Drinkers really like to drink

Why alcoholics are allowed to drink sometimes

The problem: Abstinence programs only reach ten percent of alcoholics.
The solution: In Germany, too, controlled drinking is becoming more and more popular - with success.

"I've been dry for 12 years," said my friend Paul over dinner with his wife Margaret and me. Then he picked up the glass of red wine he had ordered with the lamb.

My jaw dropped in shock, and it wasn't because I had no idea that this well-groomed, gentle man - a successful physical therapist with his own practice - had had a massive alcohol addiction for more than a decade. We had known each other for a long time, almost ten years, but not very well. In his practice he also likes to advise his clients on a healthy lifestyle, sport and nutrition. It was only at this dinner that he spoke for the first time about his brutal childhood, how he ran away from home as a teenager, ended up on the street, drank too much to keep warm. How he completely crashed with his alcohol addiction and then later resorted to hard drugs. "Really gutter, homeless," Paul described his youth in short, drastic words. "And then addiction clinic, alcoholics anonymous, the whole program."

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My horrified look followed him as he brought the glass of Merlot to his mouth. The clichés sloshed in my head: Once Alki, always Alki. He noticed my gaze, put the glass down again and explained, in a tone that signaled that he had to repeat this a thousand times: "I know, I know, I've got it under control."

It was through Paul that I heard about "controlled drinking" for the first time. Put simply: an alcoholic, with the help of an addiction counselor, sets an individual goal of only drinking a certain amount of alcohol per week. At Paul, that's five glasses of wine or beer a week. Paul is semi-dry, so to speak. But people like Paul are also the reason why the concept of controlled drinking is a red rag for many addiction counselors. The belief that addiction is under control has already led too many to the next crash.

We Germans in particular are frontrunners when it comes to alcohol consumption: Each of us drinks an average of 240 liters of beer per year, the equivalent of 10.7 liters of pure alcohol. According to the Munich Institute for Therapy Research, one in six people regularly drinks so much that it is harmful to their health. With corresponding consequences: every year more than 74,000 people in Germany die as a result of their alcohol abuse. Alcohol is our most pressing addiction problem. No wonder that addiction counselors warn against playing down the dangers of a glass of wine.

Alcoholics Anonymous has helped millions of addicts with their lifelong abstinence programs and shaped the debate. But at the same time, there is hardly any disease where the treatment gap is so large: "Of the two million alcohol addicts in Germany, only 10 to 15 percent get professional help," the addiction researcher Karl Mann recently explained in the time. “Imagine what it would be like in cancer medicine if only one in ten cancer patients were treated. Such are the numbers for alcohol addiction, which is scandalous. Addiction researchers and medical professionals should ask themselves whether we shouldn't give other approaches than absolute renunciation a greater chance. "

The truth is, abstinence programs have a devastatingly small success rate. According to the drug commissioner of the federal government, only ten percent of addicts go into addiction therapy at all, and even with these ten percent only a fifth remain abstinent for more than a year. The principle of all or nothing often leads to nowhere.

In Canada and Australia in particular, addiction therapists are trying a different approach: controlled drinking or so-called MAPs, Managed Alcohol Programs. In Canada, the first MAP was introduced 22 years ago in the largest homeless shelter in Toronto, especially for the most severe cases. In most homeless shelters the rule applies: if you drink, you are thrown out. The MAPs not only allow alcohol, but the homeless are even served it regularly every few hours. Damage control is paramount: the MAP programs prevent people from ending up on the streets, drinking themselves to death, or dying from the cold.

The principle has been becoming more and more popular in Germany for some years now and is now officially an alternative in the guidelines of the specialist societies. In Freising, the psychosocial counseling and treatment center PROP has recently started offering a counseling program on controlled drinking. This week the group meets with its nine members for the ninth time. "Basically we work with people who are not yet dependent, but who have too much habitual consumption," says addiction counselor Anne Krüger, who heads the group. “But we also take in people who are dependent. Our motto is: Better drink less than change nothing at all. «Abstinence is the ideal solution, says Krüger, but she mainly directs her offer to problem drinkers who are not (yet) ready to abstain. “I give the patient responsibility for their decision. If someone doesn't want to be abstinent, you can turn yourself upside down, but as long as someone doesn't have the motivation, you can't force anyone to do it. "

Instead, the participants in their outpatient group keep a drinking diary, talk about how the past week went and set themselves a goal for the coming week, for example never before 6 p.m. or not drinking hard alcohol: “We have patients who can then say I'm abstinent during the week and drink three beers on the weekend. «With addicts this is of course more difficult, because addiction just means that you lose control.

Krüger plays out specific scenarios: How do I deal with slip-ups? What are the risk factors? If I go to the folk festival, how much do I drink or do I manage not to drink anything? What can I say if I am offered alcohol? For example: "I have to drive, that's why I won't drink anything today."

Success proves her right: "Most of them manage to keep their goals pretty well." Only one of the first group dropped out, but for a good reason: he decided to abstain. The social worker also admits: “Abstinence is easier than controlled drinking. With controlled drinking, everyone is responsible for when and how much they drink. To say, 'I don't drink anything' is easier than saying 'I'll have two beers today and then stop'. "

Anne Krüger completed her training with the German addiction researcher Joachim Körkel, who made the programs for controlled drinking popular in Germany and advertised that on average the controlled drinkers reduced their consumption by half. By the way, Krüger is also trained to advise people on controlled smoking and controlled drug use, on all drugs from cannabis to party drugs and heroin.

For a not-for-profit, respected association like PROP, this fits into the program: PROP offers outpatient advice centers, a drug emergency service, an in-patient facility and assisted living, almost the entire range from addiction prevention to withdrawal and aftercare with job placement. "So it makes sense that we also offer controlled drinking," says Krüger. "So far we have not had an offer for patients who were not ready to abstain, they fell through all the grids." The only ones for whom the program is out of the question are those who are already abstinent. Logical, because they can't reduce anything.

Therapy with modern drugs such as nalmefene, which are supposed to stop the supply of dopamine when drinking alcohol, i.e. the high, is only sensible in Krüger in individual cases: “I lack the component of personal responsibility. That treats the symptoms, not the causes. "

The controlled drinking program is also recognized by the health insurers that subsidize the course. “Many also come to abstinence through controlled drinking. Everyone can and must decide for themselves, "says Krüger, and then comes the decisive sentence:" The ways out of addiction are as individual as people are. "

With controlled drinking, the stigma is lower, the entry threshold is lower, and the abstinence dogma "never again even one liqueur praline" scares off many. While Krüger primarily looks after those at risk of addiction, others use it primarily for long-term alcoholics. This is also increasingly being promoted in Germany. The reason is simple: Especially for heavily alcoholics, a supervised program with controlled alcohol dispensing is healthier than the vicious cycle of falling - rehab - falling.

In Munich, this is even done with severely addicted people in homeless shelters: the addiction counselors consider it a success when a long-term alcoholic drinks beer instead of high-proof schnapps. "Strong drinks," said a Munich addiction counselor in an interview with the SZ, »Destroy mind and brain in fast motion. Not giving alcohol to addicts at all would be dangerous. They have to keep their level, otherwise there is a risk of convulsions and delirium.

Of course, the concept arouses vehement critics who consider abstinence to be the only true path. Criticism is particularly loud on programs such as that of the City of Amsterdam, where homeless alcoholics swept streets for six hours and were rewarded with five beers and half a pack of cigarettes. “Search at state expense?” Read the headlines.

Former professional soccer player Uli Borowka, dry alcoholic and author of the autobiography Full bottle, recently accused Sandra Maischberger of the pioneers of controlled drinking even of "bodily harm to dry alcoholics."
15,000 can drink in a controlled manner. ”He was sitting across from the pensioner Monika Schneider, 72, who after numerous withdrawal therapies in her retirement home is given three glasses of champagne a day - not enough to get drunk, but enough to keep her level. Monika Schneider's retirement home is now one of many that offers controlled drinking under supervision in Germany.

There aren't many serious studies on the subject, but the few that do show that controlled drinking is a serious alternative to the dogma of abstinence - especially when done under supervision, with experienced mentoring and the support of a group of like-minded people .

A study carried out in the Canadian Medical Association Journal was released stating that MAP participants in Ottawa not only reduced their alcohol consumption, but also reduced their stays in prisons and emergency rooms. The largest study to date of 651 participants in the UK, which compared abstinent and controlled drinkers, concluded that the self-motivation of those involved is the decisive factor for success, not the goal of abstinent or non-abstinent. A recent study in Harm Reduction Journal from 2016 shows that MAP participants in Ontario experience positive changes, "including fewer hospital stays, rehab programs and police contact." The proponents can demonstrate that the costs of MAPs decrease significantly not only for those affected, but also for the general public. Bernie Pauly from the University of Victoria / Canada, who led the latest study, thinks this is an important argument: "It is probably easier to convince society if we can make a clear cost-benefit calculation." The main benefit is of course to those affected: "You will not become homeless, you will stay healthier, you will find work more easily and your quality of life will improve massively."

The most interesting thing is that addiction counselors find that when they give their clients alcohol on a regular basis, they often drink less. That sounds paradoxical, but it makes sense. Because who wrestles with the alcohol devil, usually also struggles with the fear of withdrawal symptoms, which he thinks he has to treat with alcohol. But those who constantly drink moderately can ideally choose to drink less without struggling with severe withdrawal symptoms.

As with Paul. He almost never reaches his quota of five glasses of wine a week. The glass of Merlot with me was his first that week.