Alcohol Abuse

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When drinking becomes alcohol abuse

Drinking alcohol is a part of Western culture. It is almost a rite of passage and most people who drink alcohol don't get into any real trouble with it.

But some do. As individuals and as a society we need to recognize when drinking alcohol becomes alcohol abuse, so we can do something about it.

Alcohol abuse is any kind of drinking that has negative effects on the drinker or on those around him. Obviously, if your drinking leads to impairment, you are abusing alcohol. But if it leads to social, legal, employment, family or financial problems, it is considered to be alcohol abuse. If your drinking is affecting your health, you are abusing alcohol.

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Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol
ABSTRACT

Background: People who are homeless and chronically alcoholic have increased health problems, use of emergency services and police contact, with a low likelihood of rehabilitation. Harm reduction is a policy to decrease the adverse consequences of substance use without requiring abstinence. The shelter-based Managed Alcohol Project (MAP) was created to deliver health care to homeless adults with alcoholism and to minimize harm; its effect upon consumption of alcohol and use of crisis services is described as proof of principle.

Methods: Subjects enrolled in MAP were dispensed alcohol on an hourly basis. Hospital charts were reviewed for all emergency department (ED) visits and admissions during the 3 years before and up to 2 years after program enrolment, and the police database was accessed for all encounters during the same periods. The results of blood tests were analyzed for trends. A questionnaire was administered to MAP participants and staff about alcohol use, health and activities of daily living before and during the program. Direct program costs were also recorded.

Results: Seventeen adults with an average age of 51 years and a mean duration of alcoholism of 35 years were enrolled in MAP for an average of 16 months. Their monthly mean group total of ED visits decreased from 13.5 to 8 (p = 0.004); police encounters, from 18.1 to 8.8 (p = 0.018). Changes in blood test findings were nonsignificant. All program participants reported less alcohol consumption during MAP, and subjects and staff alike reported improved hygiene, compliance with medical care and health.

Interpretation: A managed alcohol program for homeless people with chronic alcoholism can stabilize alcohol intake and significantly decrease ED visits and police encounters.
CMAJ 2006;174(1):45-9

Alcoholism is well known to affect homeless people. It has been reported to affect 53%-73% of homeless adults,1-3 with a high frequency of heavy alcoholism (i.e., > 20 drinks/day).4-6 Because of its availability and low cost, nonbeverage alcohol (e.g., mouthwash) is commonly used.7,8 People with chronic alcoholism are frequent users of crisis health services such as the emergency department (ED);9,10 at one centre, alcoholism was a characteristic of 81% of homeless people who sought care.11 ED visits because of alcohol intoxication, withdrawal or its complications are recurrent.9,11 In addition, homeless people have higher rates of chronic illnesses,12,13 longer hospital stays with higher costs14 and increased mortality15-18 compared with those who have home addresses.

Police encounters are recurrent for public drunkenness.19,20 In one study,3 70% of homeless alcoholic men had a history of imprisonment.

Although treatment with detoxification and abstention ("detox") is the best option from a health perspective, the likelihood of rehabilitation among among people both alcoholic and homeless is low.6,21-25 Obstacles to sobriety include psychiatric illness, poor social support, lack of stable housing, duration of addiction and refusal of treatment.

Harm reduction is a policy to reduce the adverse health, social and economic consequences of substance use without requiring abstinence. Methadone maintenance treatment of opioid dependence, for example, is superior to detox in reducing heroin use and behaviours that increase the risk of HIV infection.26 After an inquest into the freezing deaths of homeless alcoholic men, a pattern was noted of heavy alcohol consumption before shelter entry to achieve in-shelter abstinence, followed by early-morning alcohol-seeking to avoid the symptoms of withdrawal.27 Despite the high incidence of people with chronic alcoholism dying homeless in cities worldwide, this population has been underrecognized in program development and in the clinical literature. In response, a managed alcohol harm-reduction program was developed for people with long-term homelessness and refractory alcoholism.

In Ottawa, an estimated 1000 people are chronically homeless,28 with 48%-63% having a history of alcohol abuse.13 With the city and the University of Ottawa, the Managed Alcohol Program (MAP) was developed in a harm-reduction model to deliver health services to homeless adults within the shelter system. The objective of this study was to examine the effectiveness of MAP, as proof of principle, in reducing the use of crisis services and consumption of alcohol and improving health care in a cohort of chronically homeless people with refractory alcoholism.

Methods

MAP is an ongoing 15-bed shelter-based project in Ottawa. Potential participants are referred by shelter staff, police or community workers familiar with them as being chronically homeless, having severe alcoholism (according to DSM-IV diagnostic criteria for alcohol abuse) and showing evidence of harm to self and community, and for whom abstinence-based programs had failed or been refused. Admission was arranged upon agreement of the participant, shelter staff and the program manager, a registered nurse.

Study subjects were housed at the shelter in an area designated for MAP and were provided with beds and meals. The program employed a client care worker to supervise the participants, give aid with activities of daily living, help fill out applications for social benefits, accompany them to medical appointments and dispense regular medications. Participants were given up to a maximum of 5 ounces (140 mL) of wine or, 3 ounces (90 mL) of sherry hourly, on demand, from 0700-2200, 7 days per week. Medical care was provided 24 hours per day by nurses and 2 physicians associated with the project, with daily nurse and weekly physician visits. Medical records were kept on a secured online system developed by the Ottawa Inner City Health Project.29

Program participants were enrolled into MAP and included for analysis with approval from the Ottawa Hospital research ethics board and police services. Inclusion required continuous program participation for at least 5 months by July 2002. Data for all 17 eligible subjects were included for analysis; no one left the program before 5 months or was excluded from the study. A consent and confidentiality statement was read to each person at program entry, and written consent obtained to access hospital and police records. The project was analyzed as a before-and-after study design. Charts from all 5 area hospitals were reviewed for 3 years before program entry and while participants were in the program for number of ED visits, ambulance use and diagnoses of trauma, seizures or intoxication at presentation. Hospital admissions and lengths of stay were recorded, as were blood-test markers of alcohol use. The police services' computerized database was accessed for each participant by name, date of birth and all aliases, and the number of police encounters recorded for the same period as for hospital records.

Descriptive statistics using the mean and standard deviation were used for normally distributed continuous outcomes. Average monthly rates of use of ambulance services, visits to hospital EDs, diagnoses, hospital admissions and police encounters were calculated for a 36-month period before and up to 24 months after program enrolment. Differences in outcome measures before and after program entry were assessed with the paired Student's t test. Average values for blood-test results were calculated for the 24 months before and during program enrolment for each participant, and analyzed for statistical differences.

Eligible participants underwent structured interviews about their drinking patterns before and after enrolment and their perceived health, nutrition and sleep. Participants estimated their typical daily beverage and nonbeverage alcohol consumption before program entry, which was compared with in-program daily alcohol intake averaged over the program period. Life satisfaction was measured by means of Diener's Satisfaction With Life (DSWL) Scale.30 The client care workers involved were interviewed for their observations of the participants' drinking patterns, hygiene, sleep, nutrition and medication compliance.

Results

Fifteen men and 2 women who had been homeless for at least 2 years participated in MAP for 5-24 months (mean 16 mo; Table 1). The majority were single white males aged an average of 51 years, had alcoholic parents, had started drinking in their early teens and were not educated beyond high school. Study participants had been alcoholic for an average of 35 years, with most consuming nonbeverage alcohol regularly. Typical consumption before MAP enrolment was reported to average 46 drinks per day. Most had tried detox and abstention, but were unable to maintain sobriety. Fifteen (88%) had at least one chronic medical or psychiatric illness.

For the 3 years before entry into the program, the total mean monthly number of ED visits by all participants was 13.5, a monthly mean per participant of 0.79 (Table 2). During the program, this number decreased to a group monthly total of 8.1 (mean 0.51 visits per participant), with a decreased mean monthly paired difference per subject of 0.28 (standard deviation 0.35, p = 0.004; Fig. 1). Use of ambulance services, hospital admissions and ED visits all showed a decreasing trend, as did diagnoses of intoxication, trauma and convulsion, although statistical significance was not attained. Police encounters decreased from a monthly mean of 18.1 for the group to 8.8 (p = 0.018).

When concentrations of blood markers of alcoholism recorded during the 2 years before enrolment were compared with those obtained during the program, differences in group averages were nonsignificant, as were individual paired differences (results not shown).

Three people declined to be interviewed about their drinking history, health and life satisfaction, and 3 others died before being interviewed. The remaining 11 participants all reported a markedly decreased consumption of beverage and nonbeverage alcohol, and most reported improved sleep, hygiene, nutrition and health. Paired data were available for 10 participants to compare the amount of alcohol they were consuming before program entry with the amount consumed during MAP (Table 3). Subjects noted that a typical day's consumption was difficult to estimate; most described drinking all the alcohol that was available and would drink until they lost consciousness. For all participants, the absolute amount of alcohol consumed was found to decrease, from an average of 46 drinks per day to 8 (p = 0.002). Ten participants who agreed to be administered the DSWL Scale scored a median of 22, consistent with feeling "slightly satisfied" with life.30

The client care workers interviewed all noted improved hygiene and nutrition for all participants during the program. Compliance with medication, defined as taking it as prescribed at least 80% of the time, was noted for 88% of subjects. The majority were reported to attend scheduled medical appointments.

A cost analysis was performed (results not shown). Mean monthly direct cost of the program was $771 per client, with estimated per-client reductions in the costs of ED services of $96; hospital care, $150; and police services, $201.

Interpretation

This article describes the effect of providing supportive shelter for a subset of chronically homeless people with alcoholism and providing them with institutionally administered alcohol as a harm-reduction measure. The 17 participants enrolled in MAP drank heavily and had long drinking histories. They were regular users of nonbeverage alcohols such as mouthwash, had significant medical and psychiatric comorbidities, and were frequent users of emergency, hospital and police services. Within MAP they received housing, health care and treatment of their alcoholism with doses of alcohol that were modest in comparison with their previous levels of consumption.

Police encounters decreased by 51% and ED visits by 36%, which, given the associated "unit encounter" costs ($93 and $270, respectively), offset a portion of the costs of MAP. Police encounters and ED visits were seen to increase for 2 subjects (Fig. 1), but both had been in jail or living in another province during the 2 years before MAP enrolment and their reports were not captured in the Ottawa system. Blood-test markers of alcohol use remained stable, and participants and client care workers reported improvements in health, nutrition and hygiene. Compliance with prescribed medications and attendance at medical appointments was excellent compared with what might be predicted for alcoholic individuals living without homes. Three participants died of causes and at ages that have previously been described among homeless people;15,16,18 they died of intracerebral hemorrhage, cardiac arrest and acute alcoholic hepatitis, respectively. It must be noted that MAP is intended as a program with no stop date per admitted individual; participants would be expected to die of causes that are consequences of life-long addiction.

This study had limitations. Although it may have been preferable to compare 2 such groups in a randomized controlled trial, logistical, population and financial constraints made such methodology unfeasible. Potential biases identified with the one-group pretest-post-test study design include biases of history, maturation, testing and instrumentation, as well as statistical regression to the mean. However, there has been no change in ED, police or social policies to account for the decreased use of ED and police services. Maturation or biologic changes in the participants over time would tend to bias against MAP, with expected declines in health. Pre- and post-program hospital and police encounters would not be subjected to testing bias, since external databases were used. Observations were repeated over time with no instrument decay or regression to the mean. Clinical regression, in which participants might enter MAP when addictive consequences were at their worst and therefore appear to improve, is another possible source of bias; but the addiction in this group was of a severe and long-standing nature, and severity at program entry was likely representative of overall severity.

Continuity of care among homeless people has been found to be exceptionally difficult. Shelter operators already having demonstrated cultural competence in caring for the homeless were integrated into a shelter-based medical model of care to address previously unmet needs. This served to treat vulnerable individuals in a timely manner and coordinate their care, which allowed timely discharge from hospital. Police in frequent contact with people repeatedly inebriated in public have the opportunity to refer potential program participants to MAP and address a need within a system otherwise obliged to repeatedly process minor offences and bring people in for overnight detox in a police cell. Program development is ongoing for preventive care against infections such as tuberculosis and hepatitis and for administration of HIV tests and immunizations. For people whose drinking pattern has stabilized in MAP, psychiatric evaluations and follow-up have been successful.31 Finally, the option to detoxify from alcohol is always presented; once stabilized in the program, a few participants have successfully been medically detoxified and received housing, a formidable accomplishment considering the severity of an on-average 35-year addiction in which subjects drank daily to unconsciousness. This appears attributable to tempering alcohol consumption in a safe environment, which makes alterations of behaviour, including detoxification, possible.

In one large study,32,33 mentally ill homeless people in supportive housing had decreased shelter use, incarcerations, admissions to hospital and lengths of hospital stay. In another study,24 only 20% of people with case-managed alcoholism were able to maintain housing. Although housing is immensely beneficial for health, it is difficult to maintain without appropriate skills. Part of the success of MAP has likely been due to the supportive housing provided, but housing alone would not have prevented alcohol-seeking, consumption and the harm therefrom.

MAP is an innovative program based on a harm-reduction model that, when evaluated in a small group, appeared to be effective in decreasing alcohol consumption and the use of crisis services. Those responsible for the well-being of homeless people should consider the implementation and prospective evaluation of programs that integrate health services within shelters using a harm-reduction strategy.

Editor's take

* Homeless people with severe alcoholism are frequent users of health care services, especially the emergency department, and have high rates of hospital admission and death. Treatment programs involving abstinence rarely succeed.

* Based on a framework of harm reduction, this homeless shelter program dispensed alcohol on an hourly basis to alcoholics in the shelter.

* Program participants consumed less alcohol, visited emergency departments less often and had fewer police encounters. Staff and clients reported improvements in hygiene, general health and compliance with medical care.

Clinical implications: Harm reduction is now a mainstream approach to drug abuse. This pilot project demonstrates that the strategy may be successful even in this very-difficult-to-treat group of longstanding homeless people addicted to alcohol.

REFERENCES
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32. Culhane DP, Metraux S, Hadley T. The impact of supportive housing for homeless people with severe mental illness on the utilization of the public health, corrections, and emergency shelter systems: the New York-New York initiative. Washington: Fannie Mae Foundation; 2001. Available: www.fanniemaefoundadon.org/programs/pdf/rep_culhane_prepub.pdf (accessed 2005 Nov 16).
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[Author Affiliation]
This article has been peer reviewed.
From the Inner City Health Project, University of Ottawa, and the Department of Medicine, Ottawa Hospital (Podymow, Turnbull); the Clinical Epidemiology Program of the Ottawa Health Research Institute and the Department of Medicine, University of Ottawa (Coyle); the University of Ottawa (Yetisir); and the Department of Epidemiology and Community Medicine, University of Ottawa (Wells), Ottawa, Ont.
Competing interests: None declared.
Contributors: Tuna Podymow, Jeff Turnbull and George Wells contributed to the study conception and design, and the data acquisition and analysis, and drafted and revised this article. Elizabeth Yetisir did the statistical analysis, and Doug Coyle, the cost analysis. All of the authors approved the final version and support the findings of the study.
Acknowledgements: We are indebted to the following for their assistance: Pat Hayes, superintendent, Emergency Operations Division, Ottawa Police Service; Vela Tadic, who helped with data management; and Wendy Muckle, Director, Ottawa Inner City Health Project.
This work was supported by a grant from the Human Resources Development Corporation, Government of Canada, for the Inner City Health Project.

The form of the drinking does not matter; that is, it could be moderate social drinking, heavy regular drinking, binging or addictive drinking. Whether your alcohol use should be considered alcohol abuse depends entirely on the effects of your drinking. Those effects could be poor judgment, memory lapses, deteriorating social skills, interference with job, deteriorating health, interference with education or a chaotic family life.

How does this play out in real life?

In my own case I have an allergic reaction to alcohol in any form and in any quantity. So for me a glass of wine once a week would be alcohol abuse, because it would have a bad effect on my health. So I don't drink anymore.

For someone else, it might not be a problem at all to have a daily glass or two of wine with dinner or a beer on coming home from work. It all depends on the effects.

Let's look at some examples of alcohol abuse.

A man is periodically absent from work because of hangovers. He is abusing alcohol, because his drinking is affecting his work. He has an alcohol problem even though he may never drink on the job.

If there is money to buy alcohol, but not enough to buy needed groceries, there is alcohol abuse.

If alcohol leads to domestic violence, it's alcohol abuse.

If drinking leads to impaired driving, it's alcohol abuse.

The above examples are pretty obvious. Let's look at an example of alcohol abuse that is not so obvious - that of the student drinking on weekends.

A good memory is critical to being a successful student. But what if the student's memory were affected by going out for a few drinks on Friday night? Then it would be alcohol abuse.

Recent research has shown that a relatively small amount of alcohol consumed on Friday night wipes out the student's memory for much of what he learned on Thursday and Friday. Since so many students drink on weekends, one cannot help but wonder how much more effectively they would learn if they simply abstained.

You get the picture. Whether drinking has become alcohol abuse is determined entirely by looking at the effects of the drinking - socially, financially, professionally, educationally, mentally, legally, family-wise and health-wise.

If the effects of your drinking are turning negative, it is time to do something about it. Do it before you spiral downwards into low self-worth, shame, failure and unhappiness.

Alcohol is the root cause

Dear Editor: After reading Dr. Paul Wilson's article "Suicide or Genocide in Nain?", which appeared in The Western Star on Tuesday, July 18, I felt a need to respond.

The Oxford definition of `genocide' is "the deliberate extermination of a race of people". This isn't the case here. On the one hand, I appreciate Dr. Wilson's sympathetic view. Aboriginal people across Canada, including the Labrador Inuit, were unfairly and unjustly treated and abused. I, as well as Dr. Wilson, see the need to educate thousands of people who do not know aboriginal history and therefore do not understand how European contact created huge underlying problems for many aboriginal people.

I won't go into detail. On the other hand, sympathy and pity from others, including many in our own group, need to end. In saying this, I wouldn't wish for anyone to undermine the negative impacts of our history. But we have to stop looking and living in the past and realize that ours is a problem about the present. I wish that the mind-set that we are still an unjustly, unfairly treated people stop.

As long as we keep adopting this view, we are keeping ourselves victimized thus preventing any kind of healing. Articles like Dr. Wilson's, while they educate the outside population, perpetuate within our own group the idea that we are victims. In wanting to abandon this mind-set, I am no implying that governments need to forget their obligations. But in order to come to terms with the real problems, we need to deal in the present. For the problems in Nain right now, we, as residents, need to accept responsibility and accountability for the situation in our town. It's time we held ourselves responsible for the actions of this town and it's time we held ourselves accountable for the outcome. For many people, these statements will be difficult to hear and accept, because it is always easier to shift the blame to someone else and cast aside responsibility and accountability. Others will agree with some statements and have been and still are acting towards creating a healthier community.

I would like to comment on some of Dr. Wilson's statements:

"What we have left in Nain is a society deeply wounded and stripped of the means of healing itself; a once proud culture reduced to despair." `A society deeply wounded' - yes, `stripped of the means of healing itself' - no. Healing must come from within. Who will heal us if we don't do it ourselves?

`A once proud culture reduced to despair'? Are we, as a culture, reduced to despair? I don't believe so. I think that our town is in despair, but as a culture I believe we are still proud.

"In these cases, we also like to wash our hands by pointing to alcohol abuse as the major contributing factor. It is a convenient self-deception." I disagree. I believe that alcohol is the major contributing factor. It many not be the major underlying factor, but it is most definitely the major contributing factor. There are other underlying problems, but how can those problems be faced, how can the people come to terms with their own problems if they bury them with alcohol? Alcohol abuse will keep problems buried, and in that sense it is the major contributing factor. If people didn't abuse alcohol, they might attempt to look for solutions to their problems, instead of adding to them in paramount proportions. And they wouldn't be passing those problems down to their children. I don't mean to sound naive by saying that cutting alcohol out of the equation will solve all of the problems, but it certainly would be a step in the right direction.

"Is there any hope? I wish I could respond positively to this question. I know that the option of returning to the past is not possible. I am quite sure that the Inuit do not want to go back living a nomadic existence. But there will be no healing in Nain or elsewhere until the Inuit regain their economic freedom, until they reconnect to their own spirituality, and consequently develop an image of themselves that will engender pride and not despair." I agree that the option of returning to the past is neither realistic nor desirable. However, Dr. Wilson has it the wrong way around. Instead of waiting to regain economic freedom (if there even is such a thing) and reconnecting to our own spirituality in order to develop an image of pride, we should be working on improving our self-image right now. How can Inuit reconnect to their own spirituality when there is so much alcohol abuse? `Regaining economic freedom and reconnecting to our own spirituality' isn't the ultimate solution to our problems, though I do realize that it is very positive. I hate to sound cynical but while we are waiting for all of this good stuff to be worked out, we still have too many people abusing alcohol and on their way to becoming alcoholics. What we have to do is ban alcohol from our community. Perhaps by doing this, we will pave the way to `developing an image of ourselves that will engender pride and not despair'. This has to come first.

Suicides happen, in large part, because people have lost hope. And there are other people out there on the way to a similar fate. They need to be shown by the people, the leaders, the elders in our community that life is worth living. This is where alcohol can be cut out of the equation. As Inuit, we need to realize that if who we are as a people is important to us, then we have to be the ones to make the change. We need to start passing down our culture, language and traditions to our children instead of passing on the problems that ensue with alcohol. That's why we're losing our culture, because we have forgotten what's important.

No one can deny the hurt, pain, and anger caused by contact with Europeans and everything which that entailed, but look at the damage that those unresolved emotions are now inflicting upon our community. No one can deny the pain and confusion caused by the dominant white society when they put down our culture and language and punished children for speaking their language in places like residential schools. However, if we continue in this destructive path of victimization, we will lose our culture and language forever.

Saying that alcohol is a factor in many of these deaths, but that the abuse of alcohol itself has its source in the deep despair of the community almost excuses alcohol abuse. It brushes off alcohol abuse saying it's a symptom. But symptoms have to be treated too. Alcohol abuse may be a symptom of the older generation, but for the younger generation, it is probably the single biggest problem. Considering the state of our town, it's time we had zero tolerance to alcohol. If we want real change in our community, then we must be prepared to make the effort. We have to stop pussyfooting around. We have to stop tolerating drunkenness and consequently abusive behaviour - physical, sexual, verbal, and emotional. Our leaders must realize that condoning the presence of alcohol in our community and tolerating abusive behavior negates the power of leadership.

There is talk of a plebiscite since the Steering Committee of the Ulapitsaijet (Listeners') Report, which has representation from every local group and organization, was formed. This is a great step in a positive direction. I think banning alcohol from Nain requires all of the leaders to join forces in promoting a dry community. Will this happen? I don't know. It depends on how important a healthy community is to those people. Are we willing to make sacrifices for the betterment of the community?

Have parents listened to the voices of their children in our Ulapitsaijet Report? It will be very interesting to see the result of the plebiscite. What is more important to the people of Nain, alcohol, or a healthier, safer environment for everyone? The outcome will show not only the residents of our town but our whole country what we are willing to do for ourselves. How can we expect help from other sources if we're not even prepared to help ourselves?

No on said that there would be any easy answers, no should we expect any. If we did ban alcohol, I wouldn't assume to know how best to proceed from there, but at least we would have a starting point from which to aim for a better quality of life. To aim for a better quality of life for the children of Nain and all of its residents, I will support the plebiscite and give up alcohol. We have nothing to lose and everything to gain.

Lonesome elderly prime candidates for alcohol abuse

After her husband died from Alzheimer's disease, the 73-year-old woman confined herself to her home.

Her only contact was with the driver of the Dial-a-Bottle home delivery service who kept her supplied with the liquor she drank in ever-increasing amounts.

By the time authorities found her, Rose - not her real name - was suffering severe malnutrition and dementia - a condition that causes mental confusion, said Marilyn Wright of Victoria.

Wright is co-ordinator of the Victoria Innovative Seniors Treatment Agency, or VISTA, an alcohol treatment program designed to meet the needs of the elderly.

She said Rose is typical of the older people counselled by VISTA.

"The majority of our clients are women 67 to 75 years old who are suffering from loneliness, grieving after the death of a spouse or are separated from supportive family members and friends."

Many of these women, when it came time to retire, moved with their husbands to the balmier climate of Canada's West Coast from the harsh weather of the Prairie provinces, Wright said.

"When their spouse dies, they're thrown into isolation and they turn to alcohol for solace," she said. "Most were only social drinkers during their earlier years and were able to handle an occasional glass of hard liquor or wine."

However, as people get older and their bodies change, they can't metabolize alcohol as effectively, said Wright. In addition, alcohol is a depressant that can interact with prescribed medications; this can lead to falls, or make an older person appear confused.

VISTA was started in January 1989 with a $320,000-a-year grant from the drug and alcohol branch of British Columbia's labor ministry.

To be eligible for the program, clients must be 55 or older and be referred by medical professionals, homemakers, agencies, friends, family or other people affected.

The VISTA team includes counsellors trained in social work, psychiatric nursing and psychology as well as a medical consultant who specializes in geriatric medicine.

Wright said there have been more than 300 referrals to VISTA in the last year. Currently, 175 clients are in active treatment.

She said that too often family and friends may attribute an older person's unnatural slowness or confusion to dementia rather than alcohol or drugs.

In Rose's case, when she received counselling and the support she needed and the alcohol was removed, the so-called dementia as well as the malnutrition disappeared and her life improved.

"Sometimes doctors unwittingly view the side-effects of drug and alcohol abuse as signs of normal aging," Wright said.

"Doctors don't seem comfortable talking to their elderly patients about alcohol abuse."

In fact, some VISTA clients have been prescribed "a drop of brandy" at bedtime to help them sleep.

Wright said most VISTA clients are assessed and treated in the privacy of their homes, "or when necessary in either acute or chronic-care settings."

A small number can be treated in group therapy sessions.

Wright said anyone who suspects an older family member or friend has a problem with drugs or alcohol, should watch for these signs:

Sallow skin.

Yellow or bloodshot eyes.

Increased incidence of infection.

Abnormal bleeding.

Water retention in hands and feet.

Gastric disturbances.

Cigarette or other burns on hands, chest or clothing, furniture or carpet.

Bruises, especially at furniture height and backs of hands.

Excessive smoking.

Changes in sleep patterns, especially insomnia.

Little or no appetite.

Nesting - a favorite chair with a table to hold ashtray, drinks, etc., where one can sit and drink, usually facing the television.

Unkempt personal appearance.

Slovenly surroundings.

Persistent financial difficulty.

Frequent hand tremors.

Moodiness and mood swings; outbursts of anger or tearfulness and helplessness.

Teenage alcohol abuse is preventable

What is alcohol abuse? It's drinking recklessly, without regard for potential dangers. Some examples of alcohol abuse are: Drinking to get drunk; chugging beer; downing shots; daring one another to drinking contests; and drinking then driving, which places other people in danger as well as the drinker.

In my research, alcohol is the No. 1 drug problem among teenagers. There are millions of teenagers suffering from drinking problems. Their troubles range from arguments with parents and friends, to legal and health problems. But teenage alcohol abuse is preventable.The first step is understanding why young people abuse alcohol.

Here are some reasons: Adolescence, the bridge between childhood and adulthood, is often a difficult time. The pressure adolescents are under is apparent in their answers to the question, "Why do you drink?" For example, they say they drink to assert independence. Drinking is seen as adult behaviour. Another reason is to help overcome nervousness. Most teenagers want to fit in with a crowd and be popular. Many times, however, they feel insecure and shy. Alcohol helps loosen inhibitions and makes them feel relaxed, witty and popular.

Teens may abuse alcohol for excitement. Young people often feel they are indestructible. As a result, some drive cars too fast, challenge each other with dares and drink too much.

Others drink to rebel and disobey authority. They are ready to fight any rules. When adults say "don't drink," these adolescents believe they must do the opposite.

Alcohol abuse can have harmful results. It can affect a teenager's life in many ways -- socially, educationally and physically.

There are strategies to prevent alcohol abuse. (Teenagers who feel good about themselves don't need alcohol to feel good. If they do decide to drink, they are less likely to abuse alcohol.)

Encourage teenagers to develop these positive qualities: Self- reliance, self-discipline, optimism, direction, responsibility, self- esteem, ambition and confidence. Openly discuss the problem of teenage alcohol abuse. Teenagers who understand the facts are less likely to be swayed by peer pressure. Also try to teach skills that will be useful for a lifetime. Encourage wellness, that is, a "whole person" approach to health. This means respecting one's body (and mind) and treating it well.

Emphasize: Good nutrition, rest, exercise and no harmful habits. It helps to provide alternatives, such as activities that bring teenagers together in a non-alcoholic setting. I find one of the biggest complaints teenagers have is that "there is nothing to do." You can help deal with this complaint by providing recreational activities, especially those that teenagers can organize and run themselves. Some ideas are: Dances, hobbies, crafts, sports, trips and outings and possibly plays or musicals. Help teens help others. Teenagers who are interested in helping others can offer peer group discussions or teach elementary and junior high school students about alcohol.

Support community based efforts to combat alcohol abuse. Find out what you can do to help. Participate actively and make a financial contribution if you can. If there is no prevention program in your community, start one.

Counselling services: These may be public, private or part of your local mental health services or school department. These services, which are important to treatment of alcohol problems as well as prevention, need your support.

Law enforcement programs: Your local police department and highway safety personnel may offer educational programs on topics such as drinking and driving. See that these programs get the publicity they need.

Special groups: For more information, contact AA, AL-Anon family groups or ask your family physician. You can do something to prevent alcohol abuse. Talk with and listen to your teenage children, help them develop the strength to stand up to peer pressure, offer social and recreational activities that are realistic alternatives to alcohol, and examine your own values and attitudes toward drinking and the example you set. With your help, teenagers can have fun without using alcohol!

Psychotherapy is one of a series of health-related columns which appear on a rotating basis in Monday's Spectrum.

Sometimes parents discover that their teenager has a drinking problem from a teacher, police officer or even a friend. In Living With Your Teenager (McGraw Hill), author Marlene Brusko describes six signs to watch for:

FAIRLY SUDDEN ONSET OF PROBLEMS WITH SCHOOL:

A student who is high from morning to night will hardly hear what goes on in class, let alone study.

ALMOST TOTAL BREAKDOWN IN COMMUNICATION WITH PARENTS FOR NO OBVIOUS REASONS:

Teenagers who are drug abusers do not respond positively, despite concerted parental efforts to efforts to communicate with him or her.

SUDDEN CHANGE IN FRIENDS:

Teenagers often change friends, but usually these changes involve individuals, not types of friends. A new association with a very different group of friends could signal a drug problem.

SEVERE MOOD SWINGS:

Some mood swings are normal with teenagers. But if your son or daughter is bright, bouncy and helpful one day and the next swears at you, refuses to do the dishes and won't come out of her room for dinner, you may be dealing with an abnormal mood swing. Too many severe mood swings are another sign of alcohol abuse.

CHANGES IN EATING AND SLEEPING HABITS:

A teenager who suddenly decides that staying up all night is cool or who goes from raiding the refrigerator every hour to barely eating anything may also be showing signs of drug or alcohol abuse.

Early risers may suddenly start sleeping half the day and getting up tired. Insomnia and sleeping too much are also signs of depression, as is loss of appetite. But they can also point to drug or alcohol abuse.

OTHER CHANGES IN BEHAVIOR:

Some people are normally a little paranoid or secretive. But if this isn't true of your adolescent, the onset of such behavior is another sign.

An adolescent who is neat and conscientious about his or her appearance may become slovenly. An energetic, involved young adult may become morose and lethargic.

Each of these signs can indicate other problems - either serious or normal. However, if your teenager shows a number of these signs, the chances of drug or alcohol abuse are good. If you suspect a problem, you should ask school administrators and teachers directly whether your child is part of the alcohol or drug culture at school or ever appears high in class.

The consequences of alcohol abuse

Francis McIntosh, 46, of 99 Third Ave. pleaded guilty to impaired driving and was sentenced to 21 days in jail and prohibited for six months from operating a motor vehicle anywhere in Canada. He was also placed on probation for four months and ordered to participate in any counselling, treatment or program recommended by his probation officer to deal with alcohol abuse in relation to driving.

Allen E. Davis, 52, of 195 Raglan Rd. pleaded guilty to impaired driving and was fined $900 and prohibited for three months from operating a motor vehicle anywhere in Canada. He was also placed on probation for three months and was ordered to participate in any counselling, treatment or program recommended by his probation officer to deal with alcohol abuse in relation to driving. The results of Davis's breath analysis showed that he had more than three times the legal limit of alcohol in his system when police arrested him, their attention drawn by his rapid acceleration on a green light.

Robert J. Hall, 32, whose last address was on Adelaide St., pleaded guilty to assault and disobeying the condition of his recognizance of bail that required him not to initiate any contact with his victim. Because he has been in custody awaiting trial since Sept. 25, Hall was given a suspended sentence on the assault, was placed on probation for two years and was ordered to stay away from his victim. He was also ordered to continue therapy to deal with his agression and to participate in any counselling, treatment or therapy recommended by his probation officer for alcohol abuse. He was sentenced to one day in jail for disobeying his bail condition.

High cost of alcohol abuse

I commend Karl Barden's views on alcohol abuse and condemnation of proposals put by a government committee investigating Ontario's liquor laws (March 20).

Alcohol abuse is costing Canadians an enormous amount of money. However, there is an even greater cost: the loss of life, injuries, and destruction which result from alcohol abuse.

The proposed measures increase the visibility and accessibility of alcohol and this can only hinder efforts to educate ourselves on the dangers of the drug.

Impaired driving continues to be a major problem in Canada in spite of somewhat weak attempts by governments to provide stiffer penalties.

I am annoyed by court cases in which the accused has been acquitted or given a light sentence because he was too drunk to understand his rights, or because the breathalyzer was not applied properly, or because the accused has a past history of being a law-abiding citizen. Our justice system is failing in its obligation to deal with crime involving alcohol abuse.

Canadians have a responsibility to deal with this issue. In our system, reform can only come about if we make our opinions known.