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The following letters are reprinted with the permission of the Salem Evening News

Dear Dr. Levy:

I have heard that one line of cocaine can lead to addiction. But I know many people who have used cocaine and never got addicted. What is the truth and can using a drug one time lead to addiction? Thanks.

You ask a great question and let me share with you some information about this. In general, most people who have tried drugs do not get addicted. Research has shown that for most drugs, more than half of these people did not continue to use the drug in the year following their first use. For example, after first using heroin, 69% of the people no longer used it and 75% of people who used crack cocaine did not continue to use it. In fact, alcohol and marijuana were the only substances in which the majority of people who tried these drugs continued to use them in the year following their first use. In particular, 71% of people who used alcohol continued to use it and 52% of people who used marijuana continued to use it. It is also clear that most people did not get addicted to the drugs, and the highest rates of addiction occurred with heroin (13% got addicted), crack cocaine (9%) and marijuana (6%).

That being said, while most do not become addicted or even continue to use the drug with the exception of alcohol and marijuana, there is a danger of addiction when using any drug, and a person never knows for certain whether addiction may result. And quite obviously, if a drug is never used, a person will never get addicted to it. In addition, excluding addiction, drug use carries many other risks, so because a person doesn’t get addicted does not mean that there is no risk to using drugs. These risks include overdose, legal problems, physical problems, and even death, to name just a few. So in summary, while most people do not become addicted after using cocaine or other drugs, addiction is a risk, along with many other potential problems.

Dear Dr. Levy:

My son is 39 years old. He has just completed a 3 day detoxification for alcohol abuse. He also has a drug problem which he takes Methadone for, 40 Milligrams everyday. He has been feeling anxious and nervous since coming out of the hospital. He saw his physician, who is giving him Zoloft, once a day. He started this about a week ago. He is still feeling anxious in the morning and it seems as tough when he takes his Methadone it helps. He just wants to know how long does it take for the effects of withdrawing from alcohol to subside.

In general, withdrawal from alcohol is a 4 day process, though some need somewhat longer and others need somewhat less time. The detoxification and the medications given are based upon signs and symptoms of withdrawal. So at this time, I don’t believe that his feelings of anxiety are alcohol withdrawal. That being said, there can be a protracted withdrawal from alcohol where someone's sleep may be off for quite some time. However, feelings of severe anxiety and nervousness related to withdrawal should not be continuing.

It is possible that his feelings are not related to alcohol withdrawal but perhaps due to some kind of anxiety disorder. It is also possible that these feelings could be a side effect from the Zoloft. Also, I hope that he has not been taking another kind of drug such as some kind of benzodiazepine as withdrawal from that kind of drug can last from 7-10 days, and withdrawal can cause anxiety. So in answer to your question, a withdrawal from alcohol is generally a 4-day process, although it can sometimes last a little longer. His feelings of anxiety can be caused by a variety of different things, and I would encourage him to speak with his doctor about this. If I can be of further help, please contact me again.

Dear Dr. Levy:

I stopped drinking and drug use about one month ago and started going to meetings. To tell you the truth, I don’t like them (and never did), but my wife is insisting that I go so I have been. She says that going to meetings is the only proven thing that works. As I said, I don’t think I get anything from them and I am wondering if you think I should continue. Is AA really the only thing that works? Thanks.

Let me first say that it is wonderful that you have made the decision to stop your drinking and drug use, and work hard to continue on that path. Now, without knowing the specifics of your situation let me offer the following:

First, AA can be very useful and it has helped many, many people. Clearly, AA has been the life saver for many people who struggle with alcohol and drugs. The sheer number of AA meetings and the people who attend says something very powerful. Because of this, I often recommend that people at least check out some meetings to see if they can find benefit. Without going, one will never know and I typically suggest that people can attend several meetings per week for at least one month in order to make a true assessment if AA is for them. That being said, there are also many people who have achieved abstinence and gotten their lives together and have never been to an AA meeting. There are also people like you who have attended AA, but they never connected to the program or its philosophical approach and they stopped going to meetings. So it is my opinion that while AA is invaluable for many, it is not right for everyone.

In addition, it is not proven that AA is the only thing that works. There are many different kinds of treatment that are effective and people need to find the one or ones that work for them. As I often state, everyone is different and people require different kinds of treatment. There are many different paths into recovery and people need to find the path that suits them best.

So in your case, if you have given AA a fair shot, and it doesn’t fit with you, I do not think it is essential that you continue to do this. You should, though, think of what kind of support may be helpful. Perhaps some individual counseling might be a better fit for you. There is also another kind of self-help program that is very different than AA, called SMART Recovery. This program is very different from AA in terms of philosophy and approach, and this may be a better fit for you. A search on the internet can give you all the information you need about SMART Recovery. Their website is www.smartrecovery.org. I wish you the best and feel to re-contact me with any further questions.

Dear Dr. Levy:

Are there medications that can be used to help a person who is quitting methamphetamine? I know someone who struggles with depression when he stops and I am wondering if an antidepressant can be helpful. Thanks.

You ask an interesting question and like your friend, many people struggle with feelings of depression, fatigue, and a lack of pleasure when they stop using methamphetamine. As a result, some research has tried giving such people antidepressant medication to help with these feelings and to help them to achieve abstinence. Unfortunately, to date, none of this research has shown benefit. I am aware of research that has used Paxil, Prozac, and Zoloft, and thus far, these have not been helpful. In fact, some of the side effects of these medications may have had negative effects as people who were not prescribed this medication did somewhat better.

As a result of these studies, researchers have recommended that such people not be given these kinds of medications unless the person truly has a separate depressive disorder. This research also suggests that the etiology of feelings of depression that result from methamphetamine withdrawal differ from those of primary depression.

In summary, at this time, antidepressant medication has not been found to be beneficial for the treatment of methamphetamine dependence. However, psychosocial therapy can be helpful and one practice specifically developed to help people who struggle with methamphetamine use that has shown benefit is called the Matrix Model. If your friend is not in therapy, I would encourage this, in addition to his attending some self-help meetings.

Dear Dr. Levy:

Can you tell me the most widely used illicit drug used by kids? Thanks.

Research has shown that in looking at past month use, the most widely used illicit drug is alcohol, which about 30% of 8th, 10th, and 12th graders reported using in the last 30 days. And this reflects a drop from 35.5% six years ago. The other most prevalent illicit drug of use is cigarettes. Past month use of cigarettes was reported by 13.6% of youth, and this is also a drop from 6 years ago, when it was 20.2%. The other widely used drug is marijuana, which was used by a total of 12.4% of youth in the last month. And this also reflects a drop from 16.6% six years ago.

This is all good news, but unfortunately these numbers are still high. But even of greater concern is the use of prescription drugs, such as Vicodin and OxyContin, which has shown no decrease and is holding at steady levels. Just to give you an idea of the extent of this problem, among 12th graders, slightly over 15% reported using these drugs within the past year. So while we are making headway in the prevention of drug use, we still have a way to go. So in answer to your question, alcohol is the most widely used illicit drug among youth.

Dear Dr. Levy:

I have a brother who is, and has been, an alcoholic for many, many years, and my husband has an uncle and cousin who are recovering alcoholics on his side of the family. My question to you is what are the chances of my children becoming alcoholics? Is it greater because we both have them in our families? Also, my children are only 8 and 5, but are there signs that we should be looking for? I realize the importance of discussing the dangers of substances, but if you have an addictive personality I think I would need to do more. I have seen and lived the pain and sadness of dealing with alcoholics and I don't ever want to go through what my parents have been going through for so long. Any advice you have would be very helpful. I appreciate your advice.

In general, as there is a genetic vulnerability to develop an alcohol problem, your children are at a somewhat higher risk, but that does not mean that they will become alcoholic as alcoholism is determined by many things including genes and heredity, one's psychological makeup and value system, and the environment in which a person lives. Within a family, alcohol often are present in some members, but not others, which is the case with you and your husband’s families. In looking at children of alcoholics, research has shown that children of alcoholics have a fourfold increase of developing alcohol problems compared to people who do not have parents who are alcoholic. So if alcohol problems affect 7-10% of people, their chances are more like 28-40%. But again, there are so many other factors that play a role other than genes.

I think the best protective factors to help children not turn to alcohol or drugs is having a positive caring relationship with them, which needs to continue into their adolescent years. In addition, as your children get older, it is important to talk with them about the dangers of using drugs and alcohol and to know who their friends are and what they are doing. Take an interest in them, spend time with them, and do what you can to ensure that they are involved in extracurricular activities that they enjoy. There is more I can say, but hopefully that gives you some ideas. While doing this will not guarantee that your children won’t turn to alcohol, it is still the best way to protect against this.

Some early signs of potential and eventual problems with substance use are youth's acting out and hyperactivity, temper dyscontrol, an inability to sooth oneself, and a general heightened level of agitation. Research has shown that these traits, which I will refer to as neurobiological vulnerabilities, exist among individuals who may eventually develop alcohol or other substance use disorders. This is not to say that all people who develop substance use disorders have these vulnerabilities nor does it mean that people without these vulnerabilities will never develop a drug use disorder. However, this is a risk factor. I hope this helps and if I can be of further help, please contact me.

Dear Dr. Levy:

Can you recommend a rehab program for my husband who has had a drinking problem for many, many years? He is finally ready to do something about his drinking and I want him to go the best program possible. We are even willing to pay for his treatment. Thank you so much.

Recommending a specific treatment program is difficult because I cannot say with certainty that one program is better than another one or that one program has demonstrated the best treatment outcome by following their clients post-discharge and monitoring how they do in terms of maintaining abstinence. In truth, there are many programs that offer competent care and if your husband is ready to address his drinking, there are many programs that can be of assistance and can help him to build a foundation for his recovery. It is also very hard to find differences in treatment outcome between programs as there are so many factors that play a role in treatment outcome, with the most important reason being the client and how ready the person is to change. With that being said, let me say a few things.

First, I am not sure if your husband’s drinking has been so heavy that he first needs to be medically detoxified. If he does, this must be the first step and when contacting a program, ensure that the program he contacts offers detoxification as well as further rehabilitative care. Second, while you are willing to pay, if you have health insurance, you can first find out what programs your health insurance company offers as those programs may easily be able to meet his needs. You can certainly spend your money, but the care he receives may be no better. Third, whatever program you contact, you should get a good feel about the program right from the initial phone call. You can ask them about what medication protocols they use, whether they include family members in treatment, the kinds of groups and clinical treatment they offer, how often patients meet with their clinician or case manager, and if they offer recreational opportunities. This may assist you in getting a feel for a particular program. It is also important that wherever your husband goes that he feels comfortable there. While addiction cuts across all people, he may feel more comfortable in one program as opposed to another based upon the people who are being treated there and the type of facility. If a program doesn’t feel right to him, he could leave treatment early, which obviously would not benefit him. Finally, after he gets discharged, it is important that he continue in some kind of outpatient care, which will be set up prior to him leaving the program.

As I previously stated, you can speak with your insurance company. However, another great website sponsored by the Substance Abuse and Mental Health Services Administration is findtreatment.samhsa.gov. On this website, you can click on facility locator and it lists many treatment programs across the country by state and type of facility. I hope this helps. If I can be of further assistance, please contact me.

My son was recently diagnosed with attention deficit disorder and a stimulant medication has been recommended to him. I have heard that this kind of medication is addicting and I wonder if he should take this. I guess my question is whether taking this medication can lead to his getting addicted to it or could taking this medication lead to him eventually developing an addiction. Thank you so much.

This is a question that many parents worry about and let me share with you what I know about this. First, if your son has attention deficit disorder, stimulant medication may help him to better concentrate and attend. It should not cause addiction as this kind of medication would have a paradoxical effect with him. Instead of speeding him up, it may actually slow him down and again, help him to better focus.

In regards to whether taking this medication can lead him to eventually develop an addiction, a recent study followed youth, ages 6 to 17, with attention deficit disorder for 10 years. Some of these youth were prescribed a stimulant medication and others were not. This research found that there were no differences in the rates of alcohol, drug, or nicotine use disorders between these two groups of people. That is, being treated with this kind of medication did not increase or decrease the chances of eventually developing an addiction. So, it appears that youth who are prescribed such medication for attention deficit disorder do not have an increased chance of developing an addiction to drugs than youth who were not prescribed such medication.

Dear Dr. Levy:

My boyfriend, whenever he drinks, gets real angry and we usually end up in a fight. It seems to change his personality and he just gets nasty. I have told him he has a drinking problem, but he says he doesn’t. He says that he doesn’t drink that much (and he doesn’t drink that much) and he usually only drinks on weekends. Do you think he has a drinking problem? Thanks.

When I evaluate whether a person has a drinking problem, an important point to consider is what occurs when the person drinks and whether the person or others suffer harmful consequences due to the person’s use of alcohol. In this regard, while how much and how often the person drinks is relevant, what is more important is the quality of the drinking and what happens when a person drinks. From what you report, it sounds like your boyfriend’s drinking is causing problems as it changes how he acts and consequently, his drinking is a problem. It is certainly affecting you and your relationship with him.

Perhaps you can try to talk with him when he isn’t drinking and to let him know how much you care for him, but you have noticed when he drinks, he acts differently and that you are concerned about this. I would not tell him he is alcoholic, but rather that you are concerned about his drinking and how it affects your relationship. Maybe if done in a caring way, he can hear what you have to say and this will enable him to look at his drinking. I wish you the best and if I can be of further help, please contact me.

Dear Dr. Levy:

I work in the Department of Mental Health treatment system and I am wondering if you know whether using drugs can cause a psychotic disorder in some people? I see so many young people who experience a psychosis and so many of them have a history of using drugs. Thanks so much.

You ask an interesting question and let me share with you some recent findings about this subject. And for those that do not know, a psychotic disorder is a severe mental disorder that can be very debilitating and can include symptoms such as impaired reasoning, delusional thinking, and hallucinations.

That many people you see struggle with both a psychotic disorder and a substance abuse problem has been well documented and it has been reported that about 50% of such individuals use drugs. And in this vulnerable population, even small amounts of drugs can greatly affect their mental status, and cause additional problems for them. And of course, like anyone, large amounts of drugs is also very concerning.

In regards to your question, some recent research has looked at whether drug use can cause this kind of disorder. In this study, the researchers specifically looked at individuals at high-risk to develop psychosis based upon family history and early signs of a psychotic disturbance. This study showed that among people with such risk, those that used drugs became psychotic about twice as often as those who did not use drugs. And this was true regardless of what particular drug or drugs were used. The authors who researched this speculated that this association between drug use and development of psychosis may be due to “psychosis-promoting” changes in the brain caused by drug use.

Another question is whether drug use can lead to a psychotic disorder among people who are not vulnerable to psychosis. This phenomenon is rarer and less clear, but there has been some research that suggests some drugs may possibly have an effect in some people. In addition, some drugs can lead to a psychotic disorder due to the effect of the drug, but when the drug leaves the person’s system and wears off, the psychotic disorder also goes away. For example, individuals who heavily use cocaine can experience a paranoid psychosis, which fairly quickly goes away when the person stops using the drug. And this phenomenon can certainly occur among people who are not vulnerable to psychosis.

It is also important to remember that many individuals who struggle with a psychotic disorder turn to using drugs as a way to cope, although this obviously isn’t the best way to cope in the long run. That is, the drugs do not cause the psychosis, but instead, the psychosis can increase the chances of drug use for a whole variety of reasons. This is another reason why many people you see struggle with both a psychotic disorder and drug problems.

So there are many relationships between psychosis and drug use, but in regards to your question, among individuals vulnerable to psychosis, drug use can increase the chances of a psychosis occurring.

Dear Dr. Levy:

Someone was telling me that at some point in the future, people may be able to get a vaccine so that they won’t be able to get addicted to cigarettes. Is that true? Thanks.

Researchers are looking at developing vaccines to cigarettes and other drugs, such as cocaine, which will help decrease the chances of people getting addicted to these agents. The vaccines work by creating antibodies that attach to target molecules and prevent them from reaching the brain. If the drug cannot reach the brain, the person will not feel the drug’s effects, which in turn, can decrease rates of addiction as the person will not want to continue using the drug. Also, periodic booster shots are needed to keep the vaccines effective.

People who got the vaccine used to combat cigarette smoking report that when they smoke, it felt like they were smoking a light cigarette and they didn’t taste the typical flavor. The company that is developing a nicotine vaccine reported that 43% of smokers in a recent test remained abstinent for a year, compared to 21% of a group who received placebo. A drug called NicVAX has been fast-tracked by the Food and Drug Administration after studies showed that 40% of users remained abstinent after six months, compared to 9% of a group who did not receive NicVAX. So it appears that vaccines are being developed, though they are still several years away from being available if tests continue to show that they are useful as an adjunct to treatment.

Dear Dr. Levy:

I hear so much about kids lives getting destroyed by drugs and I am wondering if the problem is getting worse and worse or if we are making any headway to helping kids to not use drugs in the first place? Thanks.

You are right that far too many youth use drugs and their lives are getting destroyed as a result. However, on the positive side, it appears that we are making some progress on this huge problem. The Monitoring the Future Study, which is conducted every year and assesses youths’ drug use has found that from 2001-2007, drug use has declined by about 24%. In particular, this study found that past month drug use among 12th graders decreased from 19.4% to 14.8%. While that is still way too many youth who are using drugs, the progress is evident. I should also mention that the most common type of illicit drug use, not including alcohol, is marijuana. And this is followed by prescription drug use, which includes a variety of substances. This is very concerning as most often, youth get these drugs from medicine cabinets, relatives, and their friends. One take home message is for relatives and parents to be very mindful of how they store their medication and to discard medications that they no longer need or use. Parents should also carefully monitor any medications their children have, particularly if the medication has known abuse potential. So in answer to your question, we are making headway, although the problem is still very evident.

Dear Dr. Levy:

Is there any evidence that cravings or urges to use drugs is physical as opposed to psychological? I ask because urges can be so intense and powerful that they feel physical. Thanks.

You ask a great question and you are correct that urges and cravings often feel physical. And a huge task, particularly in early recovery, is for a person to learn how to deal with powerful urges to use. As we learn more about the brain, it is becoming clearer that urges to use do have a physical basis. This is not too surprising because if we think of a person holistically, the mind and body go together and most, if not all, mental experiences probably have a physiological basis. A huge focus of research in the addiction field is trying to learn more about how drugs and alcohol interact with the brain, and the more that is learned about this, medications can be developed to target these processes and help in the treatment of addiction.

Recently, using magnetic resonance imaging (MRI) techniques, researchers have demonstrated that when images of cocaine are subliminally shown to cocaine addicts, activity in their limbic system occurs, which is a part of the brain involved in emotional responses. Researchers believe that the activation of circuits in this part of the brain may play a role and be responsible for driving drug-seeking behavior. The goal over time is to develop medications that reduce the brain’s sensitivity to such cues and might help addicts to better deal with urges and cravings to use. So in answer to your question, recent research is demonstrating that cravings to use appear to have a physiological basis.

Dear Dr. Levy:

Can you tell me what buprenorphine is? My son, who is 19, has been buying this from one of his friends. He says it isn’t addicting, but I am still upset that he is using any drugs. How dangerous is this?

Buprenorphine, or trade name, Suboxone, is a partial opiate agonist. What this means is that it acts like an opiate-type drug, or pain killer, but another part of the drug acts in an opposite way, or is an opiate antagonist. Due to these properties, it binds to opiate receptor sites in the brain, but both the opiate agonist and antagonist bind to it. What this means is that while a person can get a “high” from taking this drug, the drug only goes so far, and person can only get so “high”. This medication is being prescribed through doctors for the treatment of opiate addiction.

This drug can cause dependence and for some people, taking this drug can lead to addiction. No one should take this drug unless the person is being prescribed this drug by his or her physician. Your son is taking this drug illegally and he should not be doing this. Regarding its dangerousness, while a person will not overdose on buprenorphine, taken in combination with other drugs, such as anti-anxiety drugs, it can be quite dangerous. Again, I would strongly encourage your son to stop taking this drug. If he has trouble stopping this, I would refer him for treatment.

Dear Dr. Levy:

Do you know whether rates of alcohol problems have been increasing? With all the stress in the world, I would think that alcohol problems are probably getting bigger and bigger. Thanks.

You ask an interesting question. There was a study conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the organization in our country that researches alcohol problems. A survey of alcohol problems was done in 1991-1992 and then again in 2001-2002. The researchers looked at alcohol abuse problems and alcohol dependence problems in our society among people aged 18 and older. Alcohol abuse is when the use of alcohol is interfering in a person’s life and causing the person problems. Alcohol dependence is a more severe form of this illness or problem and in alcohol dependence, the consumption of alcohol is a central preoccupation in the afflicted person’s life.

What the researchers found is that while alcohol dependence decreased slightly from 4.4% of the population to 3.8%, alcohol abuse increased from about 3% of the population to 4.65% of the population. They also found that rates of alcohol problems were greater among males as well as among younger individuals. Overall, in the 1991-92 survey, about 13.8 million people suffered from either alcohol abuse or dependence, and in the 2001-2002 survey, alcohol problems affected 17.6 million people

The researchers were not sure why rates of alcohol dependence had dropped, whereas the rates of alcohol abuse had increased. However, they speculated that it is possible that as social attitudes may have become more negative concerning very heavy drinking, this could also have led to increased interpersonal conflict about drinking, which could have played a role in the increased rates of alcohol abuse, as a cardinal feature of alcohol abuse problems is social or interpersonal problems caused by drinking. Whatever is responsible, in answer to your question, taking into account both alcohol abuse and alcohol dependence, rates of drinking problems have increased from about 7.4% to 8.45%. Obviously, problems related to the use of alcohol are a major public health issue.

Dear Dr. Levy:

I have heard that the new drug Chantix that helps people to quit smoking may cause suicidal thoughts. Is that true?

In fact, the Food and Drug Administration (FDA) recently stated that it is “increasingly likely” that the drug Chantix, which is used to help people quit smoking, can cause depression, suicidal thoughts, and other psychiatric problems. The FDA further stated that Chantix may cause a worsening of current psychiatric symptoms even if they are currently under control. In addition, it may cause an old psychiatric illness to reoccur.

In this regard, anyone who is considering using this medication to stop smoking should speak with their physician about any current or past psychiatric problems.

Dear Dr. Levy:

I have heard that there is a new drug to treat cocaine abuse. Do you know what this is and is it available?

I am not sure what you are referring to, but I think that you may have heard about a medication called Vigabatrin, which is an anticonvulsive drug. The Food and Drug Administration (FDA) is presently looking at this medication and if approved, it would be the first drug approved by the agency for the treatment of cocaine and methamphetamine dependence. Researchers believe that this drug works by blocking craving and euphoria by increasing the level of gamma-aminobutyric acid, which is a neurotransmitter. It is believed that gamma-aminobutyric acid can help to block the increase in dopamine that occurs when individuals use cocaine and other drugs. Testing is still underway and a larger scale clinical trial is being planned. We are still quite some time away from this drug being approved by the FDA.

Dear Dr. Levy:

Is it true that alcoholism is inherited? I know some people who came from an alcoholic family, but they don’t seem to have alcoholism. Thank you.

Research has clearly shown that an alcohol problem has a genetic, inherited component. That is, children of parents who are alcoholic have an increased risk of developing an alcohol problem, even if they are raised in a non–alcoholic family. In fact, their risk is greater than children of non-alcoholic parents who were adopted away at birth and raised in an alcoholic family. So clearly, genetic, inherited factors are important.

That being said, not everyone with alcoholic biological parents develops an alcohol problem. While inherited factors are important, the genetic loading that gets passed on in the genes may not be passed on to a particular person. Also, even if a genetic loading is passed along, an alcohol problem is very complicated, and in addition to biology, psychological and social factors are also very important. In fact, for an alcohol problem to develop, genetic, psychological, and social factors all coalesce together to cause the problem. And this is not unlike other conditions such as cancer or heart disease, for example. While a person may have a heightened risk to develop cancer or heart disease due to biology, not everyone with such a genetic risk develops these problems and many other factors are responsible in determining whether this genetic risk ever leads to cancer or heart disease. In fact, for many problems, there must be a genetic-environment interaction, where a genetic vulnerability exists, but it must interact with a certain environment for the vulnerability to actually occur and come into existence.

So in answer to your question, there is clearly an important genetic component to developing a problem with alcohol, but many other factors play a role in determining whether a particular person actually develops a problem with alcohol.

Dr. Levy,

I was both appalled and shocked at your column regarding "Is Abstinence The Only Answer For Alcoholics?" I am a recovering alcoholic and have just recently completed a 5 month stay at a sober house for both alcoholics and drug abusers. I have lived with both drug and alcohol abusers who have time and time again relapsed because they felt that they could maintain control over their addiction and the mere suggestion that they may someday drink socially or occasionally is insane. Insanity as defined by AA is repeating the same behavior over and over again and expecting a different outcome. As any educated alcoholic knows from attending AA meetings and or therapy, the addictive brain, when once again introduced to its drug of choice, will behave in exactly the same way time and time again.

I had abstained from alcohol for over two years and thought that I had it beat. Then on one summer afternoon at a friend’s house for a cook out, I had two beers on this hot summer day. This was not an excessive amount and I was not in the least bit intoxicated. However, those two beers reactivated that euphoria feeling in me and I spiraled downward in the next few weeks frequently blacking out and nearly destroying my life and those I love. Had it not been for the teachings of AA as well as the sober environment that I was fortunate to have lived in, I would still be trying to take that one social drink and denying the fact that Abstinence "Is" The Only Answer For Alcoholics. I'm sorry to say that your article will not be interpreted by many addicts in the manner in which I'm certain you meant it, but rather because of your credentials and knowledge of addiction, as permission to try it again and to continue this insane lifestyle of personal destruction.

First, thank you for writing in and expressing your opinion. As I stated in my last week’s column about this topic, this is a very controversial subject. Your experience with alcohol is like many other people: one drink leads to uncontrolled drinking along with the destruction of life. In addition, as you well articulated, for many people, the main reason a relapse occurs is because they cannot accept that they cannot have one drink and they deny this to themselves. As you did, they erroneously believe that one or two drinks will be fine, but instead, after one or two is taken, it leads to a major relapse.

That being said, I still stand by what I stated in that some people with past alcohol dependence can learn to drink in moderate ways that do not cause them problems, and this is something everyone who struggles with alcohol needs to figure out for themselves. I know that this adds gray and ambiguity to the treatment of alcohol problems, but nonetheless, this outcome has been well documented.

As you wrote in your letter, some people who are abstinent may interpret what I stated as permission to try to drink again, which is not what I intended, as you also noted, and I hope that this does not occur. In fact, I am very glad you wrote in so that I can again restate what I wrote in last week’s column: if abstinence is working, I would not do anything different, and this is very important to remember.

Dear Dr. Levy:

Do you believe that some alcoholics can learn to consistently moderate/control their drinking as opposed to not drinking at all? I thought that once a person became alcoholic, they could never go back to drinking. Thank you.

This is a controversial topic and one that I have closely monitored and studied. And as you may know, I recently wrote a book designed to help people who struggle with alcohol and this topic is addressed.

In looking at this research, studies have clearly shown that some individuals who were dependent upon alcohol, or who were alcoholic, were able to learn how to moderate their drinking. In a well designed study sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), it was found that about 38% of people who suffered from alcohol dependence were successfully addressing their problem by engaging in low risk drinking. Low risk drinking was defined as never exceeding safe drinking practices recommended by NIAAA, which is no more than 14 drinks/each week for a man, and no more than 7 for a woman. Also, men could not have drunk 5 or more drinks on any occasion, and for a woman, no more than 4. Finally, all people had to be doing this for at least a time period of one year.

When these same individuals were assessed three years later, it was found that 48% of them were continuing to drink in such a fashion and had been doing this for at least one year. Another 11% drank somewhat more than the recommended limits I just described, but still, the researchers did not think that these individuals were abusing alcohol in any way, and again, this pattern had occurred for at least one year. It should also be noted that 18% were abstaining completely. So in this study, about 60% of individuals who struggled with alcohol dependence were able to drink in ways that no longer caused them difficulties. This study also looked at relapse rates and it was found that about 25% of these people had experienced some type of relapse during the past three years, but 75% had not. And most of the people who relapsed again had gotten back on track, and most did this by again controlling their drinking.

There is much more I can say about this topic, and if you or anyone else has other questions, please feel free to write in. However, in answer to your question, some alcoholics can learn to moderate their drinking, although it is also true that many cannot and need to achieve abstinence in order to resolve their drinking problem. What is also true is that individuals who have had more severe problems related to alcohol have less of chance of being able to drink moderately. Finally, I must also say that if a person is reading this and has achieved abstinence, and this is working well, I would not do anything different! As the saying goes, “If the clock isn’t broken, don’t fix it.” Stay the path and continue to maintain abstinence.

Dr. Levy,

I have a 19 year old son who recently got into some trouble (arrested for possession and intent to distribute). He has moved back home since he was kicked out of the college he was attending and he has been accepted to a local community college. I told him one of the conditions of living at home is no drugs in the house and no smoking the pot in the house. He is not abiding by this condition.

We are constantly fighting. We recently had a fight when I told him I don’t want him living here anymore. How do I get him out of the house if he won’t leave? In addition, he has an anger management problem. He has a short temper and flies off the handle too easily. He is also very disrespectful to me. During that fight, he threw something at me. The other day, he was fighting with his girlfriend and he was swearing and calling her all kinds of names. How do I get him to counseling if he won’t go? And if he agrees to counseling, how am I assured that he won’t “con” the counselor like he did in the past. Any suggestions would be greatly appreciated. Thank you

First, I am so sorry to hear about this horrible situation.
Unfortunately, this is a situation that a number of parents face. As your son is 19 years old, he is a young adult and he no longer needs to live with you or another parent or guardian. If you haven’t, I would suggest that you talk with him, when things are calm, and let him know that you no longer can have him live with you. Be firm and consistent, and he needs to know that you are not saying this due to a recent crisis, but that you have thought about this and are very clear on what you want. If necessary, you can force him out of your home, even if you need to contact the police. If he is violent towards you, a restraining order can also be taken out. These aren’t easy decisions, but these options are open to you.

Regarding counseling, you don't really have control over him and what he is willing to do, and in fact, he may refuse counseling. One idea would be to make his staying at your home contingent on whether he goes to counseling, and he would need to give his therapist permission to let you know whether he comes to his appointments. He may "con" or not be completely truthful with his therapist, but again, there isn't much you can do about that. It is possible, though, that at some point, if he was willing, you and he could meet with his therapist together, and you could share your perspective. And whether he attends counseling or not, if his behavior is so bad that you no longer can tolerate his living with you, that is something that you can enforce, again, even if it is necessary to get the police involved and force him out.

Again, this is a very difficult situation for you and one other idea, if you haven't already done this, is to get some help for yourself, either through counseling or Al-Anon. These kinds of supports may assist you in being able to better deal with this very difficult situation. My best and if I can be of further help, please contact me again.

Dear Dr. Levy:

In my work as a nurse practitioner, I see many people who smoke and I always encourage people to stop. Some people listen and make the decision to quit, but many others don’t and it goes in one ear and out the other. My question is whether there is anything more I can do to help smokers to make the decision to quit smoking other than advising them? Thank you.

As you know, for most every smoker, there is much ambivalence or mixed feelings about stopping smoking. There is a part of the person that enjoys smoking and wants to continue to smoke and there is another part that wants to stop. And as I am sure you know, the scales must tip in favoring of no longer smoking until someone is ready to change, and the person, him or herself, must come to conclusion that it is time to stop smoking. Most every smoker on some level wants to stop smoking, but it is hard to put a plan into action.

There is an intervention that can be used to help people to change. Or at least, this intervention can help to increase a person’s internal motivation to change. This intervention is called motivational interviewing and it is designed to help people look at themselves and tip the scales in favoring of changing. Motivational interviewing gets a person to express both the pros and cons of no longer smoking, as well as the pros and cons of continuing to smoke. By doing this, the bad things about smoking can be highlighted, as well as the positive things about stopping, and these reasons all came from the smoker as opposed to someone else’s lecture. This can help create even more ambivalence about continuing to smoke, and then hopefully, this ambivalence can be resolved by the person making the decision to change and developing an action plan to stop smoking. Also, by doing this, you can discover along with the person, what the person’s biggest concerns are about quitting and then helpful ways to cope with these concerns can be developed.

For example, if a person says that one of the cons of no longer smoking is concern about weight gain, a plan can get developed to help minimize this concern. There are certainly no guarantees that this technique will get the person to stop, but this intervention may help. There is much more to motivational interviewing than what I can write here, but you can certainly look around for training and I would encourage you to read a book the book, called Motivational Interviewing, by Miller and Rollnick.

And as an interesting side note, I read a research study that asked smokers who had quit what did it for them. What was found was that TV antismoking ads helped more people quit than any other intervention, including nicotine-replacement therapy, telephone help lines, cessation programs, medication, self-help materials, or professional help. Among the group of former smokers studied, 30.5 percent credited TV ads with helping them quit, compared to 20.8 percent who credited nicotine-replacement therapy, 11.1 percent who gave credit to professional counseling, and less than one percent who said telephone quit lines helped them stop smoking.

Finally, I would say that the most important thing for you is to not get frustrated, as even with motivational interviewing, some people are just not ready to make the decision to stop smoking, at least not yet. Over time, many people do quit, and you need to remember that there is only so much that you can do. All you can do is continue to plant seeds whenever you see your patients, try to get them to look at their own ambivalence about stopping smoking, and over time, some of these seeds will grow.