Loosening the Grip: A Handbook of Alcohol Information

by Jean Kinney

Starting with Haggard’s work on alcohol metabolism, these efforts marked the first modern attempt to put the study of alcohol and alcohol problems in a scientific framework. Jellinek’s influential work, The Disease Concept of Alcoholism, was a product of the Yale experience. The Yale Center of Alcohol Studies and the Classified Abstract Archive of the Alcohol Literature were established. The Yale Plan Clinic was also set up to diagnose and treat alcoholism. The Yale Summer School of Alcohol Studies, now the Rutgers School, educated professionals and laypeople from all walks of life. Yale’s prestigious influence had far-reaching effects. A voluntary organization, the National Council on Alcoholism (NCA)—now renamed the National Council on Alcohol and Other Drug Dependence (NCADD)—also grew out of the Yale School. It was founded in 1944 to provide public information and education about alcohol, through the joint efforts of Jellinek and Marty Mann, a recovering woman who became the Council’s first president.

We have to thank Yale for being pioneers in alcohol research

To promote uniformity of standards as well as facilitate recognition of credentials between states and across different certification groups, a voluntary organization—the National Certification Reciprocity Consortium—was established in the 1980s. Since that time other substance abuse specialists have emerged—tobacco addiction counselors, prevention specialists, and clinical supervisors, as well as those with special expertise in co-occurring disorders. In addition, credentials for counselors have been modified to recognize different levels of expertise and experience. In light of these developments, efforts are under way to merge the different credentialing groups to create uniform standards.

Interest in counselor credentialing began in the mid-1970s.

Its important for everyone to work with the best tools they have and not just speculate

The federal alcohol and drug institutes and the Center for Substance Abuse Treatment (CSAT) have initiated programs to improve professional education among physicians, nurses, and social workers.

the Uniform Alcoholism and Intoxication Treatment Act, passed by Congress in 1971 and dealing with the issue of public intoxication, was recommended for enactment by the states. This act mandated treatment rather than punishment.

In 2010, a federal law went into effect, The Mental Health Parity and Addiction Equity Act. This law requires that health insurance plans provide benefits for substance abuse and mental health treatment that are comparable to the benefits provided for all other medical problems. This includes the level of co-payments required, the number of visits allowed, and lifetime payment limits. Simply put, insurance plans cannot establish different levels of benefits for different medical conditions.

The Affordable Care Act, beginning in 2014, will introduce further changes. Most importantly, this law extends substance abuse treatment services to an estimated 30 million persons and prompts the integration of these services within the health care system.

So its a big problem now, not just socially but also economical

Warning labels on alcoholic beverages were introduced in 1989. The possible dangers of drinking during pregnancy are now broadly recognized. Patient education on both alcohol and tobacco is generally part of prenatal care.

Is alcohol dependence better considered a medical condition or a behavioral disorder?

There is also a tension

in treatment goals. Is the goal to reduce harm or to achieve abstinence?

Increasingly it is recognized that this is not a matter of “either–or”; rather, it is a matter of “which– when.”

An article by Rehm and Greenfield reviewed different policy initiatives and summarized the evidence of their effectiveness. Four types of interventions were examined: • Legislative intervention. This includes taxation on alcohol, drinkingdriving laws, licensing practices, and control of advertising. In brief, alcohol taxes have an impact on patterns of consumption a...

Law enforcement. The effectiveness of legislative interventions depends on the presence of enforcement. For example, the legal level of alcohol for driving has an impact, but only to the extent that there is visible enforcement, which is best accomplished by frequent random breath tests.

Treatment systems. There are two major concerns. One is the size of the untreated population. A number of factors are seen as accounting for this, including denial of problems and stigma. But there are also barriers to care, such as a lack of transportation or child care, a lack of services in the person’s area, and inadequate insurance coverage. The other concern is to enhance treatment efforts. One important component is creating a rational integrated system of care. For example, all too often people are admitted to hospitals for detoxification and then discharged without follow-up or referral for treatment. Data indicates that intensive outpatient treatment, as well as brief interventions, is cost effective. Medications, such as naltrexone and acamprosate, are effective and underutilized. AA by itself is less effective than alcohol treatment. However, alcohol treatment in combination with AA has better results than alcohol treatment alone.

Media and awareness campaigns . Evidence suggests that media campaigns are only marginally effective in reducing harm resulting from drinking or reducing consumption. However, they may be effective in providing support for the passage and implementation of legislative initiatives.

The alcohol industry’s expenditures for advertising, not including promotion, are virtually equivalent to what is spent on advertising for all other beverages combined—from milk to fruit drinks.

the beverage companies have made efforts to avoid TV programs with an underage audience above 30%, they have also worked at placing ads on the programs that are under the threshold, but not by very much. As magazine ads declined, the TV ads increased. Of all the alcohol brands advertised in the larger than 30% youth market, 20 different beverages accounted for the majority of these.

Of the estimated total of 50.52 billion drinks then consumed annually in the United States, 9.7 billion drinks went to those under age 21. That translates into 26.6 million drinks daily by those not legally old enough to consume alcohol.

The next version of energy drinks was caffeinated alcoholic beverages. Caffeine masks the subjective sense of intoxication, thus increasing overconsumption and contributing to risky behavior.

In November 2010 the Food and Drug Administration ruled caffeine added to alcoholic drinks to be “an unsafe food additive.”

Communities with large African American and Hispanic populations are more likely to see alcohol advertising on a daily basis. Outdoor billboards promoting alcohol are more common. Similarly, convenience and neighborhood stores in these communities have more alcohol ads prominently placed in store windows.

adolescents and young adults would have to watch 22 ads for an alcoholic beverage before seeing a spot promoting responsible drinking.

The same people who tell us that smoking doesn’t cause cancer are now telling us that advertising cigarettes doesn’t cause smoking. –Ellen Goodman, columnist Newsweek, July 28, 1986, page 17

A number of years ago there were efforts to work with movie and television writers, directors, and producers to change the way drinking and alcohol problems are depicted. Of concern was the way drinking was often glamorized and its consequences either trivialized or ignored. Indeed there have been changes. Characters in recovery are featured, as well as those struggling with alcohol abuse or dependence.

After caffeine, alcohol is the psychoactive substance most widely used in the United States.

By the early 1800s, other forms of tobacco were becoming more popular;

When they first appeared in the 1850s, cigarettes were viewed with disdain and considered “the smoke” of the lower classes. Cigarettes were first adopted by urban immigrants and particularly adolescent boys. Initially sold individually, not in packs, cigarettes were far less expensive than cigars. That the cigarette wasn’t the choice of any “real” man was made clear by its name, formed by adding the feminine suffix “ette” to “cigar.” Despite the stigma, circumstances made cigarette use more common. The Civil War battlefields were not well suited to leisurely smoking a cigar; a quick smoke was the safer option. In the latter part of the 1800s, periods of economic depression placed cigars out of reach, and many smokers switched to cigarettes. The invention of the Bonsack cigarette manufacturing machine and innovations in marketing promoted the adoption of cigarettes.

Much of what we now think of as advertising was introduced by the t...

Over a 60-year period, production didn’t just double or triple. Between 1889 and 1949, it grew by an astronomical 2,000%.

History Unlike nicotine and alcohol, which have been part of the American landscape since colonial times, marijuana is a far more recent arrival. Derived from the plant cannabis sativa, marijuana is native to central Asia. Anthropologists and historians have traced its spread throughout the world. It was known in China as early as 3000 b.c.e. The conventional wisdom is that it was never widely used for its psychoactive effects, and it was considered an inferior medicine. The response in India, a millennium later, was more enthusiastic. Cannabis was adopted both as a sacred plant and as a medicine capable of curing all major ills while also promoting vital energy. From India, cannabis spread to Persia in the eighth century b.c.e. While it was known in both ancient Greece and Rome, records suggest that the major interest was for its fiber to manufacture rope. Apparently, in terms of pleasure, it was dismissed as a poor substitute for wine or beer. The reception of cannabis in the Middle East was more positive, especially as the rise of Islam had led to a ban on alcohol. The term “cannabis” comes from the Persian kanabas. The extract from the plant was called hashish, which is Arabic for “grass.”

Earliest Physical Evidence of Cannabis The Yanghai Tombs near Turpan, China, have recently been excavated to reveal the 2700-year-old grave of a Caucasoid shaman whose accoutrements included a large cache of cannabis, superbly preserved by climatic and burial conditions. A multidisciplinary international team demonstrated [with multiple tests that] . . . the material contained tetrahydrocannabinol, the psychoactive component of cannabis . . . these investigations provide the oldest documentation of cannabis as a pharmacologically active agent. E. B. Russo, Journal of Experimental Botany, 2008

it wasn’t until 1942 that cannabis was removed from the list of drugs approved for medical purposes.

Although hemp had been grown from colonial times, recreational or nonmedical cannabis use was largely unknown in the United States until the last century.

Cannabis as a psychoactive substance was introduced to the American continent in the 1600s by slaves from West Africa brought to Brazil. However, it was never adopted by either the Portuguese colonialists or native peoples of Brazil. Nonetheless, use continued and, over time, gradually spread along the coasts. In the early 1900s, cannabis, under the name marijuana, indicating its Latin American roots, was introduced into the American Southwest by Mexican settlers and

into New Orleans by sailors from Mexican and Caribbean ports.

Points for Reflection Classifying psychoactive substances as either licit or illicit is not based exclusively or even primarily on their pharmacological properties. It is as much, if not more, a matter of class, race, and economic issues. During the course of your readings and study, consider several questions: If it were possible to erase all previous history and attitudes and start afresh, and you were asked to designate classes of drugs to be licit, which would you choose? What factors would you consider to be important in making these assignments? Which things would you see as important in defining harm? And harm to whom? Are there harms that are introduced or avoided by the legal or illicit status of a substance? To what extent can these be diminished? In which column would alcohol, tobacco, and caffeine be found, your licit or illicit list?

REFLECTION