Dealing with alcoholism
=======================

* Peter O'Loughlin

Stephen Hwang, in his commentary on homelessness and harm reduction,1 notes the severe limitations of the study by Tiina Podymow and colleagues,2 including the small number of subjects and the unreliability of self-reported evidence. As an addictions counsellor for many years, I have yet to encounter anyone meeting the DSM-IV criteria for alcoholism who accurately reports consumption levels; either they lie deliberately or, alas, they are too befuddled to recall. In addition, people with alcoholism tend to be “people-pleasers,” telling the researcher or counsellor what they think he or she wants to hear, which compounds the problems of self-reporting.

If you want to get at the truth about attempts to cut down, consider attending 3 or 4 “open” meetings of Alcoholics Anonymous a week for a year. Although the evidence provided at AA meetings is also self-reported, it has 2 advantages: the people involved are likely to be sober and therefore less fearful of telling the truth, and there will be considerably more “subjects,” which should also increase the reliability.

One thing that I have discovered is that until and unless a person with alcoholism discovers what he or she would rather do than drink, there will be considerable difficulty in abstaining or maintaining abstinence. There is also the frequently unspoken terror of stopping. It can take an awful lot of time and effort to bring any addict to that point, but at least by working within the framework of the transtheoretical model,3 the process can be started. 

The idea of giving a person with alcoholism a drink every hour on demand because it will help him “cut down” or reduce harm appalls me. If it's such a good idea, why don't we suggest the same for smokers?

## REFERENCES

1.  1. Hwang S. Homelessness and harm reduction [editorial]. CMAJ 2006;174(1):50-1.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo4OiIxNzQvMS81MCI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNzUvNS81MDIuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  2. Podymow T, Turnbull J, Coyle D, et al. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ 2006;174(1):45-9.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo4OiIxNzQvMS80NSI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNzUvNS81MDIuMS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

3.  3. DiClemente CC, Prochaska JO. *The cycle of change.* New York: Avon Books; 1982.