. And, while Valium and barbiturates are distinctly different drugs than alcohol, they also target the GABA(A) receptor, suggesting a kinship.

Alcohol cuts a far wider swath than GABA; it alters other receptors in the human brain:

o Drinking inhibits two of the three receptors for glutamate, the primary brain fuel and GABA's chemical opposite.

o Alcohol increases levels of a chemical messenger known as cyclic AMP, crucial for the healthy functioning of brain cells. To compensate, the brain reduces cyclic AMP levels, and over the long term, cells require alcohol to achieve normal levels.

o Levels of dopamine and serotonin, which contribute to behavioral reinforcement, also rise with alcohol consumption. Their increase may explain how alcohol tightens its grip on a drinker's habit.

o Alcohol increases levels of the brain's natural opiates, endorphins and enkephalins. This may be the key to the eternal, if politically incorrect, question: Why is drinking so much fun?

Alcohol addiction is real, and withdrawal from alcohol can require a period of unpleasant detoxification. During that period, a former drinker can suffer acute anxiety, irritability, insomnia, increased blood pressure and body temperature, and severe, though temporary, confusion. Acute symptoms may fade after a week, but subtler symptoms of unease and insomnia may persist for months, making it difficult to remain alcohol-free.

Until recently, it has been an axiom of alcoholism treatment that withdrawal requires a (usually) month-long intensive in-patient treatment regimen, and then often a modified regimen where former drinkers live in halfway houses for up to six months. During the intensive phase, the alcoholic can detoxify from the drug while immersed in 24-hour support with other recovering alcoholics and counselors (often former alcoholics themselves). Group therapy is a feature of these programs, designed to break through the alcoholics' wall of denial and help set them on the straight and narrow path to a substance-free life. These programs can cost $16,000 or more per month.

The good news is that the very physiological nature of alcohol's seductive hold can lead us to new treatments for the condition. Pharmacologists are investigating drugs that may aid in nearly every aspect of alcohol abuse, reducing the craving of newly detoxified drinkers and even alleviating cognitive impairment.

Naltrexone, for example -- a drug originally developed to combat heroin addiction -- may prevent binges when alcoholics relapse. Naltrexone blocks the opiates that the brain releases when someone drinks, so that an imbiber literally gets no kick from champagne. The drug may be most useful in the months after detoxification, when alcohol craving is strongest. Joseph R. Volpicelli, M.D., a University of Pennsylvania psychiatrist, and his colleagues found that only 23 percent of naltrexone patients relapsed within 12 weeks of treatment, versus 54 percent on placebo.

Volpicelli thinks that naltrexone may prove far more valuable than disulfiram, a 40-year-old drug well known as Antabuse. Disulfiram interferes with alcohol metabolism, so that takers suffer nausea, cramps, headaches, and vomiting when they drink. In practice, though, the drinker stops taking it, because the physiological effects often build to such a crescendo -- including violent heartbeats and hot flushes -- that impending death is feared.

Buspirone (BuSpar), an antianxiety agent, may help alcoholics by minimizing the effects of withdrawal. Many doctors traditionally give benzodiazepine drugs, such as Valium, to dampen withdrawal symptoms -- but those drugs can be addictive and may further blunt the memory of heavy drinkers. Buspirone may be a safer alternative. Other drugs that have shown promise include cipramine, which helps alcoholics who are also suffering from major depression, and deispramine, another antidepressant that seems to reduce drinking.

The new view of alcoholism is of a complex condition arising from the intricate and unpredictable interplay of social, biological, and psychological factors. "Alcoholism is not a disorder caused uniquely by genes," explains Mark Schuckit, M.D., of the Veteran's Administration Medical Center in La Jolla, California. "Some persons become alcoholic solely through environmental exposure; others have biological and psychological predispositions. There are many different paths to alcoholism. Once a person drinks regularly, however, the body's reaction to and tolerance of alcohol changes, so that the person needs more alcohol. Patients need to be educated about the many factors that contribute to the disorder, so they can understand that the situation is not hopeless."

Studies show that the type of therapy an alcoholic receives isn't as important as the fact that he or she gets some treatment.

"There are very few harmful or useless treatment programs for substance use disorders," says Schuckit. "If you are highly motivated, then you are likely to do well in almost any program you choose."

The programs most alcoholics choose are based on the Minnesota Model, which views alcoholism as an incurable disease. It involves group counseling to confront a "denying" drunk, education about alcohol's consequences, and confessional self-help organizations like the AA.

There are already cracks in the Minnesota Model's clinical monopoly. Although the personal experiences of thousands of alcoholics attest to the model's value, its failure rate -- about 50 percent -- reveals the futility of assembly-line treatment. Indeed, aversion therapy, stress-management, and family therapy are proving effective for many alcoholics.

Take the fact that an alcoholic's memory may be impaired -- leading to treatment problems that have little to do with the so-called ubiquitous "denial" syndrome. "Ten years ago, if an alcoholic didn't seem to be catching on to treatment, it was assumed that he or she was 'in denial'," says Tim Sheehan, R.N., Ph.D., of Minnesota's Hazelden Foundation, arguably the archerypal inpatient treatment center. "Now we're recognizing that there may be lingering cognitive deficits." During treatment, these patients are exposed to fewer concepts, which are reinforced often.

Three new approaches -- all of them "heretical" by the traditional abstinence model -- eschew ideology and spiritual baggage in favor of simple pragmatism. Some alcoholics do quite well with them. They are:

o Harm reduction, which recognizes that moderate drinking is preferable to lost weekends. Any decrease in alcohol intake is grounds for a (alcohol-free) toast.

o Brief intervention. In as little as half an hour, an intervention attempts to show the subject how drinking may be impairing everything from his liver to his livelihood; helps him rate himself on a series of questions about his life and drinking; and then places him on a continuum with his drinking peers so that he has a sense of the nature of his problem. In addition, brief sessions help the person focus on motivations for reducing drinking. Brief intervention, lasting four sessions at most, can be as effective as more intensive treatments for many individuals, says Donovan.

o Cue exposure, or systematically exposing and desensitizing the alcoholic to cues that might trigger drinking. According to Liljegren, "traditional treatment says it's heresy to expose the drinker, it will just increase his craving. In fact, the opposite seems true; the data suggest cue exposure is the very thing we should be doing."

By exposing the drinker to cues for drinking that might normally stimulate intense craving, and by refusing to reinforce those cues with the "pleasure" of drink, alcoholics become less responsive to those cues over time. The drinkers' sense of self-confidence and efficacy rise, proving that they can restrain from drinking in the presence of cues. And it provides the opportunity for drinkers to learn how to cope with their problem in the outside world.

Typical drinking cues, notes Liljegren, include money, payday, peers, parties, bars and other drinking settings, and emotions -- particularly anger, sadness, and fear. "I had a young woman here," recalls Liljegren, "who was very upset about her ex-boyfriend, who himself was a drinker. I asked her mother to bring in a picture of him. When she saw the picture she was very upset." Liljegren and the patient were able to explore the patient's feelings until she was confident that she would not drink when she actually bumped into the young man out in the world.

One of the biggest shifts in alcohol treatment is from inpatient to outpatient therapy. "Research has found that less costly outpatient programs may be as effective as inpatient programs," points out Donovan. Outpatient treatment allows patients whose prognosis is more favorable to adjust to life without booze in a real-world environment. And it's a lot cheaper.

In contrast, alcoholics with preexisting medical or psychiatric illnesses -- and whose insurance company or bank account can cover bills -- should consider in-patient treatment. So should those who have failed outpatient therapy, or whose family environment is chaotic.

It's during the months and years that follow initial treatment, says Schuckit, that the real work of recovery takes place. "Counselors work with the patient and family. Giving up alcoholism is a loss of a way of life -- and the alcoholic needs to grieve. Magical thinking needs to be corrected; many patients and families have the idea that all problems will fade as they become sober. Families need a way to deal with the spouse anger that inevitably comes out as the patient becomes sober, and to maintain enthusiasm.

"Contact with recovering people is important, as is access to self-help. The former drinker needs to set up plans about what to do with free time that used to be spent drinking. A whole life needs to be rebuilt without alcohol. Relapse prevention is important. A former alcoholic needs to identify the triggers to drink and rehearse strategies to help him handle those triggers. Perpetual alertness is required."

Ironically, the months following intensive treatment can put more strain on a family than years of chronic alcohol abuse. About 25 percent of marriages break up within a year of one partner's joining AA, says Barbara McCrady, Ph.D., clinical director of the Rutgers Center for Alcohol Studies. She cites three reasons:

o Traditional AA protocol calls for meetings -- lots of them. "Spouses often say, 'First I lost him to alcohol, now I've lost him to AA,'" says McCrady. The alcoholic's reliance on fellow program members, rather than family, can foster considerable resentment.

o Some families have for years blamed all of their difficulties on the alcoholic's addiction. Only when the drinker is no longer drinking do they realize that long-established alcohol problems do not just vanish overnight.

o Families that remain intact despite a member's drinking have worked out their own ways to remain a family unit. "They've reallocated responsibilities, roles, and chores, and the family functions pretty well," McCrady says. "Now there's this person who is sober and wants to reestablish a position in the family." But the family may be hesitant if the alcoholic has tried -- and failed -- to stay sober in the past.

Perhaps one of the most interesting new paths of research is the study of alcoholics who quit on their own. "We are beginning to explore in depth the characteristics of these people -- the ones who can just walk away from their addiction in the absence of any formal treatment," explains Donovan. Perhaps they simply have in greater measure the same hope and courage of the ordinary alcoholic, who frequently quits for a day or a week or a month, and then returns to the hottle. As researchers are beginning to realize, if they can emphasize the innate capacity present in most drinkers to improve, a great deal may be gained. A shift in viewpoint can help lift the burden of an all-or-nothing view where "one drink, one drunk" means that a glass of champagne on one's wedding day is an unequivocal failure.

TIPS FOR QUITTERS

Alcoholics can quit or control their drinking -- in fact they do it all the time. The real issue is, how to sustain recovery? Relapse is the bugaboo of alcoholism treatment. Whether the goal is total abstinence or controlled, moderate alcohol consumption, there are effective ways to minimize the dangers of a relapse.

o Avoiding situations like parties or bars, where you might feel pressured to drink, minimizes the need for self-discipline. "If you need to be strong, you haven't been smart," says one expert.

o Rehearse in advance what you will do or say when you are confronted with a high-risk situation. You'll be better equipped to resist.

o Keep in mind that for most alcoholics, the urge to drink lessens over time. The first 90 days are the hardest.

o Motivation for abstinence is bound to waver. Renew that motivation by frequently reminding yourself why you quit in the first place

o Realize that relapse will occur. Don't use a minor slip-up as an excuse to resume heavy drinking. Don't get fixated on recording consecutive days of abstinence. A relapse does not wipe out all that you've accomplished.

o Join a self-help group. AA is but one, Rational Recovery another. Recognize that they don't work for everyone, but since they're free, there's no risk in trying one.

CAN YOU PICK HIM OUT OF A LINEUP?

Most alcoholics, explains Mark Schuckit, are not out on the street; they are individuals as unique and at the same time ordinary as you and me. That's one more reason not to apply a uniform treatment. "Alcoholics have jobs and close relationships, rarely (if ever) develop severe problems with the law, and many go unrecognized as alcoholics by their physicians. While most of these people's lives will eventually be impaired by their substance use, it is amazing how resilient people are." Other myths about the alcohol abuser;

o Drunks stay drunk. Actually, says Schuckit, most people drink more heavily on weekends, and start out each day alcohol-free.

o Drinkers can't quit. The truth is, substance abusers have little or no trouble quitting, and often do. Temporary drying out is easy and common. The problem is that sooner or later they begin drinking again.

o Alcoholics can't control their drinking. Actually, most alcohol abusers can and do control their drinking -- for a short time, and often after a period of abstinence.

o Alcoholics have a preexisting psychiatric disorder, such as anxiety or depression, which they are attempting to mediate with alcohol. The truth: Only about 20 percent of alcoholics suffer from a psychiatric disorder. And though many claim they drink to combat depression or sleeplessness, those problems are often caused by drinking and disappear when drinking stops.

o Alcoholism is genetically determined. In fact, only about 20 percent of sons of alcoholics become alcoholics themselves; the number of women is even less. And though the risk of alcoholism is higher for identical than fraternal twins, most children of alcoholics do not become heavy drinkers themselves. As Schuckit emphasizes, "Predisposition does not mean predestination."

o Alcoholics drink because their friends do. Although it's true that we drink more often when our peers drink, the fact is that once a person begins to drink heavily, light-drinking or nondrinking friends are likely to fall away, leaving a peer group that consists mostly of other alcoholics.

o Once an addict, always an addict: therefore alcoholics should not take any psychotropic drugs, even prescribed medications. A growing body of research indicates that for some alcoholics, pharmacotherapy can provide a specifically targeted therapy that helps maintain recovery and abstinence. The AA model is traditionally distrustful of any medication.

MYTHOLOGY OR METHODOLOGY?

Bill Wilson, the founder of Alcoholics Anonymous, based his ground breaking 12-step program on what worked for him. Half a century later there are 2 million AA members worldwide, half of them in this country, and many clinicians prescribe attendance. There's no doubt that AA has helped or even saved the lives of many. Yet the fundamental tenets of the AA-style self-help movement will always remain unverified -- simply because the program is anonymous and cannot be formally studied.

According to Emil Jr. Chiauzzi, Ph.D., and Steven Liljegren, Ph.D., there is no rigorous scientific evidence to support some widespread AA teachings. Some of the disputed myths include:

o The most essential step in treatment is admitting alcoholism. Acceptance of the label "alcoholic" is considered half the battle in traditional treatment. "Hi, my name is John and I'm an alcoholic," is the typical opener at AA meetings. Yet researchers find that some individuals feel demoralized and depressed by labeling themselves the victims of an incurable, lifelong disease.

o Addicts cannot quit on their own. In fact, say Chiauzzi and Liljegren, 95 percent of smokers stop without the help of peers or professionals, even though addicted people themselves consider nicotine more addicting than alcohol. Although only about 20 percent of alcoholics recover solo, many may not be tapping their ability to do so.

o AA is crucial for maintaining abstinence. The number of alcoholics far outnumbers AA members (13 million versus 1 million), indicating that AA is not for everyone. Any increased propensity for AA members to stay on the wagon may reflect the fact that alcoholics who are already committed to recovery, are also more likely to join AA.

o Recovering patients must avoid cues associated with drinking. Researchers find that systematically exposing the patient to long-standing cues can dramatically reduce the relapse danger those cues pose. Using slides, videotapes, and other paraphernalia, researchers found decreased reactivity among those addicted to heroin, cocaine, and alcohol. Cue exposure and coping skills may offer alcoholics a helpful tool in recovery.

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