This thread started in the ADDICT-L-group by my abstract of a
population study I made in the Oslo population. In his reply, Ron
Roizen confirmed that "this abstract very economically retells the
story that survey research started telling us in the late 60ies".
 
I replied that one of the most consistent findings in population
studies is that alcohol problems to a large extent are caused by
drinkers who may not be labeled addicted and never seek alcoholism
treatment. Seen together with the close relationship between per
capita consumption and the extent of problems, I maintained that it
seems hard to avoid the conclusion that reduction alcohol problems
most effectively is done by reducing per capita consumption.
 
I also pointed to the embarrassing fact that comparing Norwegian
counties, we find a strong correlation between alcoholism treatment
facilities and rates of death from alcohol. Treatment is fine, but
society's degree of "wetness" is the main factor behind both the
demand for treatment and the deaths related to alcohol.
 
Ron Roizen has given a thorough answer in 13 numbered paragraphs,
aimed at explaining why the findings should not lead to the
conclusion that per capita alcohol consumption should be reduced.
Here, I will argue that I do not see that his 13 paragraphs leads to
this conclusion.
 
In his first 5 paragraphs, Ron gives very knowledgeable and
interesting historical remarks on the evolution of the
conceptualizations of alcohol problems in general populations.
 
In paragraphs 6 and 7, Ron states that from early findings, Jellinek
and Keller used the phrase "the alcohol problems" (in plural form),
referring to the variety of problems related to alcohol, instead of
the phrase "the alcohol problem" associated partly with the
temperance movement.
I do not believe the diversity of alcohol problems may have been
unknown to the temperance movement, and none of the terms may be
called erroneous. Thus, Jellinek's phrase does not reflect new
research findings, but mainly reflects his wish to demonstrate a
distance to the temperance movement and rhetoric, as Ron implies in
paragraph 8.
 
In paragraphs 9 and 10, Ron argues that he and "even Robin" (Room)
has written about other preventive efforts than reducing per capita
consumption, i.e. making the world safer for heavy drinkers or
refrain from drunk driving.
Who are you arguing against, Ron? Of course, all prevention agencies
do such things -  this does not contradict the fact that per capita
consumption is the main factor determining the extent of alcohol
problems. The very variety of alcohol problems limits the potential
to "make the world safe for the heavy drinker" - drunkenness and
heavy drinking remains a risk factor. In the 80ies, ARF in Toronto
was asked by the state authorities to propose initiatives to reduce
drunk driving. The first paragraph in ARF's answer was the statement
that the most important factor is the per capita consumption. After
that, other initiatives were proposed.
 
In paragraph 11, Ron argues that not everything called "alcohol
problems" really must be seen as alcohol problems. His example is
that "spending too much money on drinking" may as well be called a
budgeting or income problem. I agree in the example, and if he could
not drink, he might have wasted his money on gambling. So what?
 
In paragraph 12, Ron refers to Genevieve Knupfer's notion that the
persons reached in population surveys do not "really represent
clinical alcohol dependence". I agree that very heavy drinkers are
probably over-represented among drop-outs in population surveys. But
my clinical experience tells me that alcoholism treatment populations
are not THAT different from many respondents, although the patients
usually enter treatment after their most extreme binge periods and
therefore leaves a rather dramatic impression. In studies like the
one I presented, with a respondent rate of 77 %, we get a considerable
number with large problems.
 
In paragraph 13, Ron mentions that the book "Alcohol and the Public
Good" presents a more complicated history than I presented in my
posting. Of course. But in summary, Ron, I think your posting mainly
show that reducing per capita consumption is not the ONLY way to
reduce problems, and it most certainly is not. But the limitations
of harm reduction while maintaining the same per capita consumption
seem rather obvious to me.
 
So the basic question may be - if the population is made aware of the
importance of the general "wetness" of society upon problems and
deaths - do they think the advantages outweigh the sufferings? In a
Norwegian survey ten years ago, 80 % answered "no" to this question.
But this is a question of values, not a specific topic for professionals.
 
 
Hans Olav Fekjaer
 
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Hans Olav Fekjaer   MD, psychiatrist.   mailto:[log in to unmask]
Chief Medical Officer,  Agency for Alcohol and Drug Problems, P.O.B.
4662 Sofienberg, 0506 Oslo, Norway.  http://www.rusinfo.no/rusinfo/
Work (47) 222-03-600.   Home (47) 669-12-654.   Fax (47) 221-11-429
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