In Narcotics Anonymous and Cocaine Anonymous meetings up and down the country tonight, members will read out literature warning those attending that drinking alcohol is a risk to their recoveries. This is not based on scientific study, but on the experience across decades of those following the 12-step programme.
When considered in the light of the neurobiological, learning and genetic evidence on addiction, this makes sense and those of us working with clients in recovery-oriented settings will have seen people become abstinent only to relapse to their drug of choice through alcohol or to go on to develop an alcohol problem. So can recovering drug addicts drink alcohol safely?
Opiates & Alcohol
In opioid replacement therapy populations between one in three and one in four patients are drinking more than safe limits, which has all of the negative health consequences, but is clearly also dangerous because of the risks inherent in mixing depressant drugs. For some folk abstinent from all opiates, there seems to be an ability to drink in recovery without getting into bother, but we don’t know anything about this group.
So we have experience, we have anecdote and we have a theoretical basis. What about evidence? Well, this is where we struggle to find guidance.
William White looks elsewhere to give some pointers on this in an old article from Counselor Magazine. As he says:
History promises us important lessons if we sit at her feet and listen carefully to her stories.
History the teacher
He details the start of the Therapeutic Community movement (Synanon) when clients in treatment (generally recovering heroin addicts) could gain ‘drinking privileges’. It wasn’t that long ago in Scotland that a therapeutic community here did the same. So what?
The early policy of alcohol abstinence within Synanon was influenced by the history of its charismatic founder, Chuck Dederich. Dederich had used Alcoholics Anonymous (AA) to initiate his recovery from alcohol and Benzedrine addiction in the two years that preceded his split from AA and the creation of Synanon. Synanon maintained an alcohol abstinence policy until 1978 at which time alcohol was experimentally introduced first for board members and senior staff and then to others within the Synanon community.
Sounds progressive. So how did it go?
Alcohol problems grew within Synanon in the 1980s and contributed to Charles Dederich’s fall from grace and Synanon’s eventual implosion as an organization.
Okay, not so well then, but what about other organisations?
White reports the experiences in ‘Daytop’ a New York therapeutic community. This time there were safeguards: drinking was only permitted for those with no prior history of alcohol problems. They reasonably assumed that in this group the risk of dependence would be about the same in the general population (6-10%). They also had a policy of non-acceptance of intoxication.
So how did that go?
The first signs of problems with the alcohol policy within Daytop and other TCs followed a predictable two-stage pattern. The first stage was the appearance of drinking at social events within the TC community (e.g., staff parties) and at outside professional conferences that exceeded the bounds of social drinking and sparked other inappropriate behaviors. The second was the development of severe alcohol problems (or relapse back to heroin and other drugs while under the influence of alcohol) among some TC staff and graduates.
Estimates of risk
The prevalence of cross-addiction in the history of the TC is unknown. TC old-timer estimates of how many “ex-addicts” later got into trouble with alcohol range from the majority to less than 10%, but all of the TC elders interviewed for this article reported tragic stories of alcoholism-related deaths among early TC graduates.
White details some factors reported, but not evidenced, which might predict future problems:
1) A family history of alcohol problems,
2) A history of alcohol problems predating the emergence of another pattern of drug dependence,
3) Co-addiction to alcohol and other drugs prior to entry into treatment,
4) The presence of a co-occurring psychiatric illness,
5) A history of childhood victimization,
6) Later developmental trauma (e.g., loss via death or separation), and
7) Enmeshment in a heavy drinking social network.
When I apply these criteria to the people I typically work with, then there aren’t many left outside the fold.
Perhaps many or most (a question the scientists need to answer for us) people entering addiction treatment possess a lifelong vulnerability for addiction to a broad spectrum of substances (and experiences), while in others that vulnerability is transient or restricted to a particular drug or class of drugs.
So what should we say to clients?
We have a clinical responsibility to share warnings… at the same time, we have the responsibility to honestly acknowledge that there is much we do not know about these varied patterns of vulnerability and resilience. Lacking science, we need to offer explanatory models that help each client make personalized informed choices related to the whole spectrum of psychoactive drug use.