A noted doctor talks about alcohol and tranquilizers
Problem drinkers are increasing alarmingly and even some of the helpful new drugs are themselves habit forming. What can he done?
R. GORDON BELL
Are we really winning the fight against alcoholism? You might think so from all the publicity that has attended the new efforts to cope with this problem. It you have bothered to think about alcoholism at all. you might even believe that the situation is well in hand. Provincial programs of treatment, research and education have either been established or are being planned. On the clinical side. new. more effective methods of treatment and rehabilitation have been worked out. More physicians and hospitals are treating the alcoholic as well as their facilities permit. Industrialists and others in the community are beginning to deal with the alcoholic from a health, rather than a moral or disciplinary standpoint. 1 he temperance federations have adopted a new. more objective approach to education about alcohol and alcoholic disease. Alcoholics Anonymous continues to expand its unique and effective work in rehabilitation.
What's the true picture?
Thanks to the work of the Research Division of the Alcoholism Research Foundation in Ontario. we have some reliable information about the situation in that province. Alcoholism has don hied in Ontario since 1946! This enormous increase isn t confined to Ontario b\ anv means. What has happened in Ontario has, 1 am convinced. happened in the rest of C anada, and studies in the United States indicate that it has also happened there.
It would be alarming enough to report that alcoholism had doubled over a hundred-year period. But it has doubled, according to the best
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statistics available, over a ten-year period —and this the very period in which a variety of new efforts have been taken to combat alcoholism. Will it continue to increase at this rate? So far, there doesn't appear to be any effective means of preventing such an increase.
When 1 refer to the fact that alcoholism has doubled in Ontario—and I’m dealing with Ontario because this is the province I’m most familiar with, and not because it is a special case—I don't mean that the population is larger and that we have a correspondingly larger number of alcoholics. I mean that in every hundred thousand adults in Ontario, male and female, twenty years of age and older, there are twice as many alcoholics as there were in 1946.
The question that may come first to your mind is: how do they know? After all, much alcoholic disease can remain hidden for years. I do not intend to attempt a detailed explanation in this article of how this information can be obtained. However, since I am going to tell you some things that many may not want to believe, 1 am going to discuss the validity of these statements briefly.
It happens that the over-all incidence of alcoholism, both obvious and hidden, in a community, a city, a county or a province, bears a definite, reliable relationship to the incidence of death from cirrhosis of the liver in that area. This relationship was established by Dr. E. M. Jellinek, now secretary-general of the International Institute for Research on Problems of Alcohol, and consultant on alcoholism for the World Health Organization. in Geneva. He developed his formula after a tally prodigious amount of study of hundreds of thousands of cases of both alcoholism and cirrhosis. Furthermore, his formula for the estimation of the incidence of alcoholism has been checked and verified by research workers in several European countries, as well as in Ontario.
Records of death from cirrhosis of the liver are just as reliable as records of death from tuberculosis, for example, and are available for years back. Even though many alcoholics do not acquire cirrhosis—and cirrhosis can be caused by many other things than heavy drinking—it is only necessary to establish the relationship between alcoholism and death from cirrhosis to have a known fact throw light on a hidden situation, and that is precisely what Dr. Jellinek has accomplished.
Now we shall consider some of the implications of this rapid increase in alcoholism. For one thing, young people today — your children and mine — stand twice the chance of becoming alcoholics as they would have in 1946; and that was chance enough.
You may have heard a great deal about the new treatment facilities, both public and private, to deal with alcoholism in Canada. Should we be reassured? The last reliable study undertaken by the Alcoholism Research Foundation brought to light the fact that only seven
“At present we can’t check alcoholism as a whole, let alone prevent it”
percent of the alcoholics in a particular area had sought any kind of treatment anywhere, including Alcoholics Anonymous. 1 believe that there are still more people dying cacli year as a direct or indirect result of alcoholic disease in Canada, than are being helped by all agencies combined. I believe that there are also more new cases each year than are being helped by all agencies combined.
Alcoholism is still more prevalent among men than women, hut the women seem to be struggling valiantly to close the gap. I believe that only a small number of alcoholics who continue drinking live to a ripe old age. The life-insurance underwriters believe this too.
Accordingly, one would expect to find a higher incidence of alcoholism among the male working population, particularly between the ages of thirty and fifty. Actually, in Ontario the incidence of alcoholism in industries studied to date is about six percent of the working population. Members of this group average 18.5 days absenteeism per year. I can almost hear the snorts of disbelief of many employers at this statement. My personal opinion is that the six-percent figure could he low. Since repeated Monday morning absenteeism was one of the criteria for investigation in these studies.
I can only conclude that late, rather than early, manifestations of alcoholism were used. Apparently, we still wait for the phenomenon of recurrent “drunkenness" or absenteeism to signal the presence of problems which have involved alcohol intake in toxic quantities for many years without drunkenness or absenteeism.
If the six-percent figure for industry is even remotely clos: to the truth of the situation concerning the problems in Canadian and American industry arising from the excessive use of our most commonly used “habituating drug" (ethyl alcohol), the economic cost to industry alone is so great as to be practically incalculable.
There are still many indications that alcoholic disease is more prevalent in United States than Canada, but. in Ontario at least, we appear to be catching up quite rapidly. Even several years ago the cost of alcoholism to U. S. industry alone was estimated to be approximately one billion dollars annually. The annual cost to Canadian industry is anybody's guess, but it would be wise to assume that it is closer to one hundred million than one million dollars annually. The cost to industry in dollars and cents is but a fraction of the cost of alcoholism to the country as a whole.
Ask social-service agencies how much of their work is directly or indirectly the result of alcoholism. Ask the officials of the Department of Reform Institutions what proportion of their total budget has to be directed toward the management of problems arising out of alcoholism. Ask anyone, from the obstetrician to the undertaker, whose work directly concerns some phase of the well-being of people in this country, and you will begin to appreciate the enormity of this problem. There are approximately eighty thousand cases of alcoholism in Ontario alone.
How are we making out, so far, in our battle against alcoholism? By now you should realize that very little has been accomplished in treating the problem as a whole, and absolutely nothing has been accomplished in prevention. We can't even begin to check it. let alone prevent it. What is the immediate outlook for more effective action? In my
opinion, it is very poor, and for the following reasons:
Psychiatrists, internists. sociologists and others have conflicting opinions as to the main causes of the excessive use of alcohol. There is still no agreement as to when the use of alcohol could be considered excessive from even a clinical standpoint. There is still no agreement on terminology, on clinical procedures, on evaluation of treatment results, or even upon areas of research. The total implications of this situation, from the standpoint of social health and stability, are nothing short of frightening.
Since there is no agreement on terminology in the whole field of addiction it becomes necessary for each writer attempting to make some sense in this field to define his own terms. This 1 shall do now before attempting to suggest any solutions to this problem.
HABITUATING DRUGS: What properties does a chemical or drug require in order to he considered an “habituating drug"? The drug must be able to produce some type of welcome effect. This welcome effect is usually one of relieving such unpleasant states as pain, tension, frustration and depression, or producing the exaggerated sense of well-being that we call euphoria. From our clinical experience of the last eleven years I am convinced that any drug that could be considered a nervous-system depressant or a nervous-system stimulant can be considered an habituating drug. Whereas in 1800 there were only three or four substances available to man that could qualify as habituating drugs, today there are hundreds. Alcohol is still the most important habituating drug in our society.
ADDICTION: What is an addiction? We have come to believe that an addiction can be defined as: “A way of life that involves repeated or continuous dependence on harmful quantities of any chemical capable of producing welcome effects.” Since harmful or toxic quantities of a particular chemical are involved, sooner or later disease results from chronic toxic exposure to the chemical on which the person depends. Thus, there are at least two distinct but interrelated clinical problems encountered in the addictive process: the “way of life" itself, in which the individual depends on chemicals rather than on latent resources within himself and other people: and the physiological changes resulting from the acute and chronic toxic effects of the chemical or chemicals on which he depends.
DISEASE: Any abnormal condition in the body.
ALCOHOLISM: A complex human phenomenon. involving both addiction to alcohol and disease from it. In my opinion, it is a mistake to refer to alcoholism simply as a disease. It is more than a disease—it is both disease and addiction. In dealing with the disease part of alcoholism we treat the abnormal conditions in the body resulting from chronic alcohol poisoning. In treating the addiction part of alcoholism we try to assist the patient in the attainment of a new way of living that does not involve further exposure to alcohol and other nervoussystem depressants.
There are about twenty different types of alcoholic disease that can be an outgrowth of a way of life that involves
prolonged heavy drinking. None of them are pretty, and they can include convulsions, mental illness, paralysis, permanent brain damage, liver disease, the "shakes" —which the patient learns to treat with his “morning drink"—amnesia, hallucinations, delirium and progressive blindness.
No, I'm not trying to give an old-fashioned “temperance" lecture: I'm simply telling you of some of the conditions 1 have observed over and over again. At least we can say with reasonable safety that a way of life that involves heavy drinking is a bit dangerous.
Who are these people who first acquire a way of life that involves heavy drinking and then maintain it until disease from repeated overdosage of alcohol results? Are they bums and illiterates? Not at all. In fact, they are in every conceivable profession and business, and at ail levels. The incidence of alcoholism appears to increase with economic status, and since economic status is often related to education, we find high-school and college graduates are more commonly affected than publicschool graduates.
What about the other habituating drugs?
OLDER NERVOUS-SYSTEM DEPRESSANTS: This group is made up of such drugs as the barbiturates (phénobarbital, nembutal, seconal, sodium amytal, tuinal. etc.), bromides, paraldehyde and chloral hydrate. As with alcohol, the danger lies in taking too much, or more than the body can handle easily. When used properly in the doses prescribed by a physician these drugs can play a very important part in the treatment of a great variety of disabilities. When the patient undertakes the self-administration of these drugs in increasing doses he is headed for certain and serious trouble.
At various times we have had to treat patients addicted to all the older depressants. Most of the barbiturate addicts I have known were first alcohol addicts who later shifted to barbiturates, either on their own or with medical assistance. Barbiturate intoxication and barbiturate disease resemble alcohol intoxication and alcoholic disease but. generally speaking, are more serious. Within the past few years we have encountered very few cases of addiction to the older depressants hut have had several cases of addiction to the new nervous-system depressants known as the tranquilizers. No studies have been made that indicate the extent of addiction to any of the nervoussystem depressants, other than alcohol.
TRANQUILIZERS: The tranquilizers
hive revolutionized the treatment of many psychiatric diseases and, as such, constitute a very significant advance in medicine. As with any other chemical or drug, they can be taken in doses that produce toxic effects, and, by virtue of their ability to produce welcome effects also, they can qualify as habituating drugs. Equanil (Miltown) may have beneficial effects in some people in the recommended doses, but the effect of twenty or more tablets a day over a period of months can be equally as disastrous as chronic overdosage with barbiturates.
All tranquilizer addicts who have come to our attention to date were either formerly addicted to alcohol or had combined tranquilizers with alcohol and maintained a simultaneous intake of both nervous-system depressants in toxic quantities. How to keep from growing old!
In Canada practically all tranquilizers
are available without prescription, in contrast to the situation in the United States. Whereas in U. S. there arc some indications that the enormous use of tranquilizers ($195 million wholesale price in 1957) represents a replacement of older depressants for new, in Canada this does not appear to be the case.
I am informed by wholesale-drug companies and by druggists that their sales of the older nervous-system depressants have not been affected by the tranquilizers. In other words, the widespread use of tranquilizers represents an additional use of nervous-system depressants. The alarming feature is the rate at which the tranquilizers are gobbled up by the public. Many druggists are concerned about the quantities used by some of their customers. One druggist refused to sell any more tranquilizers to a customer, who came back in a short time with a prescription for the same substance.
Apparently alcohol and the older depressants can’t fulfill the demands of the “national" neurosis in our two countries. Of one thing we can be very sure: when we add together the sales of nervoussystem depressants from the alcohol-beverage industries and the drug houses, we realize that the nervous-system-depressant business is very big business indeed.
Have we any general program of instruction as to the early recognition of toxic effects from nervous-system depressants, including alcohol, to guide those who undertake self-administration? We have not. In fact, we do not yet provide adequate instruction on this matter for many physicians. It would be my guess that the use of tranquilizers is extensive and that not one in a thousand knows how to recognize toxic effects, realizes the significance of an increasing tolerance, or understands the problems within himself or his environment that make him feel the need for a nervous-system depressant.
NARCOTICS: I am only going to mention the opiates and other narcotics briefly. In my opinion, they do not constitute as serious a problem in Canada as the other depressants. I do not mean to imply that narcotic addiction is not a serious problem requiring more attention, but in Canada and U. S. we should give alcohol first place as a hazard to health and assume that, among all the rest of the habituating drugs, the sedatives and tranquilizers are second in importance.
NERVOUS - SYSTEM STIMULANTS:
The most important group of drugs in this class are the amphetamine compounds. such as benzedrine, dexedrine and methdrine. Within recent months two patients have come to my attention, maintaining a daily intake of about twenty times the recommended dose. Some amphetamine addicts take much more. One of these patients was a business executive who had begun using these stimulants about four years ago to keep going when fatigued. Eventually he had to have them; without them he experienced such a disabling state of mental underactivity, lack of drive, inability to concentrate, and feeling of depression that he was quite unable to carry on his work.
There is considerable evidence that amphetamines may also be used to excess by some transport drivers.
How many more people in Canada are maintaining an intake of nervoussystem stimulants in toxic quantities in order to meet the demands of their job? How many attempt to balance the effect of toxic quantities of a stimulant with toxic quantities of a depressant, and vice versa?
What is the real meaning of such an extensive use of the chemicals that affect the nervous system? Why is there such a widespread tendency to change the way we feel in such a potentially dangerous fashion? Why do so many fail to find within themselves the resources to adjust to their life situations in a constructive yet comfortable manner? Have we somehow developed social situations that no one could be expected to adjust to satisfactorily? Does most of the fault lie in the underdeveloped resources of those who depend on chemicals in toxic quantities, or have these people been deficient in resources since conception?
The last possibility I discount as being of any great significance. Most people who become addicted to alcohol, for example, impress me as having excellent latent resources which somehow have been ineffectively harnessed. 1 am also of the opinion that some industrial situations, particularly at the managerial and executive level, could not be adjusted to satisfactorily by anyone, however strong or stable.
“Should industry finance
I believe that many physicians have failed to take the possibility of addiction into account seriously enough when prescribing drugs. 1 am absolutely convinced that special precautions should be taken routinely in prescribing any nervous-system depressant to anyone who already has or has had an addiction to that or any other nervous-system depressant.
I have a few suggestions about some aspects of our alcohol and drug problems.
Concerning early diagnosis, 1 suggest that it would be extremely helpful if every health examination of an adult in Canada would include at least an attempt to assess the relationship between the patient and the drugs that directly affect the nervous system. We still check for syphilis fairly routinely, even though syphilis is now encountered rarely. Why not at least attempt to check the possibility that a patient may be assuming a way of life that involves the intake of a nervous-system depressant or stimulant in toxic doses?
The immediate hazards associated with the acute toxic effects of nervous-system depressants are most frequently encountered in the operation of a motor car. In this regard it should be understood that the parts of the brain concerned with judgment are affected before the parts that control our movements. Impaired judgment could thus occur without staggering or slurred speech. Some people can tolerate more alcohol than others before the obvious signs of depressed brain function occur. It is equally true that some people can drive more safely than others at speeds in excess of fifty miles an hour.
If there is any sense to laws about speed limits, there is equal sense to laws about alcohol limits. In my opinion, anyone found with a blood alcohol level of one part per thousand or more -should be guilty of an offense, as automatically as the person exceeding the speed limit. On the one hand we have more and faster motor cars with an increasing requirement for mature judgment, fast reflexes and a high standard of physical and mental health; and on the other hand we have an increasing general tendency to
depress the very functions required.
The most important aspect of any addiction is the “phase of resistance”—the period during which the addict maintains his way of life by rationalization, coverup, lying, hiding his supply, blaming others for his problems, and resenting those who attempt to have him change his way of life.
This phase is common to all addictions, and the addict usually maintains his addiction long after it has become extremely hazardous to himself and others. 1 have known addicts who persisted in their addiction until they killed someone during their episodes of uncontrolled behavior. Thousands upon thousands maintain it until they have destroyed their homes, psychologically crippled their children and lost their jobs.
When a person acquires tuberculosis he acquires a condition that is progressively dangerous to himself and others. Wc have a law that at least takes some account of the situation and forces the tuberculous patient to begin treatment. In spite of the fact that alcoholic disease is equally as destructive from the patient’s standpoint, and much more destructive to those with whom he is closely associated, we persist in allowing the alcoholic’s own sick thinking to be the main determining factor as to when, if ever, he accepts treatment for his condition.
When, and only when, we have adequate facilities for earlier treatment and rehabilitation of alcohol and drug addicts, we should consider new legislation to enable more effective management of this unwholesome social situation. By adequate facilities I mean facilities quite separate from those designed for the mentally ill.
Finally, I have a few suggestions about prevention. The prevention of alcoholism will only come about when we have re-examined the very roots of our modern way of life—its values, its purpose, its weakness and its strength. I he correct answers to the alcoholism problem alone should shed new light on every psychological and social problem with which we are presently faced.
If our governments can find billions in response to possible threats from without, could they not find at least millions for known threats from within? If alcohol alone could be responsible for a loss to Canadian industry of a hundred million dollars annually, would it not be sensible for industry to finance research into this problem to the extent of at least one percent of this figure, or a million dollars annually? Would not many families who have had to live with alcohol or drug addicts be willing to contribute ten dollars a year toward research into these problems? Research on just such a scale could begin to be effective quickly provided the central direction could be completely free of political interference.
In conclusion, I quote a statement from Dr. J. K. W. Ferguson, chairman of the Medical Advisory Board of the Alcoholism Research Foundation in Ontario: “Our basic problem is not habitforming drugs, but habit-forming people." Attempts to place the whole responsibility for the excessive use of nervous-system depressants on the alcohol-beverage industries and the drug manufacturers are only indicative of ignorance of the over-all problem and of our futile attempts to cope with it thus far.
When our basic research into addictions is in keeping with the size of the problem, then, and then only, will we be in a position for positive action. Then and then only can we count on educational programs and clinical procedures that can institute prevention. ★