Alcohol Must Be Part of the Harm Reduction Conversation 

    Alcohol is our favorite recreational drug besides caffeine. According to SAMHSA’s National Survey on Drug Use and Health, 179 million Americans aged 12 or older consumed it in 2018. It’s a figure that dwarfs use of nicotine, or any prescription medication, or any illegal drug (the equivalent number for cannabis, easily the most popular federally illegal substance, was 43 million).

    Most people who drinkas for people who use any drug—experience no significant problems. According to SAMHSA, 67 million Americans engaged in “binge alcohol use” (defined as consuming four or more drinks on one occasion for women, or five or more for men) in 2018. A much lower figure of 16.5 million engaged in “heavy use” (binge drinking five times or more in a given month). Many people in these categories will still not experience serious harms, and at a whole-population level, as Stanton Peele has argued in Filter, alcohol probably conveys a net health benefit.

    Despite these caveats, alcohol-related harms—including deaths (combining alcohol with other drugs, like opioids, is particularly risky), disease, many negative personal impacts and harm to others, such as through drunk-driving accidents—are real and severe for a minority of millions.

    An estimated 13.9 percent of adult Americans met criteria for alcohol use disorder in the past year and 29.1 percent will meet these criteria at some point in their lifetime. (Note that alcohol use disorder is defined by the American Psychiatric Association according to the life problems people experience, rather than any set amount of consumption).

    So why is alcohol so often ignored in harm reduction conversations?

    One answer is the traditional focus of many harm reduction groups on illegal drugs—although alcohol was notoriously criminalized during Prohibition and many punitive restrictions on its sale and use remain. Many harm reduction workers are unfamiliar with alcohol harm reduction strategies—although, in my experience, they eagerly embrace these strategies once they learn about them.

    Another is the dominance of Alcoholics Anonymous. Founded in this country in the wake of the Temperance movement, AA takes an abstinence-only approach to problematic drinking and boasts over 1.4 million members in North America, together with huge cultural traction. AA’s problems include its religious nature and its role as a hunting ground for sexual predators, the ways it is used coercively—and the simple fact that it doesn’t work, with a “success” rate estimated at between 5-8 percent.

    “We’re getting the word out that you have rights, whether you drink or not.”

    There are harm reduction alternatives—and they need to be amplified. One of them is the nonprofit HAMS (Harm Reduction, Abstinence and Moderation Support), for which I am the director of organizational development.

    HAMS is a free-of-charge, lay-led support group for people who want to change their drinking habits. Unlike AA and many other groups, it doesn’t insist on abstinence. Members are instead encouraged to set their own goals, which range from abstinence, to moderation, to drinking the same amount more safely.

    To illuminate the work of HAMS, I had a conversation with its founder and my colleague, Kenneth Anderson.

     

    April Smith: What does HAMS do? 

    Kenneth Anderson: HAMS offers support through a closed Facebook support group with over 5,000 members, and an online forum.  There, members can get support anytime, day or night, for their alcohol-related issues.  If you’re up at 3 am in New York, you can post to the group and get responses from people as far away as Australia, Denmark or South Africa.

    We also have a book called How to Change Your Drinking: A Harm Reduction Guide to Alcohol. This is a user-friendly guide to setting your own goals, addressing the issues that keep you from achieving those goals, and tracking your progress.

    HAMS also works to inform the public that there are options other than the traditional approach to alcohol problems. We are about to launch a 99 cent e-book of success stories of HAMS members.  This shows that people can succeed without AA, rehab or abstinence (though we respect abstinence if it is freely chosenit’s our middle name!).  

     

    How did HAMS get started?

    I was the online director for Moderation Management, a group that advocates for drinking according to specific limits (no more than three drinks per day and nine per week for women, and four per day and 14 per week for men) from 2002-2006. During that time, I was also volunteering at a needle exchange in Minneapolis.

    The two groups gave me a kind of cross-fertilization between harm reduction approaches. Meanwhile, I voraciously read everything published in the field. I am an autodidact: although I hold a master’s degree in this field I have studied the scientific literature constantly for two decades whether in school or not.

    I noticed that many of the people coming into Moderation Management wanted to reduce the harm their drinking caused or decrease the quantity they consumed, but they weren’t interested in sticking with strict limits Moderation Management required.

    I had personally been drinking about four fifths of whiskey a week, and that was quite a bit too muchenough to cause problems. I tried going to AA and that did not agree with me at all. I drank more when I was in AA than I ever had before. I drank five liters of whiskey in five days and had to check into county detox to keep from dying of alcohol withdrawal. It was at that point that I left AA and started to get better.

    Through reading and self-experimentation, I taught myself how to control my drinking. I was effectively doing a harm reduction program for alcohol. I cut down from four fifths of whiskey a week to one fifth per week, and found that most of the drinking-induced problems in my life were solved. I do not abstain, and I have had no lasting negative consequences from my drinking in 17 years. I have not met any diagnostic criteria for alcohol dependence in that time.

    A group of other Moderation Management members and I started to develop a harm reduction program, hoping to implement it within Moderation Management. Unfortunately, the people in charge there weren’t interested in that. They wanted to stick with moderation programs, and with their strict limits.

    I had learned from needle exchange that you’ve got to support all positive change. As we say in HAMS, “Better is better!” So we left to form our own organization in 2007.

    Kenneth Anderson. Photo via HAMS.

     

    How does the HAMS approach work? How is it different from AA or other programs? 

    HAMS has 17 Elements, based on evidence-based interventions published in scientific journals. (We also have short videos explaining the Elements on our website, and much more helpful, scientifice-based information.)

    They are not new ideas at all. Most have been around since the ‘60s or before, such as writing down the pros and cons of your drinking versus the pros and cons of the changes you want to make.

    Another Element involves counting your drinks and using a drinking diary to chart your consumption. People have been doing this for years with food: Write everything you eat and count your calories. We apply these tools to alcohol.

    We call the parts of our program Elements and not Steps because one is not required to do all or any of them. They do not have to be done in any particular order. Most people pick one or two, or several, and find them quite useful. You put the elements together, and design your own program. Our book contains many worksheets to help readers set their goals, make a plan and achieve the change they want.

     

    Is there any scientific evidence that says that people with alcohol problems (“alcoholics”) can just reduce their drinking?

    Yes. The US government’s National Institute on Alcohol Abuse and Alcoholism conducted a giant, three-wave study called the National Epidemiologic Study on Alcohol and Related Conditions (NESARC). Starting in 2001, NESARC surveyed over 40,000 people per “wave.”

    Unlike previous studies, this one surveyed the general populationnot just people who had been in treatment. That gives a much clearer picture of what is happening in the real world than focusing solely on those who have, for whatever reason, joined AA or gone to rehab.

    The most important thing learned from NESARC is that of people with alcohol dependence as defined by the DSM-IV [Diagnostic and Statistical Manual, the book clinicians use to label psychiatric disorders], 90 percent recover. Of all those people, only about 14 percent ever get any sort of treatment or attend AA. Those who go to AA represent only about 10 percent of those who recover.

    Recovery is the normal outcome of alcohol dependence. You don’t have to go to AA to recover. The vast majority of people who recover do it on their own. Moreover, just over half of those who recover do so via controlled drinking rather than abstinence.

    Hundreds, if not thousands, of papers were written based on this NESARC data. One of them looked at patterns of recovery from alcohol dependence. “Progressing”i.e., getting worseis the least common outcome. “Jails, institutions and death”a scare-phrase AA likes to repeatare the least likely outcome. Very few people get worse. Almost all get better.

    Those who do get worse are sometimes called “chronic severe.” One of the interesting things about chronic severe individuals is that they are the ones who utilize treatment the most. The ones who go to rehab again and again. Those who went to AA, drank again, but “kept coming back.”

     

    Aren’t people’s brains hijacked once they become addicted? Many people think that those who are addicted lose the power to choose once they pick up that first drink.

    People’s brains are not hijacked. People do not become automata when they drink. It’s a myth used to promote treatment centers who make a lot of money out of sucking you in and sucking your bank account dry. Moderation and safer drinking are the most common outcomes in scientific literature—contrary to popular mythology.

    One other thing that we see is that when people make small changes for the better, they tend to go on and continue to make more and more changes and get better and better.

     

    What are some concrete strategies that HAMS suggests for members to change their drinking?

    Giving your car keys to your partner before you go out. Taking a limited amount of money to the bar when you go, and when it runs out, you’re done. Eating before drinking, and staying hydrated. Drinking at home instead of drinking out to avoid driving home drunk or getting into a bar fight. Avoiding drinking to deal with strong emotions. I always say, “Sad drinking is bad drinking.” The 17 Elements go into more detail, and the Facebook group is filled with suggestions from members on how they change their drinking.  

    Our Facebook groups also provide a place for members to talk about the issues that drive their drinking. I hear that the HAMS for Women group talks a great deal about life stressors that make them feel like drinking more than they want, but I don’t read that group because it’s a closed group solely for women.

     

    As an administrator of that group, I can verify that. Also, we love to post pictures of our pets! We’re not just about drinking: We talk about life. What do you say to AA’s Step One: “We admitted we were powerless over alcohol?”

    I found the message that alcohol is more powerful than human beings to be extremely harmful to me. AA tells me that I have no power to stop after the first drink, but that I can only be saved by a “Higher Power.” This makes no sense. God doesn’t swoop down and cure cancer, so how can he swoop down and cure alcoholism?

    Having the constant message that we have no power got ingrained in my subconscious and it was extremely damaging. Many people have a similar experience.

    I respect the decision of those who want to join AA. I respect all choices. If you want to say you’re powerless, more power to you. But people should know that there are other choices as well. I know several people who joined the Hare Krishna movement and quit alcohol. I’d rather do that than sit in a church basement saying I’m powerless. The only problem is I don’t believe in it and I don’t want to give up pork chops. Nor do I want to give up alcohol. I enjoy certain things, and why not?

    I would prefer it if we were the standard and AA was the alternative but we haven’t reached that point yet. There are several other alternatives for people who don’t find AA useful or palatable. There’s SMART Recovery, Life Ring, Women for Sobriety. HAMS if a lot like SMART, but they are focused on abstinence. Both are based on Cognitive Behavioral Therapy—an approach that has been standard in all kinds of therapy for decades. 

     

    HAMS provides social support primarily online. Don’t people need meetings to recover?  

    Live meetings may have made sense at a time when there was no other way to communicate in real time, but now, almost everyone communicates online. An online platform provides the opportunity to reach out anytime, day or night, when you need help or just want to talk. People don’t have to take an hour (not including travel time) away from their work and family lives to get support from HAMS the way they do for AA meetings. They can log on for a minute, an hour, or however. They can check the page three times a day, once a week, or never. Again, it’s all about choices.

    There’s also much more anonymity in an online group. While privacy is never guaranteed on the internet, you’re less likely to run into your neighbor on the HAMS Facebook group than at the AA meeting down the street.  

     

    What do you see as the future of HAMS? 

    HAMS is ripe for growth. People are learning about Narcan for overdose reversal.  People are learning about harm reduction. The general public is becoming more supportive of alternatives to AA and complete abstinence. Our program is based on science and common sense, not religion. That resonates with an increasingly-secular public more now than a philosophy born in 1935.

    There is a desperate need for support for people trying to change their drinking. We provide that. The challenge is getting the word out that they have an option. There is a place where free, non-judgmental support and rational, evidence-based tools are there for the taking.

    We are also working to get our message out to the public. We have an ongoing project to get How to Change Your Drinking into prison libraries and start live HAMS meetings in prisons, where people don’t have internet access.  We’ve just begun an initiative to educate people about their rights within the medical system.

    People with substance use issues are routinely treated in ways that are unethical, against government regulations and profoundly traumatizing when they seek healthcare. Stories of unnecessary use of restraints, forced medication and coerced commitment abound within our community. We’re getting the word out that you have rights, whether you drink or not. 


    Photo by Johann Trasch on Unsplash

    • April Smith

      April is the director of organizational development for Harm Reduction, Abstinence and Moderation Support (HAMS), an international group founded by Kenneth Anderson that supports people in harm reduction approaches to their alcohol consumption. She has a master’s in Public Health from Thomas Jefferson University. She presented her thesis research on the experiences of LGBT people in traditional 12-step rehabs at the National Harm Reduction Conference in 2016.

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