Germany’s success with its multi-pronged approach illustrates that addiction is “a more complex problem” than the current American response has acknowledged.
KHN correspondent Shefali Luthra reported this article from Germany as a 2019 Arthur F. Burns Fellow.
HAMBURG, Germany ― In 2016, 10 times as many Americans as Germans died as a result of drug overdoses, mostly opiates. Three times as many Americans as Germans experienced opioid addiction.
Even as the rates of addiction in the U.S. have risen dramatically in the past decade, Germany’s addiction rates have been flat.
That contrast, experts say, highlights a significant divergence in how the two countries view pain as well as distinct policy approaches to health care and substance abuse treatment.
Unlike in the United States, where these pills are commonly dispensed after surgeries and medical procedures, opioids have never emerged as a front-line medical treatment in Germany.
“Among the most important reasons we do not face a similar opioid crisis seems to be a more responsible and restrained practice of prescription,” said Dr. Peter Raiser, the deputy managing director at the German Center for Addiction Issues.
Doctors must first try alternative treatments, which the nation’s universal health insurance system typically covers. Before prescribing opioids, physicians must get special permission and screen patients to make sure they aren’t at risk for addiction.
“Here in Germany, they prescribe opiates if all the other drugs don’t work,” said Dr. Dieter Naber, a psychiatrist and researcher at the University of Hamburg. “It’s much, much, much more difficult.”
Analyses show that opioid painkillers in Germany are prescribed somewhat more than they were 30 years ago. But that boost hasn’t fueled abuse.
Research published this spring shows that the number of Germans addicted to opioids has changed only slightly in the past 20 years. In 2016, 166,300 Germans experienced opioid addiction ― about 0.2% of the population. In 1995, between 127,000 and 152,000 Germans were believed to have used heroin, specifically; in 2000, the range of Germans addicted to opioids was estimated between 127,000 and 190,000.
In the United States, in 2008, the government-administered National Survey on Drug Use and Health found that about 10,700 people took pain relievers or heroin for nonmedical purposes (even if they weren’t necessarily addicted). By 2016, about 2.1 million Americans ― 0.6% of the population ― experienced full-on opioid addiction.
The contrast speaks to differences in how the two countries approach medical care. Because of Germany’s health system ― which emphasizes primary care and keeps cost sharing low ― people who are prescribed opioids are more likely to keep up with their doctors’ visits. If they exhibit warning signs of addiction, physicians have a better chance of noticing.
To be sure, illicit drug use also occurs in Germany, and opioids are the main killer in drug-induced deaths. Still, the drug-induced mortality rate has gone down here, per the most recent European figures.
Even when people here get addicted, they are far less likely to die as a result. In 2016, 21 per million Germans died from drug-induced overdoses (of which most were opioid-induced). That same year, 198 per million Americans died from the same cause.
Experts said this speaks to differences in how the countries view the issue of addiction.
Because of Germany’s generous public coverage, it is easier to get treatment ― which, in the United States, can be hard to find, and expensive if you don’t have a health plan that covers it.
“Money regarding treatment is really not an issue here,” Naber said.
That said, Canada and Scotland both insure everyone and still face substantial addiction rates.
But, in Germany, drug addiction is treated with medication and “harm reduction” approaches, including so-called safe-injection sites ― people experiencing addiction take drugs under medical supervision, with clean needles to prevent the spread of disease. These facilities even have protocols in place to prevent overdose. Germany has more than 20 such sites, with four in Hamburg. The approach has “certainly reduced mortality,” Naber said.
Such strategies are controversial in the United States. A federal judge ruled early in October against a Trump administration effort to block a safe-injection program in Philadelphia. The administration argued that such efforts enable and encourage addiction, and pledged to continue efforts to block safe-injection sites.
But “harm reduction,” generally, and supervised injection, specifically, have been cited as best practices by the Organization for Economic Co-Operation and Development, a coalition of developed, mostly Western nations.
“We know harm reduction works in terms of dealing with the problem of mortality,” said Dr. Andres Roman-Urrestarazu, a researcher at the University of Cambridge who studies addiction in the global context.
He added that Germany’s success with its multipronged approach illustrates that addiction is “a more complex problem” than the current American response has acknowledged.
Germany’s health system ― which emphasizes primary care and keeps cost sharing low ― people who are prescribed opioids are more likely to keep up with their doctors’ visits. If they exhibit warning signs of addiction, physicians have a better chance of noticing.
To be sure, illicit drug use also occurs in Germany, and opioids are the main killer in drug-induced deaths. Still, the drug-induced mortality rate has gone down here, per the most recent European figures.
Even when people here get addicted, they are far less likely to die as a result. In 2016, 21 per million Germans died from drug-induced overdoses (of which most were opioid-induced). That same year, 198 per million Americans died from the same cause.
Experts said this speaks to differences in how the countries view the issue of addiction.
Because of Germany’s generous public coverage, it is easier to get treatment ― which, in the United States, can be hard to find, and expensive if you don’t have a health plan that covers it.
“Money regarding treatment is really not an issue here,” Naber said.
That said, Canada and Scotland both insure everyone and still face substantial addiction rates.
But, in Germany, drug addiction is treated with medication and “harm reduction” approaches, including so-called safe-injection sites ― people experiencing addiction take drugs under medical supervision, with clean needles to prevent the spread of disease. These facilities even have protocols in place to prevent overdose. Germany has more than 20 such sites, with four in Hamburg. The approach has “certainly reduced mortality,” Naber said.
Such strategies are controversial in the United States. A federal judge ruled early in October against a Trump administration effort to block a safe-injection program in Philadelphia. The administration argued that such efforts enable and encourage addiction, and pledged to continue efforts to block safe-injection sites.
But “harm reduction,” generally, and supervised injection, specifically, have been cited as best practices by the Organization for Economic Co-Operation and Development, a coalition of developed, mostly Western nations.
“We know harm reduction works in terms of dealing with the problem of mortality,” said Dr. Andres Roman-Urrestarazu, a researcher at the University of Cambridge who studies addiction in the global context.
He added that Germany’s success with its multipronged approach illustrates that addiction is “a more complex problem” than the current American response has acknowledged.
Both the object of any intervention and its proponents are prone to human foibles, courage and timidity, grandiosity and prudence.
In the wake of President John F. Kennedy’s assassination, members of Congress set out to update the procedures for handling an unable president. They soon realized that some situations would be far more challenging than others.
Famed political scientist Richard Neustadt emphasized one of the most ominous of those situations when he testified before the Senate. “Constitutions,” he warned, cannot “protect you against madmen. The people on the scene at the time have to do that.”
Congress’ reform effort culminated with the 25th Amendment. It provides essential improvements to the Constitution’s original presidential succession provisions. But a novel released in 1965, the same year Congress approved the amendment, makes a strong case that Neustadt’s insight was spot on.
The recently reissued “Night of Camp David” by veteran D.C. journalist Fletcher Knebel illuminates the daunting challenges that arise when the commander in chief is mentally unfit and unwilling to acknowledge it.
Flexibility an Important Part of 25th
The novel follows the fictional Senator Jim MacVeagh, who concludes that a paranoid President Mark Hollenbach is “insane” after he witnesses the president plot to abuse law enforcement powers and to establish a world government. Unbeknownst to MacVeagh, Defense Secretary Sidney Karper reaches the same conclusion. Karper remarks, “Congress did its best on the disability question, although there’s no real machinery to spot mental instability.”
The framers of the 25th Amendment did intend for it to cover cases of psychological inability. One of the principal authors, Rep. Richard Poff (R-Va.), envisioned a president who could not “make any rational decision.”
But the term “unable” in the amendment’s text was left vague to provide flexibility.
Additionally, the 25th Amendment is intentionally hard to use, with procedural hurdles to prevent usurpation of presidential power. Two-thirds of both houses of Congress must ratify an inability determination by the vice president and Cabinet when the president disagrees. Otherwise, the president returns to power.
Some believe these protections create their own challenges. As Harvard Law Professor Cass R. Sunstein observes in “Impeachment: A Citizen’s Guide,” “The real risk is not that the Twenty-Fifth Amendment will be invoked when it shouldn’t, but that it won’t be invoked when it should.”
This risk is heightened when the president may be psychologically unfit. Psychiatric assessment is descriptive and less evidence-based than other areas of medicine. In the novel, President Hollenbach’s doctor reports no evidence of a mental ailment. And there is a reason for that: Psychiatric illness is not beyond conscious manipulation.
A deft politician, President Hollenbach knew enough to hide his paranoia. While he seems overtly paranoid in the solitude of Aspen Lodge at Camp David when he is sharing his delusions with MacVeagh, he appears completely sane, dare we say presidential, in public appearances. There is a long history of presidents hiding their ailments from the public, including Presidents Lyndon Johnson and Richard Nixon, who both grew paranoid in private.
What Psychiatry Can Contribute
To further complicate assessment, the more subjective nature of psychiatric diagnoses introduces potential political biases among clinicians who might be asked to evaluate a president.
As critically, the American Psychiatric Association’s Goldwater Rule expressly prohibits armchair analysis by psychiatrists who have not directly examined the president. Those who had the opportunity would be equally constrained by patient confidentiality. This creates an ethical Catch-22.
Yale psychiatrist Bandy X. Lee and colleagues in “The Dangerous Case of Donald Trump” eschew this prohibition and feel it their ethical obligation to share their professional insights, invoking a duty to warn responsibility. One of us (Joseph) has suggested that while psychiatric diagnoses cannot be made from afar nor confidences breached, physicians have a supererogatory obligation to share specialized knowledge.
This is especially important when discussing psychiatric conditions, which may be hard to apprehend. The objective for mental health professionals is not diagnosis from afar but rather to educate the citizenry about these conditions so as to promote deliberative democracy.
Beyond these issues is the bias of any president’s advisers and allies. Their loyalty may blind them to presidential inabilities and have them protect an unfit president.
Then could be the political disincentive to acknowledge what presidential incapacity means. After all, Cabinet members serve at the pleasure of the president. Beyond that, it is just too frightening to imagine that there might be a madman in the White House in the nuclear age. So the tendency is to look away.
Officials hoping to avoid a direct challenge to presidential authority might engage in harm reduction, a concept drawn from public health where certain harms are accepted to reduce more harmful consequences: for example, needle exchange. This is the workaround that the fictional Defense Secretary Karper takes in “Night of Camp David.” Instead of attempting to convince the president’s allies of his concerns and invoking constitutional means to remove the president, he convenes a top secret task force to consider checks on the president’s power to use nuclear weapons.
Karper’s steps to limit the president’s unilateral authority have real-world precedent.
Amid President Nixon’s emotional turmoil during the depths of Watergate, Defense Secretary James Schlesinger instructed the military to check with him or the secretary of state before following orders from Nixon to launch nuclear weapons. More recently, former Defense Secretary James Mattis was reportedly among White House officials attempting to frustrate President Trump’s impulses.
The fictitious Senator MacVeagh goes down a different, more perilous and isolating path. He seeks the president’s removal and, as a result, experiences retribution. Top officials view him as paranoid, prompting them to order his involuntary psychiatric hospitalization. Instead of worrying about an impaired president, Washington’s political elite punish the young senator.
The bottom line: it is almost impossible to reverse the results of the electoral process and oppose entrenched power even when one is paradoxically trying to preserve the republic.
In “Night of Camp David,” the nation’s fortunes only begin to turn when MacVeagh and Karper overcome the collective action challenge and the compartmentalization of knowledge. Officials can overcome these obstacles by coming together and realizing their common purpose.
It was only after a group of senior Republican lawmakers, led by Sen. Barry Goldwater – ironically of the eponymous Goldwater Rule – banded together and confronted President Nixon during Watergate that the 37th president resigned. More drama ahead?
The current White House drama is still in manuscript form, but the plot has thickened. Worrisome tweets are prompting fresh concerns about presidential fitness, even from prominentmembers of President Trump’s own party.
Are these warnings the real-life equivalents of those from MacVeagh and Karper? Time will tell. But in this national drama, we are more than readers of fiction; we too are characters.
Richard Neustadt had it right. The “people on the scene” must be ready to place the interests of the nation above their own. Constitutions cannot protect against madmen, as he warned, because they create rules and institutions that are only as strong as the people tasked with protecting them.
Both the object of any intervention and its proponents are prone to human foibles, courage and timidity, grandiosity and prudence. When darkness descends, whether on Camp David or other halls of power, the nation is left to rely on the integrity and judgment of its leaders and its citizenry.
This article was written by John Rogan, Fordham University, and Joseph J. Fins, Cornell University and was originally published in April 2019 at The Conversation.
Most drinkers do not develop a disorder. But, research shows that Americans are drinking more and for longer each time they drink than ever before.
It’s the most wonderful time of the year, when holiday parties collide with collegiate and professional athletics events. What do they all have in common? Booze, lots of it, and often free. It’s no wonder the lead reindeer has a red nose.
Of course, drinking isn’t limited to a single season, but it holds a prominent place during the holidays. Across a few short weeks, consumption of spiked cider, boozy nog, wine, beer, cocktails and variations thereof may be higher than at any other point in the year. One industry study suggested that drinking doubles at this time of year. During this party time, we see up close the drinking habits of our partners, co-workers, relatives and, of course, ourselves.
This holiday season, you might take notice of just how much you drink. You may start to question your motivation for drinking. Or wonder about the long-term effects. While it might be tempting to dismiss these unsettling reflections, as director of the University of Florida Center for Addiction Research and Education, I encourage you not to.
How Many Is Too Many?
About one in eight U.S. adults met criteria for an alcohol use disorder in 2013 – the most recent year for which we have data. Compare that to just over one in 12 in 2002. That’s a nearly 50% increase. Alcohol misuse can lead to interpersonal violence and physical injury and worsen medical and psychiatric conditions. Besides its impact on health and well-being, alcohol misuse costs the U.S. an estimated US$224 billion a year in lost productivity, health care costs, criminal justice costs and others. More than 75% of those costs are associated with binge drinking.
But these statistics don’t answer the question I get most often from friends, family, casual acquaintances and even strangers at parties or on cross-country flights. What everyone wants to know is, “How much can I drink without being an alcoholic?” The answer is, “It depends.”
For Starters, Stop Calling Names
To effectively address the question, we must rethink our use of the term “alcoholic.” People have disorders; they are not themselves these disorders. The distinction is not merely a matter of semantics. It is fundamental to eliminating the stigma of substance use disorders and other psychiatric conditions.
Still, the more appropriate question, “How much can I drink without developing an alcohol use disorder?” gets the same answer: It depends. The amount that a person drinks doesn’t directly determine an alcohol use disorder diagnosis. But how can a “drinking problem” not have a definitive cutoff?
That’s because two people could drink the same amount and experience completely different consequences. So, the diagnostic criteria for alcohol use disorder focus on those consequences, rather than number of drinks imbibed.
For example, inability to control your drinking, no matter how much you drink, is a red flag. Having cravings for alcohol is another one. Does drinking interfere with your work, school or home responsibilities? Do you drink in situations in which you know it’s risky to do so?
Of course, the more you drink, the more likely it is that you will experience negative consequences.
Risky Business
Most drinkers do not develop a disorder. But that doesn’t mean you’re off the hook. Research shows that Americans are drinking more and for longer each time they drink than ever before. And, adults are continuing to drink into older ages than ever before.
Women, in particular, seem to drink more as they age. A significant percentage of drinkers over age 55 often exceed the National Institute of Alcohol Abuse and Alcoholism’s suggested guidelines for moderate drinking without necessarily meeting criteria for an alcohol use disorder. Whether you have a diagnosable disorder or not, all this drinking can cause problems.
One of those problems is driving. People mistakenly think of this as a young person’s problem. But about one in four adults 45 to 64 and another one in 12 over age 65 report driving after drinking in the previous month.
At blood alcohol concentrations equivalent to one or two drinks, older adults show notable shifts in cognitive performance, neural activity and driving strategies compared to younger ones.
Putting all this in the context of the holidays, it’s not just the pervasive presence of booze that makes us drink. It’s the party culture. If you’re seen without a drink, you are often encouraged to take one. If you lose track of your drink, you get another (full) one.
This excess may meet criteria for a binge drinking episode. For women, that’s four or more standard drinks in a single occasion. For men, it’s five or more. And, as for “standard” drinks, we all know that many of us are typically pouring ourselves two to three times the standard in every glass.
Binge drinking, too, is increasing in older adults. And that matters because it has an immediate impact on driving abilities, fall risk and prescription medications.
Should I Take Action?
If your alcohol use is gnawing at your conscience, you have options. Talk candidly with a trained professional about your drinking. Access the National Institute of Alcohol Abuse and Alcoholism website, where you can assess your drinking and seek help. If you believe a friend or relative has a problem, talk with someone who can help you identify next steps.
Here are some ways to be a safer drinker:
Before that party, eat something, even if you have to eat it in the car.
Make your first drink nonalcoholic. It keeps you from gulping down the first “real” drink and allows your “car snack” time to settle.
Alternate alcoholic and nonalcoholic drinks.
Eat (actually, graze) throughout the evening. Assuage guilt about calories by prioritizing fitness.
Disregard peer pressure. Susceptibility to it may lessen with age, but seldom vanishes. When you reach your limit, don’t be swayed.
To escape from an awkward conversation, don’t make a beeline to the bar. Take an indirect route through the room, mingling, checking out decorations.
Take a ride-share home or to and from a party.
If you think your holiday drinking could be a sign of a year-round issue, discuss it with a medical or behavioral health provider. There are a variety of options, including the support and help of Alcoholics Anonymous, which is free. Online AA meetings are also available. For more information, visit: https://www.aa.org.
Unlike most recovery groups, abstinence (sobriety) is not a requirement for HAMS. HAMS encourages all positive change, from abstinence to moderation to safer drinking.
The following is an excerpt from HAMS’ (Harm Reduction, Abstinence and Moderation Support) new book, in which members tell their stories of success and struggles along the way. Find more information about HAMS at the end of this excerpt.
Jessica’s Story
I had been a heavy drinker for 10 – 20 years. The increase in my drinking happened gradually, but then one day I became very ill after drinking and realized I could have been going through withdrawal. Yet it didn’t sink in and I continued on my path to destruction.
I work in drug addiction so I wasn’t oblivious to harm reduction, but the consensus where I live is that it doesn’t work, and everyone pushes AA. I didn’t want to go to AA and felt I couldn’t because I am in a very public position in my career in the addiction field. So I started to Google around and came across the HAMS website, but I didn’t join yet.
Then in December of 2016 I took a bad turn. I had been binge-drinking on a public holiday, and I was very sick, but I had to go into work on Monday. That’s when I finally joined HAMS. It was the first time I ever expressed to anyone, even myself, that alcohol had become a problem. Being able to do that in a safe environment was very important to me. There were so many people on so many different paths, including many who had been abstinent for years or moderating successfully, as well as those who had serious problems.
I was a member of HAMS for several months before I embarked on a taper. It had its limitations because I work long hours and I don’t drink during work so obviously with the consumption of alcohol I used to have during my hours off work it was very difficult to taper while not drinking for 12 hours a day. But tapering works. I did a long taper – perhaps it was more psychological than physical, but I live alone and I didn’t want to risk DTs.
I tried moderating, but it didn’t work for me. Once I start to drink, there is no stop button. So I made the decision last year to be alcohol-free. Once I tried moderation again, but drank way too much. It wasn’t even stress or trauma: I just thought I deserved a treat so I tried it again, but once I started I kept going. I contacted a doctor I knew from Facebook who was a specialist in addictions and who I knew would keep my confidence, and he prescribed an at-home detox with Ativan. Unfortunately, I still had to go to work, and I don’t know how I managed but I did. So I came to the conclusion last year that I need to be alcohol free because this moderation thing does not work for me.
I found the HAMS Facebook group very helpful because sleeping has always been a problem for me, and it was especially acute when I first stopped drinking. I am in Central Europe, so when I couldn’t sleep at night, everyone in the US was up. When I couldn’t sleep at 2 or 3 am my time, there was always someone in the group I could talk to. I’ve made a lot of good friends in HAMS, and we usually don’t even talk about alcohol. We talk about other things in our lives. My mantra has always been that I am much more than my alcohol problem, so talking with HAMS friends about things other than alcohol keeps me focused on the life I have beyond alcohol.
Another thing I like about HAMS is how many members are female. Women have a very different experience with alcohol than men do, and I feel that most treatment is geared to men. Women often have more at stake: a woman I know went to the ER because she was in withdrawal, and they called child protection services on her. I didn’t want to join AA because as a female, I didn’t want to be preyed upon by the men there. Women are so vulnerable, especially when we first stop drinking. I know of many women who have been taken advantage of by men in AA. That doesn’t happen in HAMS. I’ve never felt pounced upon or been contacted in any inappropriate way.
The support in HAMS has made it possible for me to become alcohol-free. The fact that it is international, I can get support any time day or night, and I don’t have to worry about my identity being exposed in the country where I work, have all been important. I want us to continue to grow and help people all over the world see that changing your drinking really is possible. With HAMS, no matter who you are or where you live, you are never alone.
HAMS – Harm Reduction, Abstinence and Moderation Support – is an over 5,000-member group of people worldwide who are working to change their drinking. Unlike most such groups, abstinence (sobriety) is not a requirement for HAMS. HAMS encourages all positive change, from abstinence to moderation to safer drinking. Members are encouraged to set their own goals and make a plan for achieving them. HAMS provides confidential, 24/7 online support through closed Facebook groups, including a 1,000-member group for women only. Members interact with each other from the privacy of their own homes, and no judgement is allowed – just support and encouragement. HAMS provides support for those who want to set their own goals, think for themselves, and improve their drinking.
When all is said and done, you’re the cause of your own hangover pain, and you’re the one who must pay for all the fun of the night before.
Debaucherous evening last night? You’re probably dealing with veisalgia right now. More commonly known as a hangover, this unpleasant phenomenon has been dogging humanity since our ancestors first happened upon fermentation.
Those nasty vertigo-inducing, cold sweat-promoting and vomit-producing sensations after a raucous night out are all part of your body’s attempt to protect itself from injury after you overindulge in alcoholic beverages. Your liver is working to break down the alcohol you consumed so your kidneys can clear it out ASAP. But in the process, your body’s inflammatory and metabolic reactions are going to lay you low with a hangover.
As long as people have suffered from hangovers, they’ve searched in vain for a cure. Revelers have access to a variety of compounds, products and devices that purport to ease the pain. But there’s a lot of purporting and not a lot of proof. Most have not been backed up well by science in terms of usefulness for hangover treatment, and often their effects don’t seem like they’d match up with what scientists know about the biology of the hangover.
Working Overtime To Clear Out the Booze
Hangovers are virtually guaranteed when you drink too much. That amount varies from person to person based on genetic factors as well as whether there are other compounds that formed along with ethanol in the fermentation process.
Over the course of a night of heavy drinking, your blood alcohol level continues to rise. Your body labors to break down the alcohol – consumed as ethanol in beer, wine or spirits – forming damaging oxygen free radicals and acetaldehyde, itself a harmful compound. The longer ethanol and acetaldehyde stick around, the more damage they can do to your cellular membranes, proteins and DNA, so your body’s enzymes work quickly to metabolize acetaldehyde to a less toxic compound, acetate.
Over time, your ethanol levels drop through this natural metabolic process. Depending on how much you consumed, you’re likely to experience a hangover as the level of ethanol in your blood slowly returns to zero. Your body is withdrawing from high levels of circulating alcohol, while at the same time trying to protect itself from the effects of alcohol.
Scientists have limited knowledge of the leading causes of the hangover. But they do know that the body’s responses include changes in hormone levels to reduce dehydration and cellular stress. Alcohol consumption also affects a variety of neurotransmitter systems in the brain, including glutamate, dopamine and serotonin. Inflammation increases in the body’s tissues, and the healthy gut bacteria in your digestive system take a hit too, promoting leaky gut.
Altogether, the combination of all these reactions and protective mechanisms activated by your system gives rise to the experience of a hangover, which can last up to 48 hours.
Your Misery Likely Has Company
Drinking and socializing are cultural acts, and most hangovers do not happen in isolation. Human beings are social creatures, and there’s a high likelihood that at least one other individual feels the same as you the morning after the night before.
Each society has different rules regarding alcohol use, which can affect how people view alcohol consumption within those cultures. Drinking is often valued for its relaxing effect and for promoting sociability. So it’s common to see alcohol provided at celebratory events, social gatherings and holiday parties.
In the United States, drinking alcohol is largely embraced by mainstream culture, which may even promote behaviors involving excessive drinking. It should be no surprise that overindulgence goes hand in hand with these celebratory social events – and leads to hangover regrets a few hours later.
Your body’s reactions to high alcohol intake and the sobering-up period can influence mood, too. The combination of fatigue that you experience from sleep deprivation and hormonal stress reactions, in turn, affect your neurobiological responses and behavior. As your body is attempting to repair itself, you’re more likely to be easily irritated, exhausted and want nothing more than to be left alone. Of course, your work productivity takes a dramatic hit the day after an evening of heavy drinking.
When all is said and done, you’re the cause of your own hangover pain, and you’re the one who must pay for all the fun of the night before. But in short order, you’ll forget how excruciating your last hangover was. And you may very soon talk yourself into doing the things you swore you’d never do again.
Speeding Up Recovery
While pharmacologists likeus understand a bit about how hangovers work, we still lack a true remedy.
For example, Kudzu root (Pueraria lobata), a popular choice for hangover remedies, has primarily been investigated for its effects in reducing alcohol-mediated stress and hangover. But at the same time, Kudzu root appears to inhibit the enzymes that break down acetaldehyde – not good news since you want to clear that acetaldehyde from your system quickly.
To fill this knowledge gap, our lab is working with colleagues to see if we can find scientific evidence for or against potential hangover remedies. We’ve focused on the benefits of dihydromyricetin, a Chinese herbal medicine that is currently available and formulated as a dietary supplement for hangover reduction or prevention.
Dihydromyricetin appears to work its magic by enhancing alcohol metabolism and reducing its toxic byproduct, acetaldehyde. From our findings in mice models, we are collecting data that support the usefulness of dihydromyricetin in increasing the expression and activity of enzymes responsible for ethanol and acetaldehyde metabolism in the liver, where ethanol is primarily broken down. These findings explain one of the several ways dihydromyricetin protects the body against alcohol stress and hangover symptoms.
We are also studying how this enhancement of alcohol metabolism results in changes in alcohol drinking behaviors. Previously, dihydromyricetin was found to counteract the relaxation affect of drinking alcohol by interfering with particular neuroreceptors in the brain; rodents didn’t become as intoxicated and consequently reduced their ethanol intake. Through this combination of mechanisms, we hope to illustrate how DHM might reduce the downsides of excessive drinking beyond the temporary hangover, and potentially reduce drinking behavior and damage associated with heavy alcohol consumption.
Of course, limiting alcohol intake and substituting water for many of those drinks during an evening out is probably the best method to avoid a painful hangover. However, for those times when one alcoholic beverage leads to more than a few more, be sure to stay hydrated and catch up on rest. Your best bet for a smoother recovery is probably some combination of nonsteroidal anti-inflammatory drug like ibuprofen, Netflix and a little downtime.
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José’s son was diagnosed with schizophrenia and bipolar disorder last year and has faced barriers to getting affordable treatment, in part because he doesn’t have legal status.
When José moved his family to the United States from Mexico nearly two decades ago, he had hopes of giving his children a better life.
But now he worries about the future of his 21-year-old-son, who has lived in central Illinois since he was a toddler. José’s son has a criminal record, which could make him a target for deportation officers. KHN is not using the son’s name because of those risks and is using the father’s middle name, José, because both men are in the U.S. without legal permission.
José’s son was diagnosed with schizophrenia and bipolar disorder last year and has faced barriers to getting affordable treatment, in part because he doesn’t have legal status. His untreated conditions have led to scrapes with the law.
Mental health advocates say many people with untreated mental illness run the risk of cycling in and out of the criminal justice system, and the situation is particularly fraught for those without legal status.
“If he gets deported, he’d practically be lost in Mexico, because he doesn’t know Mexico,” said José, speaking through an interpreter. “I brought him here very young and, with his illness, where is he going to go? He’s likely to end up on the street.”
Legal Troubles
José’s son has spent several weeks in jail and numerous days in court over the past year.
On the most recent occasion, the young man sat nervously in the front row of a courtroom in Illnois’ Champaign County Courthouse. Wearing a white button-down shirt and dress pants, his hair parted neatly, he stared at the floor while waiting for the judge to enter.
That day, he pleaded guilty to a criminal charge of property damage. The incident took place at his parents’ house earlier this year. He had gotten into a fight with his brother-in-law and broke a window. His father said it was yet another out-of-control moment from his son’s recent struggles with mental illness.
Before beginning proceedings, the judge read a warning aloud — a practice that is now standard to make sure noncitizens are aware they could face deportation (or be denied citizenship or reentry to the U.S.) if they plead guilty in court.
José’s son received 12 months of probation.
After the hearing, he said that his life was good just a couple of years ago: He was living on his own, working and taking classes at a community college. But all that changed when he started hearing voices and began struggling to keep a grip on reality. He withdrew from his friends and family, including his dad.
One time, he began driving erratically, thinking his car was telling him what to do. A month after that episode, he started having urges to kill himself and sometimes felt like hurting others.
In 2018, he was hospitalized twice and finally diagnosed with schizophrenia and bipolar disorder.
José said that during this time, his son — who had always been respectful and kind — grew increasingly argumentative and even threatened to hurt his parents. The psychiatric hospitalizations didn’t seem to make a difference.
“He asked us for help, but we didn’t know how to help him,” José said. “He’d say, ‘Dad, I feel like I’m going crazy.’”
José’s son said he met with a therapist a few times and took the medication he was prescribed in the hospital. He was also using marijuana to cope, he said.
The prescribed medication helped, he said, but without insurance he couldn’t afford to pay the $180 monthly cost. When he stopped the meds, he struggled and continued having run-ins with the police.
Undocumented and Uninsured
For people who are both undocumented and living with a mental illness, the situation is “particularly excruciating,” said Carrie Chapman, an attorney and advocate with the Legal Council for Health Justice in Chicago who represents many clients like José’s son.
“If you have a mental illness that makes it difficult for you to control behaviors, you can end up in the criminal justice system,” Chapman said.
People with mental illness make up only a small percentage of violent offenders — they are actually more likely, compared with the general population, to be victims of violent crime.
Chapman said the stakes are extremely high when people without legal status enter the criminal justice system: They risk getting deported to a country where they may not speak the language, or where it’s even more difficult to obtain quality mental health care.
“It could be a death sentence for them there,” Chapman said. “It’s an incredible crisis, that such a vulnerable young person with serious mental illness falls through the cracks.”
An estimated 4.1 million people under age 65 who live in the U.S. are ineligible for Medicaid or marketplace coverage under the Affordable Care Act because of their immigration status, according to the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Among them are those who are undocumented and other immigrants who otherwise do not fall into one of the federal categories as a lawful U.S. resident. People protected from deportation through the federal government’s Deferred Action for Childhood Arrivals policy, or DACA, also are ineligible for coverage under those programs.
For many people in all those groups, affordable health care is out of reach.
Some states have opened up access to Medicaid to undocumented children, including Illinois, California, Massachusetts, New York, Oregon, Washington and the District of Columbia, according to the National State Conference of Legislatures. But residents lose that coverage at age 19, except in California, which recently expanded eligibility through 25.
For those who can’t access affordable health insurance because of their undocumented status, medical care is largely limited to emergency services and treatments covered by charity care or provided by community health centers.
It’s unclear how many people have been deported because of issues linked to mental illness; good records are not available, said Talia Inlender, an attorney for immigrants’ rights with the Los Angeles-based pro bono law firm Public Counsel. But estimates from the American Civil Liberties Union suggest that tens of thousands of immigrants deported each year have a mental disability.
Inlender, who represents people with mental disabilities in deportation hearings, said that when the lack of access to community-based treatment eventually leads to a person being detained in an immigration facility, that person risks further deterioration because many facilities are not equipped to provide the needed care.
On top of that, she said, immigrants facing deportation in most states don’t generally have a right to public counsel during the removal proceedings and have to represent themselves. Inlender points out that an immigrant with a mental disability could be particularly vulnerable without the help of a lawyer.
(Following a class action lawsuit, the states of Washington, California and Arizona did establish a right to counsel for immigrants with severe mental illness facing deportation. For those in other states, a federal program is designed to provide the same right to counsel, but it’s only for certain detained immigrants.)
Medicaid For More People?
Chapman and other advocates for immigrants’ rights say expanding Medicaid to cover everyone who otherwise qualifies — regardless of legal status — and creating a broader pathway to U.S. citizenship would be good first steps toward helping people like José’s son.
“Everything else is kind of a ‘spit and duct tape’ attempt by families and advocates to get somebody what they need,” Chapman said.
Critics of the push to expand Medicaid to cover more undocumented people object to the costs, and argue that the money should be spent, instead, on those living in the country legally. (California’s move to expand Medicaid through age 25 will cost the state around $98 million, according to some estimates.)
As for José’s son, he recently found a pharmacy that offers a cheaper version of the prescription drug he needs to treat his mental health condition — and he’s feeling better.
He now works as a landscaper and hopes to get back to college someday to study business. But he fears his criminal record could stand in the way of those goals, and he’s aware that his history makes him a target for immigration sweeps.
José said his greatest fear is that his son will end up back in Mexico — away from family and friends, in a country he knows little about.
“There are thousands of people going through these issues … and they’re in the same situation,” José said. “They’re in the dark, not knowing what to do, where to go or who to ask for help.”
Christine Herman is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @CTHerman.
This story is part of a partnership that includes Side Effects Public Media, NPR and Kaiser Health News. Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
Making blanket statements that “anyone can recover” whitewashes and overlooks the gross inequities that people of color and marginalized communities face.
Recovery is possible for anyone, but it isn’t the reality for everyone. We may see an increasing number of people on social media proudly displaying their recovery as badges of honor — which in turn reduces stigma about addiction and a life in recovery — but it doesn’t accurately depict the true picture that recovery isn’t accessible to everyone, it heavily depends on your privilege.
Recovering “out loud” has gained so much momentum that it’s now a social justice movement: we are now questioning advertisers who normalize the excessive use of alcohol, challenging the use of biased language, highlighting the inequity in authorities tackling opioids but overlooking alcohol as the leading cause of drug-related deaths, and advocating for policy changes that affect people with substance use disorders.
While this recovery activism should be celebrated, we are still overlooking the inconvenient truth lurking beneath the surface: recovery is, unfortunately, still a privilege. Can we really be part of a social justice movement if we overlook the role privilege plays in the accessibility of recovery?
The Role of Privilege in Substance Use Disorders and Recovery
Many people within the recovery movement believe that recovery is possible in spite of race, ethnicity, economic circumstances, nationality, sex, gender, access to health insurance, and a strong support system — in other words, privilege. This simply isn’t the reality. There are great disparities both in how addiction affects people and how much recovery capital is available to us based on privilege.
Rates of addiction are higher in oppressed populations, especially among LGBTQ people and people of color. Black women over 45 are the fastest growing population with alcohol use disorder, and the risk of developing a substance use disorders is 20-30 percent higher for individuals who identify as LGBTQ+.
We don’t hear about those statistics, though; we see an opioid epidemic that is largely affecting white people. When drugs have a detrimental impact on communities of color, the media is less interested in covering it. Advocate Shari Hampton explains “Nobody gave a damn when black lives were being ravaged by crack cocaine in the 80’s. Families were ripped apart; communities were literally destroyed. People were thrown in jail and some of them are still there.”
She continues, “I’ve witnessed grandparents raise grandchildren right up to their grave while their grown children suffered from a crack addiction or a jail sentence that is so ridiculously long, it might as well be life. But now we have an opioid epidemic. It’s affecting a different demographic. And now, now it’s a treatment issue. This is disparaging and discouraging, especially to the black and brown folks that have never been treated with even a remote sense of compassion compared to what we see today.”
This disparity continues in access to recovery. Recovery is vastly different for those who lack recovery capital — the resources that can be used to sustain recovery: financial security, education, health insurance, and a support system — which is heavily linked, again, to our privilege.
Not all people who speak openly about their addiction and recovery are blind to the reality of the effects of privilege. In her recent book Strung Out, author Erin Khar unpacks the role of privilege in her own recovery: “Escaping addiction, and it truly does feel like an escape, requires protective layers of aftercare. I have been incredibly fortunate to have access to the support I’ve needed.”
She continues, “We don’t have a system in place that makes it simple or easy for people to get help or support. There are financial, social, and racial barriers to getting help. If we are going to see a real downshift in the opiate crisis, support is what is needed — not just from peers and family members, but also the medical community and government.”
Studies show that African American and Latinx individuals are far less likely than white people to complete outpatient and residential substance use disorder treatment.
The inequity is also in access to medication. NPR highlighted a recent study by Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan, who stated that “this epidemic over the last few years has been framed by many as a largely white epidemic, but we know now that’s not true.”
Lagisetty found that as overdose deaths rose between 2012 and 2015, so did though the number of medical visits where buprenorphine was prescribed. However, researchers found no increase in prescriptions for African Americans and other minorities. In fact, the study found that white populations are almost 35 times more likely to have a buprenorphine visit than African Americans even though death rates among people of color were rising faster than white people. Researchers also observed that these visits were paid for by cash (40 percent), or private insurance (35 percent) rather than with Medicaid (25 percent), suggesting inequalities in healthcare.
“We shouldn’t see differences this large, given that people of color have similar rates of opioid use disorder,” says Lagisetty. “As the number of Americans with opioid use disorder grows, we need to increase access to treatment for black and low-income populations, and be thoughtful about how we reach all those who could benefit from this treatment.”
People of color have less access to treatment not only due to socio-economic circumstances. There is also a disparity in how drug use is viewed in communities of color. Despite similar rates of drug use and sales, people of color are more likely than white people to be arrested and receive harsher punishments for drug-related offenses.
Khar reflects on the criminalization based on race: “Some might say it’s a miracle that I never got pulled over, never got caught with that briefcase of drugs. But I see it less as a miracle and more because I was a young woman with passing-white privilege in a Jetta.”
She continues, “I’ve thought about this often, that had my skin been darker, had I come from less privilege, I have no doubt that I would have been arrested early on. I’ve thought about how that would have changed the trajectory of my life, how early arrests may have kept me forever trapped in a cycle of incarceration. Our drug laws are undeniably skewed to keep people of color and people of less privilege imprisoned and enslaved. And I’ve always been aware of that.”
The true picture of addiction and recovery inequity are often ignored on social media because our privilege blinds us to these realities. But if we really want to create a social justice movement, we have to change how we relay what substance use disorders and recovery looks like for all.
Creating a More Impactful Social Justice Movement
Let me be clear: this article is not intended to shame anyone for their privilege; instead, I’m suggesting that we can’t ignore the true picture in favor of a prettier, more palatable version. Making blanket statements that “anyone can recover” whitewashes and overlooks the gross inequities that people of color and marginalized communities face.
Advocate Shari Hampton explains this discomfort that underlies many recovery advocacy conferences. “I went to a conference earlier in the year and the white fragility in the room was nauseating. I literally didn’t understand why even talking about inequality caused so much discomfort. Simply discussing the topic had white folk with pursed lips and clenched fists. White folks can’t bear to examine a system that has entitled them to more, as being broken. It’s like admitting that Jesus was black. It’s not going to happen. To do so would disrupt all things.”
When asked how we can make a difference, Hampton responds: “America’s history teaches that black people are inferior to white people — that we don’t deserve the same treatment or opportunities. The mindset must shift. Because until we are seen, truly seen as magnificent beings, equal and worthy of the same quality of life and opportunities afforded to whites, very little will change.”
If we really want to create a more impactful social justice movement, we need to get uncomfortable. We need to be more mindful in our social media posts and consider if what we are portraying is an accurate representation of recovery, and question if our privilege played a role in our access to resources. We need to consider if we are amplifying the voices of those marginalized and oppressed. If not, why not? And in creating events to address addiction, or in going to Washington, DC seeking policy changes, we need to stop and ask ourselves if we have invited the people who are most affected by these policies. If not, we need to ask ourselves why we aren’t amplifying the voices of the people who most need to be heard?
We cannot divorce recovery from true social justice. Writer and sobriety coach Holly Whitaker says: “For those people who don’t want to ‘dirty up’ or confuse recovery spaces with talk of racism, classism, transphobia, homophobia, ableism, classism, etc. — remember that recovery is about awareness, and that this path is about inclusion, love, and acknowledging wrongs and injustices. If we aren’t talking about the way the system works, and who gets crushed by the system, we aren’t actually talking about recovery. We’re still just talking about our comfort zones, and using our privilege to deny other experiences.”
Our recovery is not up to angels, demons, or gods. It is up to us.
An audio version of Common Sense Recovery is now available on Audible.
Science Is Not a Four-Letter Word
A lot has been learned since Bill and Bob first met. I like to think that they did not so much set things in stone as set them in motion.
But we must always keep in our minds that the deep roots of AA in religion have set into our fellowship a long standing tone of anti-science and anti-learning. Religious organizations such as Alcoholics Anonymous tend to be subtly, if not overtly, hostile to new ideas, to science, to change, and to anyone or anything which calls into question their traditional view that the big and important questions have all been answered, and the answer is God.
I am not an expert on the subject matter, and this is not going to be a science paper. Yet we would be doing ourselves and all the suffering alcoholics, now and in the future, in and out of the rooms, a huge disservice if we failed to recognize the ways in which a rapidly expanding body of knowledge might enhance our efforts. So, for example, there is an ever-growing body of scientific data to support the view that positive thinking and associated actions can literally re-wire the brain’s circuitry.
So let’s consider just one important area of investigation which will suggest the kind of exploration I think we have an obligation to more diligently pursue. Recent findings in the neurosciences suggest that the human brain is more malleable than once thought to be. Our experiences can actually rewire our “plastic” brain. Simply put, when we form habits of behavior, such as drinking or any of the destructive habits of thought associated with the alcoholic lifestyle, we forge strong pathways in our brain, neural connections that are reinforced over and over again, becoming stronger and stronger each time we repeat the patterns of thought and behavior.
The good news is that change is possible. The even better news is that positive change, consistently different thoughts and actions, will re-wire our neural pathways, literally changing our brain’s structure. The more we engage in the new behavior, the more that particular set of neurons fires together and wires together. The new connections, perhaps very tenuous at first, grow stronger and stronger with each reinforcing positive thought and activity. Meanwhile, the old pathway literally begins to atrophy from non use. The old habits fade, while the new ones become stronger and stronger with each repetition.
I find it encouraging that we have this growing body of evidence supporting many of our traditional teachings. Repeated alternate behavior choices can actually restructure our mental map. “Fake it till you make it” is scientifically verifiable. “Living our way into right thinking” is not a mere slogan on the wall, but an empirically verifiable technique for altering our brain chemistry and, thereby, our entire lives. How encouraging to know that, as hard as it may be at first to have an “attitude of gratitude”, habitually cultivating one through practice and repetition can, over time, literally change the way we see the world at the most basic level.
One of the more influential books I have ever read in my own personal recovery is an old school classic called A New Pair of Glasses, by Chuck C. Amongst many other insights, the book offered up the idea that god was in fact, simply, a new way of seeing the world, a new pair of glasses. This idea is suggested throughout the Big Book. The whole point of the AA experience is to initiate a “psychic change” (p. xxix), one which will “revolutionize our whole attitude toward life” and “toward our fellows”. (p. 25. Here, as in many places, I intentionally edit out Bill and the old timers’ copious references to god, spirit or higher power. This is quite intentional, and represents in fact a main thrust of my argument: Alcoholics Anonymous is replete with a wonderful and useful toolkit that can help anyone stay sane and sober if they are willing, even after we take out all the unnecessary, distracting, obfuscating religious language.) They may no longer be with us, but I suspect that Bill and Bob, Carl Jung, Dr. Silkworth and Chuck C. would all have been impressed by the correlation between this focus on a new pair of glasses and contemporary findings in the brain and behavioral sciences.
So, scientific findings support our experience: we can act our way into right thinking. We can ultimately enjoy lasting, whole scale changes in our personalities through seemingly small, incremental changes in behavior. Every time we experience a desire to drink and, instead, go to an AA meeting, call a friend, or work with a newcomer, we weaken that demon and strengthen that angel. We do the next right thing and, at some point, we realize that all these slow incremental steps have produced a significant, “miraculous” transformation. Our brain is literally being rewired, slowly but surely reprogrammed.
The AA tradition is to call this kind of change “spiritual” for two reasons. First, because of tradition. This sort of personal transformation, prior to the last couple hundred years of human history at least, was generally considered the sole province of religion, the handiwork of angels and deities.
Second, the caulk thing again. We find the radical change inexplicable, so we apply the magic, one-size-fits-all explaining power of theism as a metaphysical caulk in order to satisfy the never-ending human thirst for understanding or explanation.
Most importantly, these responses are not merely unnecessary; they are demeaning and disempowering in a very important sense. Our recovery is not up to angels, demons, or gods. It is up to us. We are responsible for taking the necessary actions that ensure the necessary changes which make for lasting, contented sobriety. Furthermore, supernatural explanations such as this give the false impression that we know all we need to about the phenomenon in question. As such, they tend to stand in direct conflict with the kind of curiosity and exploration which will grow the recovery sciences and our understanding of the relevant social and psychological processes.
The Real Higher Power
The most miraculous and inexplicable force at work in Alcoholics Anonymous may be fellowship itself. Even the most devoutly religious members depend upon our society, upon the power of the group. Often they will describe their fellow AAs, in a typical example of religious interpretation, as the mouthpiece through which god speaks to them. The fellowship is understood as a mere vehicle, or as a temporary expedient to be replaced by the real Higher Power when the newcomer finally “comes to” or “comes to believe”. But the experience of most recovering alcoholics is that, what guides and sustains us on a day-by-day basis are peer support, empathy, mentor guidance, and the emotional reinforcement of group membership. In short, what keeps us sober from day to day is fellowship.
Consider these three suggestions, probably the most common ones made to an alcoholic who is suffering:
Go to a meeting
Call your sponsor
Work with another alcoholic
What do all three have in common? They all entail immersion in the society of recovering peers, a meaningful connection with our newfound tribe. Reams of data from social psychology, evolutionary biology and a host of other disciplines attest to the essential role played by peer groups and societies in determining both our values and our action choices, in shaping our thoughts and behaviors. Scientifically, mounting evidence suggests that the social group is the source of an important kind of basic emotional nurturance that is fulfilling to tribal hominids such as we at a most fundamental level.
Our brain evolved to be what it is over the course of five million years spent in small, familial tribes, within which complete immersion and total dependence were essential for our very survival. We are, at our core, not so much individual animals as we are pack members. Gathering in fellowship is the most important practical tool we have borrowed from religion and the church. But, in the end, the power of the group is undoubtedly a little less miraculous, a little more ancient, and a little more explicable, than once thought.
The tribe functions as the disseminator and teacher, the source of encouragement and reinforcement, that which empowers the addict to live a better life on a daily basis. The fellowship offers new ideas, role models who practice them, wise guidance and counsel, reinforcement of values and goals, and essential emotional rewards to its members. It empowers us to practice new and different behaviors until they become new and different habits. As time passes our membership within the tribe is the source of life enriching friendships.
But it also becomes an important source of a newfound sense of value and purpose as, over time, we transform into seasoned members who reap significant benefits from passing guidance and support on to the next member in need. This life sustaining mutual exchange is a huge part of recovery. It builds a web which sustains us all, a web of support that is fundamentally tribal. Our lives are saved, shaped and defined by the herd. We survive by running with the pack. The fellowship is the most tangible instantiation of a “higher power” in our lives. I would argue that we need seek no further.
For humans, isolation is death. Community is life. We overestimate the value of religious belief and faith in god: in fact, the community of fellows is the vehicle, whether it is church, temple, ashram, therapy group, mosque, sangha, a meeting of Alcoholics Anonymous, or the meeting after the meeting.
Keep in mind how miserable and close to disaster Bill Wilson was in spite of his life-changing experience at Towns Hospital. AA lore unwisely exaggerates his alleged spiritual experience. This was, in all probability, merely a side effect of the quasi-toxic, hallucinogenic Belladonna cure being administered at the time.
But when Bill went out into the world and engaged with other alcoholics, he ultimately found what he was looking for. It was not more white light, or god, or a higher power that he found, but a drunken country doctor named Bob. The lasting good they created is a society of peers who gain synergetic strength in numbers, loving support from each other, and much wisdom gleaned from years of collective experience.
The above is an excerpt from the book Common Sense Recovery: An Atheist’s Guide to Alcoholics Anonymous. The book was originally written as a journal by long-term member Adam N., as he sought to bridge the gap between the religious language and perspectives of AA, and his own increasingly secular, atheistic understanding of the fundamental principles of recovery. Now in its third edition, this work continues to be a valuable guide for many who struggle with the religious nature and language of AA and contains important insights for the future of the fellowship.
For these and so many icons whose careers were cut short, fame, talent, beauty, and wealth were not effective armor against the onslaught of alcohol use disorder.
The disease of alcoholism does not discriminate. If you were born with a certain genetic makeup, if there is a history of alcoholism in your family, if you experience worsening consequences of your drinking and still can’t stop…you might be one of us. And alcohol use disorder is a progressive disease that only gets worse over time if left untreated.
Since alcoholism is also a self-diagnosed and self-treated disease, you have to be willing to do the work necessary to recover. Regardless of external circumstances — wealth, status, prestige, talent, access to the best resources — if you are not willing to help yourself, nobody can. As evidence of this reality, here are eight legendary celebrities who tragically died from alcohol use disorder or alcohol-related causes.
1) Richard Burton (1925-1984)
The recipient of Golden Globes and Tony Awards for Best Actor, Richard Burton was one of the biggest celebrities of the second half of the 20th century. He was also known for his love affair with Elizabeth Taylor. Together, they starred as Mark Anthony and Cleopatra in the mega-bomb Cleopatra. At the time it was the most expensive film ever made, and its failure almost bankrupted 20th Century Fox. After playing Hamlet in a remarkable Broadway production in 1964, critics raved that Richard Burton was “the natural successor to Olivier.” Afterward, the expectations were overwhelming. Is that what drove him to embrace the bottle?
According to biographer Robert Sellers, “At the height of his boozing in the mid-70s, he was knocking back three to four bottles of hard liquor a day.” Even when drinking, Burton had an impressive career. From Look Back In Anger and Becket to Equus and Who’s Afraid Of Virginia Woolf?, he gave stirring performances time and time again. Still, his fans and critics felt there could have been so much more if not for the drinking.
In his forties, Burton suffered from cirrhosis of the liver. His alcohol intake bloated his kidneys to abnormal proportions. During an operation to relieve back pain in the early 1980s, doctors discovered that his spine was covered with crystallized alcohol. Ignoring the pleas of his friends and family, Burton’s health issues continued to throttle him until his premature death at the age of 58 from a brain hemorrhage. Although alcoholism was not listed as a cause of death, the sharp downward trajectory of his health at such a young age is considered by doctors to be a direct result of his excessive drinking.
2) Truman Capote (1924-1984)
As the writer of the novella Breakfast at Tiffany’s and the true-crime novel In Cold Blood, Truman Capote proved that a writer could become an internationally-known celebrity. Published in 1966 by Random House, In Cold Blood broke new ground in non-fiction, and served as a beacon for the burgeoning and popular true crime genre. Speaking in 1974 at the San Francisco International Film Festival, Truman Capote described his extensive research for the book: “I spent four years on and off in that part of Western Kansas there during the research for that book and then the film. What was it like? It was very lonely. And difficult.” To console himself, Truman Capote drank and drank often, alone in Midwestern hotel bars.
Returning to New York after publication, Capote became a celebrity, partying day in and day out with the richest wives of New York City’s power elite. He bragged about the brilliance of his forthcoming novel, Answered Prayers. But Capote never published another significant work in his lifetime. Instead, he drank and popped prescription pills. When an individual chapter from the now legendary unfinished book was published in Esquire magazine in 1975, it proved to be social suicide. Truman Capote was ostracized from high society for revealing the dirty laundry of the rich.
Afterward, according to Vanity Fair, “Truman appeared in an inebriated state on … a local morning talk show in New York. Taking note of Truman’s incoherence during the interview … the host asked, ‘What’s going to happen unless you lick this problem of drugs and alcohol?’ Truman, through the fog of his own misery, replied, ‘The obvious answer is that eventually, I’ll kill myself.’” Fulfilling this prophecy, he spent his final years mostly alone in his New York high-rise apartment, drinking himself into sad oblivion. On August 25, 1984, Truman Capote died in Bel Air, Los Angeles, while visiting one of his last loyal friends. According to the Coroner’s Report, the cause of death was “liver disease complicated by phlebitis and multiple drug intoxication.”
3) F. Scott Fitzgerald (1896-1940)
Like Ernest Hemingway, F.Scott Fitzgerald was a respected author and member of the “Lost Generation” of the 1920s. From The Great Gatsby to Tender Is The Night, Fitzgerald’s novels revealed the luxurious decadence of the Jazz Age. At the same time, he was one of the biggest drinkers during a notorious period of massive consumption. Later, during Prohibition, Fitzgerald’s extraordinarily heavy alcohol intake became the stuff of dark lore.
Fitzgerald and his wife Zelda pushed the limits, leading to extreme health problems that he denied were caused by alcohol. According to Nancy Milford, Zelda’s biographer, Fitzgerald’s claim of contracting tuberculosis was a beard to cover health problems caused by excessive drinking. After Zelda was institutionalized for schizophrenia, his drinking worsened. Fitzgerald’s deterioration was finally publicly revealed in “The Other Side of Paradise, Scott Fitzgerald, 40, Engulfed in Despair,” an article published by the New York Post in 1936 that exposed his excesses and their devastating toll.
Between 1933 and 1937, Scott was hospitalized for alcoholism on eight separate occasions. During this period, he also had two heart attacks. However, he would not stop drinking and even boasted of reducing his gin consumption by consuming 37 beers a day. At 44 years old, F. Scott Fitzgerald dropped dead of another massive heart attack brought on by chronic alcoholism. It’s not surprising that he’s known for saying, “First you take a drink, then the drink takes a drink, then the drink takes you.”
4) Errol Flynn (1909-1959)
The greatest action hero of his time with starring roles in Captain Blood (1935) and The Adventure of Robin Hood (1938), Errol Flynn was an Australian actor who achieved worldwide fame for his ability to play the dashingly handsome, romantic swashbuckler. In Hollywood, he had a reputation for womanizing, hard-drinking, and chain-smoking. A regular attendee of lavish parties at Hearst Castle, Errol Flynn once became so drunk that the newspaper baron had him escorted off the property. Flynn later shared a bachelor pad with actor David Niven in Malibu. The party pad became so notorious for extreme alcohol consumption that it was nicknamed “Cirrhosis-by-the-Sea.”
Flynn would take weekend trips on his private yacht, hosting parties fueled by cocaine, alcohol, and sexual misadventures. In Errol Flynn: The Life and Career (McFarland, 2004), biographer Thomas McNulty describes Errol Flynn and Fidel Castro meeting in late 1958 and drinking hard together. The encounter inspired Boyd Anderson’s novel Errol, Fidel, and the Cuban Rebel Girls (University of Queensland Press 2010). In The Last of Robin Hood (Samuel Goldwyn Films, 2013), an independent movie about Flynn’s final days, the aging actor’s sexual misadventures with a 17-year-old girl and the resulting scandal are highlighted. His alcoholism led to a spectacular failure in judgment that nearly sent him to prison.
In his thirties, Errol Flynn collapsed in an elevator and nearly died. A steady diet of alcohol had ravaged his heart, lungs, liver, and kidneys. Still, he continued drinking, injecting vodka into oranges when he was forbidden to drink on set. When he died of a heart attack at the age of 50, the medics who treated him told reporters they thought they were trying to save an eighty-year-old man.
5) Billie Holiday (1915-1959)
Born in Philadelphia to a teenage mother, Billie Holiday chose her eponymous stage name as a tribute to movie star Billie Dove and her father, jazz guitarist Clarence Holiday. Holiday suffered significant trauma as a child and later turned to prostitution, which led to an arrest for solicitation. After being released from prison, she landed her first paid performing gig, and her career took off. Unfortunately, she couldn’t stop drinking and drugging.
She and Lester Young, the saxophone legend who bestowed upon her the nickname Lady Day, toured Europe with Count Basie’s Orchestra to great acclaim. Coming back to the United States, she recorded the most haunting song in her repertoire. Based on a poem written by Abel Meeropol, a Jewish high school teacher in the Bronx sickened by a recent lynching of two black men, “Strange Fruit” is one of the most moving yet disturbing songs in American history. According to Frank Sinatra, “With few exceptions, every major pop singer in the US during her generation has been touched in some way by her genius. It is Billie Holiday who was, and still remains, the greatest single musical influence on me.”
Already a heavy drinker, Billie Holiday was introduced to heroin by her first husband, trombonist Jimmy Monroe. She was arrested for drug possession in 1947 and ended up serving ten months in federal prison. Afterward, the constant drinking made her voice rougher and more vulnerable. Her exhaustion with life was palpable. By 1959, Lady Day has been diagnosed with cirrhosis. In failing health, she was admitted to a New York hospital. Days later, Billie Holiday died at 44 of chronic alcoholism.
6) Jack Kerouac (1922 – 1969)
With Allen Ginsberg and William S. Burroughs, Jack Kerouac is known for being the progenitor of “The Beat Generation” in the 1950s, an American literary movement that continues to exert a strong influence on each new generation. From On the Road (1957), his most iconic novel, and The Dharma Bums (1958) to Big Sur (1962) and Desolation Angels (1965), Jack Kerouac’s work is autobiographical with the names of the characters changed and the events intensified. All of these novels read like they were soaked in alcohol. Jack Kerouac drank as he typed, furiously writing first drafts that were rarely revised.
When he moved with his mother in 1958 to Northport, a Long Island harbor town in New York, Jack Kerouac’s life revolved around alcohol. “The locals remember him mainly as a broke barfly who padded about barefoot or in bedroom slippers,” Corey Kilgannon wrote in The New York Times. “Emotionally fragile and beset by alcoholism, not to mention a complicated relationship with his mother, Kerouac was declining physically, disillusioned by his celebrity and growing apart from his radical friends and artistic colleagues.” In his last years, Jack Kerouac became a recluse, and his closest friend was a cheap half-pint of Schenley’s whiskey.
On the morning of October 20, 1969, in St. Petersburg, Florida, Jack Kerouac put down the breakfast of champions, stumbled into the bathroom, and began vomiting blood an esophageal hemorrhage. After several transfusions in an attempt to make up for the loss of blood, doctors subsequently attempted surgery. However, a damaged liver prevented his blood from clotting. His cause of death was an internal hemorrhage caused by cirrhosis.
7) Mickey Mantle (1931 – 1995)
A Hall of Fame professional baseball player for the New York Yankees, Mickey Mantle is considered to be the greatest switch-hitter in the history of the game. He is also remembered as one of the heaviest drinkers in the game. Despite winning three Most Valuable Player (MVP) awards and leading his team to seven World Series victories, the Mick was beset by alcoholism. Shortly after he began his Major League career, his beloved father, Mutt Mantle, died of Hodgkin’s disease at age 39. Devastated by the loss, Mickey Mantle started to drink hard to escape the memories. As he later wrote, “After one drink, I was off and running… I’d often keep on drinking until I couldn’t drink anymore.”
Mickey Mantle was loved by his teammates. Hall of Fame Yankee pitcher Whitey Ford describes him as “a superstar who never acted like one. He was a humble man who was kind and friendly to all his teammates, even the rawest rookie.” Sadly, Mickey Mantle played with injuries throughout his career that would sideline a modern player, including a torn ACL. In high school, he had suffered chronic damage to the bones and cartilage in his legs. Wracked by injuries, Mickey Mantle also drank to find relief. By the end of his career, he couldn’t even swing a bat without collapsing in pain.
When Mickey Mantle drank, he blacked out, often waking up in strange places with no idea of what had happened the night before. At the end of his career, he admitted he had a problem. After hitting rock bottom, diagnosed with hepatitis, cirrhosis of the liver, and liver cancer, the Mick checked into the Betty Ford Clinic in 1994. In a Sports Illustrated cover story later that year, he recounted the devastation that alcohol had caused in his life. After telling the same old stories about being drunk for years, Mickey Mantle realized they were not part of a comedy, but a tragedy. When he received a liver transplant, the doctors found the liver cancer had spread. A few months after receiving a new liver, Mickey Mantle, the golden boy of Major League Baseball, died on August 13, 1995, of this alcohol-related disease.
8) Hank Williams (1923 – 1953)
Considered one of the most influential singer-songwriters of the 20th century, Hank Williams is the archetype of the drunk country musician. A true hit-maker, Hank Williams recorded 35 singles (five charting after his death) that reached the Top 10 of the Billboard Country & Western Best Sellers chart. Impressively, 11 of those singles reached number one (three ranked after his death). He joined the Grand Old Opry in 1949 but his stay with the renowned Nashville country music broadcast was brief. In 1952, Williams was dismissed due to his unreliability and his alcohol abuse.
The holy grail in country music is authenticity, and Hank Williams helped define the word. He inspired generations of artists with hits such as “I’m So Lonesome I Could Cry,” “I Saw the Light,” and the classic drinking song “There’s a Tear in My Beer.” As singer Bobby Bare recounts, “Everybody I know wanted to be like Hank Williams. And everyone I know bought into the drinking. You figure if Hank did it, it must be OK.” Beyond his music, the lasting influence of Hank Williams is what the late Waylon Jennings described as the “Hank Williams syndrome.” To be authentic like Hank, you had to drink like Hank.
While being driven across the country, Williams combined chloral hydrate, a sedative, with excessive drinking, and fell into a stupor. After being injected by a local doctor with a vitamin and morphine combination, the trip continued, but Hank’s conditioned did not improve. Realizing the singer was unresponsive, his driver pulled over and discovered the worst. On New Year’s Day, 1953, at the young age of 29, Hank Williams died of alcoholism and drug intoxication while traveling to a concert in Canton, Ohio.
***
If only fame, talent, beauty, and wealth were effective armor against the onslaught of alcohol use disorder, imagine how many legendary celebrities would have had longer and more productive careers. Can you picture in your mind’s eye the Academy-Award acceptance speech of Richard Burton? Or F. Scott Fitzgerald accepting the Nobel Prize for his later work? How about Mickey Mantle breaking the record for the most home runs in a season? Unfortunately, none of those accomplishments ever materialized because alcoholism knocked each of these legendary celebrities down for the count.
“While I went to high school with casual weed smokers and worked at various jobs with weekend coke snorters, I was entirely unprepared for what I’ve seen in state prison.”
This article was originally published by The Marshall Project, a nonprofit news organization covering the U.S. criminal justice system. Sign up for their newsletter, or follow The Marshall Project on Facebook or Twitter.
I was on the phone with my wife as usual on a Saturday evening a few months ago when my prison’s P.A. system crackled and a stressed-out voice announced: “All rec yards are closed; offenders will report back to their dorms immediately.”
Something big was clearly afoot, and everyone rushed to the front windows to get a better view. People spoke in hushed voices, not the usual clowning, speculating about what might have happened.
It turns out that eight people had overdosed at once, most likely on “spice.” They passed out on the recreation yard, laid out side-by-side on the concrete while nurses and guards ran around with stretchers and wheelchairs trying to keep control and render medical assistance, in that order.
As far as I know, one of them is now dead, while seven have since recovered and were transferred to other compounds. I think the one who died only had about 30 days left on his sentence.
You can bet on two things following from that sort of trainwreck. One, the addicts in here will continue snorting and smoking anything they can find. And two, the rest of us will pay for the mess they’re making.
I guess I was a little naive when I was first locked up, thinking it must be hard to obtain drugs and get high while incarcerated. But to my shock, it was as common or more so than on the outside. (I’m probably in the minority in here because I don’t use, it’s that pervasive.) Spice, weed, Suboxone, Neurontin, Seroquel, orange peels—people try to get high on whatever they can find, everywhere I’ve been locked up, and no matter what security measures are in place to prevent it.
When I was first in the jail in Washington, D.C., inmates openly smoked “K2” while gathered in cell doorways. You smelled that synthetic stuff more often than weed or cigarettes, though those were common too. Some bothered to try and conceal it by blowing the smoke down the toilet, but most didn’t.
I would see correctional officers walk by and pretend not to notice; they aren’t paid enough to care. People knew which C.O.’s would write them up, and that was an awfully short list.
And while I went to high school with casual weed smokers and worked at various jobs with weekend coke snorters, I was entirely unprepared for what I’ve seen in state prison. These are mostly desperate addicts with little else to organize their days around besides the next fix. Getting high is their whole bid. The money they hustle up or that their family sends them, every hard-earned dime of it, is spent on drugs. All they get is small amounts of low-quality stuff, but they’ll take it. Because even at the ridiculously high prices this stuff sells for behind bars, that crummy, overpriced little piece will keep the shakes away for another day.
To give you some idea, a 16th of a strip of Suboxone (a “piece” in our parlance) can sell for $15 here, when supply is scarce. Go Google what a Suboxone strip looks like, imagine that cut in fourths, and then fourths again. It’s miniscule. And then remember that those $15 could have bought that addict 50 ramen soups from the commissary.
Even at the normal price of $5 for a piece, it’s a terrible waste. Five dollars is a lot of money in lockup.
They hustle to get it—they steal from the kitchen and sell the food, they gamble on sports or cards, they iron shirts or wash dishes, whatever it takes. Sometimes they even use sex as currency for the price of a high, or are coerced into it to cover their drug debt.
Or their families, or girlfriends, or buddies back home, are sending money, thinking it’s going toward keeping them well-fed and well-clothed. It’s likely money that was hard to come by, because most people in here are decidedly not wealthy. Rich drug abusers go to treatment, not prison.
Plenty of inmates have prison jobs, but those pay on average about a couple bucks a day—and you can’t get high too often on just that.
Most drugs only come in here in one of three ways: mail, visits, and corrupt C.O.’s.
Prison officials can take steps to block the first two kinds of smuggling, of course. Blocking the mail route is easy: Prisons are moving to give inmates photocopies of letters instead of the originals. And at visitation, they can strip-search us and make us wear embarrassing jumpsuits that zip up the back (the officers have to do that part). They also harass our visitors about what they’re wearing and their feminine hygiene products, to make sure that nothing gets in.
And then when people overdose, they lock us all down, and shake down our lockers, and take away our recreation time. They do random drug tests, and run drug-sniffing dogs through the dorms now and then.
But it doesn’t change anything. Until they pay correctional officers a decent wage, or strip-search them every day, there’ll always be a few guards who will take the risk of bringing in small quantities of drugs to sell, given the enormous paydays at stake. Again: Have you ever seen a Suboxone strip? It’s so small and nondescript, it’s like it was made to be smuggled.
The news media has reported statistics that highlight the scale of the problem: Virginia has just under 30,000 inmates spread across more than 40 facilities; they received almost two million pieces of mail in 2018 and 225,000 visits. That year, there were 562 seizures of drugs inside those penitentiaries; 57 emergency-transport runs to hospitals carrying overdose patients; six interceptions of substances coming in through the mail; four prison employees prosecuted and 13 who resigned or were fired for smuggling. The numbers say that the state is barely scratching the surface of the problem.
Meanwhile, treatment programs just don’t work in here. Prison is dismal and there isn’t much that’s positive to focus on, to keep an addict’s mind more productively occupied. The incarcerated person who is secure and self-aware enough to admit he has a problem and needs help is a rare breed.
“It’s wide open over there,” you’ll hear addicts say with glee in their voice, when they’re called to pack their belongings because they’re being shipped off to the two-year residential treatment facility that Virginia runs.
The big picture—that we incarcerate people for their addictions and then don’t give them adequate treatment—is a silent national disgrace. But it’s the little picture that I have to live with every day, that angers me and breaks my heart. It’s the individual human beings who have been failed by the system, and the often-already-poor families who are devastated even further by loved ones caught up in the cruelties of a vast enterprise.
One of my last bunkies was pitiful: a lying, scheming, thieving addict who ended up having two fistfights within hours over his drug debts and the stealing that he was doing to support his habit. He was about the worst I ever saw, snorting stuff about six times a day. “I have sinus issues,” he’d often claim with a straight face, as he fit the toothpaste cap to his nostril and threw back his head once again. One day I came back from work to find him frantically rummaging through his mostly empty locker, and crawling around on the floor.
“What’s up?” I asked, somewhat reluctant to involve myself.
“Someone stole a piece out of my locker,” he said, panicky.
This was certainly possible, since the addicts always seemed to be taking anything they could get their hands on, especially from each other. But instead I told him, “You probably just lost it,” hoping for less drama. I also pointlessly reminded him that a piece looks a lot like a paint chip, and those are everywhere.
Around that time I’d started composing a country song titled, “My Bunkie Is a Junkie,” but I found that not much rhymes with Suboxone. Now he’s in another housing unit, pulling the same stunts. Still, I can’t hate him for any of that, or for stealing some food from me to support his habit; it’s just too depressing.
That’s a mind-boggling number of human beings locked up because of their addictions, either directly or indirectly. Our response to this problem is to put them in prison, where they’ll get little to no help and have all the time in the world to sit around scheming about getting high.
I don’t have some smart solution for all of this. Just like on the street, little works for people who don’t want to quit using. But I know that most of these addicts don’t belong in here. Trying to incarcerate our way out of the problem is not helping them, and it’s not making society any safer either.
Because these people will all be out on the street again in a few years—and all they learned in prison was how to cheat and steal and hustle more creatively to get high.
Daniel Rosen, 49, currently resides at the Greensville Correctional Center in southern Virginia, where he is serving a five-year sentence for computer solicitation of a minor. He spent 15 years working for the departments of State and Defense on national security issues.
The District of Columbia Department of Corrections did not respond to requests for comment about allegations of drug use in its facilities. A spokesperson for the Virginia Department of Corrections declined to answer questions about the incident in which eight inmates overdosed.
