The sobering fact, says Lembke, is that long-term recovery requires ongoing maintenance work, whatever form that takes.
The sobering fact, says Lembke, is that long-term recovery requires ongoing maintenance work, whatever form that takes.

What life is like after giving up the drink

A DAY before the deadline for this story, one of my main interview subjects pulls out.

She is gracious, apologetic. But she is a public figure, and she says she can't risk appearing in a story about recovery from alcohol addiction.

She's worried the label of alcoholic will follow her around indefinitely, like a dead weight, polluting her reputation.

And who can blame her?

It's fine, in theory, to think of ourselves as an enlightened, forward-thinking society that respects how gutsy it is to beat alcohol addiction.

But when it's your own reputation on the line, it's not so easy to test it.

The stereotype of an alcoholic man living in a park, swilling cheap wine out of bottle in a paper bag is still widespread, despite the scientific research, the medical discoveries, and the procession of celebrities, who in an effort to re-orient public perception, have come out about their own past alcohol addiction.

Poster child Russell Brand has built his career around his recovery, and everyone knows about Robert Downey jnr's miraculous 180-degree turn from alcohol and drug addiction to clean living. But the list goes on and on. From icons like David Bowie, Carrie Fisher and Eric Clapton to hard men Eminem and Colin Farrell and Hollywood elite Bradley Cooper, Demi Lovato and Nicole Richie, a slew of celebrities are out the other side of a drinking problem, and talking about it.

The truth is, roughly 10 per cent of us - that's 450,000 New Zealanders - are addicted to alcohol. It's almost mundanely common. Anyone, given the right biology and environment, can suffer from it.

Let's say only 10 per cent of those addicted to alcohol recover. That's about 45,000 recovered alcoholics going about their lives among us. And despite the stereotype, many of them are women. This is the story of two of them.

Clinical psychologist Simone Barclay lives with her husband, a lawyer, and their twin boys in an exclusive inner city suburb of Auckland.

In her work she regularly conducts "Friends and Family" group therapy sessions to help people who are close to an addicted person. She always opens with the same question: "What is an alcoholic?"

The answers go like this.

"It's when you have to drink every day, and you can't stop."

"It's a homeless guy drinking out of a paper bag."

"It's someone who is weak-willed."

Then she stands up, immaculately presented, in her 10cm high heels. She says in her cultured tone, "Well I'm an alcohol addict. This is what an alcoholic looks like." It never fails to get a reaction.

She says the "out-of-control drunk in the park" perception of alcohol addiction is true of alcoholics extremely far advanced in their illness. They become undeniable, obvious to society. But most of those addicted to alcohol are much more functional.

"At one end you've got the homeless guy drinking out of a paper bag," she says. "At the other end you've got the guy running the country, the David Langes of the world."

She was brought up in Wellington by conscientious parents who drummed in the importance of etiquette and moral fibre to their two daughters.

But once Barclay started drinking, aged 14, alcohol quickly came to mean public humiliation, lost jobs and relationships, chaos and car accidents.

There was the time she got into a drunken argument with someone at a swanky work function. She slapped him. He slapped her back, and she toppled backwards into the pool, hitting her head on the side. She was rushed to hospital in an ambulance, her humiliation more searing than the gash in her head.

And the time she fell asleep at the wheel, drunk, and crashed her car into a tree 50m from home. She was 22, it was a work vehicle, and it wasn't the first time she had crashed it. She was terrified of telling the truth, so she fabricated a story that she had been car-jacked. Then she realised that if that were true, there would have been a police report, so she added that her boyfriend's five brothers had beaten the carjackers up, so they couldn't report it to the police. She'll never forget the glazed expression on her boss' face.

At the time, she explained both incidents away: she had drunk on an empty stomach, hadn't kept hydrated, had been stressed at work. To the average person, either of these incidents would have been a wake-up call. For her they went unnoticed, but they formed part of a string of crises that became more severe and more frequent as the years went by.

In the end, it wasn't anything dramatic that made her quit. She was 28, sitting at home. She had always been able to stop drinking for periods of time, and she had never needed alcohol if it wasn't there, which she took as proof she didn't have a problem. But this day she woke up and realised that yet again, she had got drunk the night before, after promising herself she wouldn't. She realised that once she started drinking, she couldn't stop. It scared her straight.

With support and hard work, she has been sober since. The beginning was the hardest. She felt self-conscious, swinging between hiding and over-disclosing her diagnosis. She remembers a job interview for a marketing role, where she explained the conspicuous gap in her work CV by coming clean about being an alcoholic. There was a wide-eyed silence from the interviewer; she didn't get the job.

"It can be like throwing a bomb into a conversation," she laughs. "Kills it dead." If she could do that interview again, she would say she'd had a period of ill health. She has a standard set of replies for when the truth is too much information: 'alcohol doesn't agree with me, I like wine but wine doesn't like me, I'm better off without it'. That kind of thing.

She used to worry people would see her as boring, a teetotaller who should be at home with her knitting - the way she used to think of non-drinkers.

She concedes that to someone who's all about boozing, she probably is boring. But she's happy with that. She'd rather be boring than the kind of exciting she used to be.

And she has realised that most people at a party are not drunk. It's a revelation to her. She used to move in a convoy of heavy drinkers who blocked out everyone else. "Now I have to be having a good time to have a good time," she says. "Alcohol can't paper over those cracks."

She was also afraid she would be wearing other people's perceptions for the rest of her life. "Who wants that banner hanging over their head?" she says. "We all want to maintain our projected image in a particular way. It's a hugely powerful part of how we can then think about ourselves."

With time, she has come to understand that it's only a part of who she is. If she thinks it will help someone, she willingly discloses it, even though there's a possibility she may be judged. "Any stigmatisation says more about the other person than it does about me," she says. "It's a lack of understanding of what alcohol addiction really is."

So if alcohol addiction isn't a moral weakness, what is it?

Addiction has been our species-long companion. Until the 1850s, people addicted to alcohol were cared for by the church, and the way addiction was understood reflected this. It was framed as a moral issue - a sign of weakness of character, a lack of discipline.

As society became more secular, treatment of the severely addicted shifted to the care of medicine.

The way addiction was understood morphed to reflect its new guardian, and most importantly, addiction was put under the microscope of modern scientific investigation, where it has remained ever since.

Dr Anna Lembke of Stanford University describes addiction as a chronic relapsing and remitting disease, which is biopsychosocial in origin. Put simply, the cause of the disease has its roots in the addict's biology, psychology, and society.

First, the biology: there are two highly inheritable personality traits which, when present in childhood, predispose an individual to developing an addiction. They are the ability to delay gratification (impulsivity), and intense mood swings (emotional dysregulation).

Second, the psychology: trauma in childhood can cause changes in the brain through epigenetics, which makes the child biochemically more vulnerable to addiction.

Third, the society: a heavy-drinking peer group normalises binge drinking and provides the exposure to alcohol necessary to developing an addiction.

The DSM5, the latest tome-like manual released by the American Psychiatric Association, which documents current understanding of mental illness, puts addiction on a continuum called Alcohol Use Disorder. It plots sufferers along this continuum, from mildly to severely addicted. The severely addicted correspond to what society traditionally terms an alcoholic.

Outgoing, articulate marketing executive Emma* always knew she had an alcohol problem. But she would never have put herself in the severely addicted category, even though the evidence was piling up.

She grew up lucky, in a loving home in suburban Auckland. She was the typical good girl: honest to a fault, pretty, high-achieving. She was school prefect, team captain, a regular recipient of scholarships.

But in her late teens, drinking slammed into her like a steam train. She drank hard right from the start, and by the time she hit her 20s, things became serious: she was arrested four times for alcohol-related misbehaviour, friends cut ties with her, she dropped out of university five times.

She also discovered drugs.

When she was 20 she overdosed on liquid Ecstacy at work, which stopped her heart. A few years later she was beaten up on the street by a boyfriend, who was jailed for the attack. She stopped using drugs, but her alcohol problem was as bad as ever.

Just before she stopped drinking, she went out with a friend for a drink at a quiet local wine bar. She blacked out (a memory lapse in which the person still functions) and came to at 7am the next morning walking along K Rd, without money, bag, phone or friend. She had no idea what had happened in the previous seven hours.

"When I'm drinking I can't control where I'm going to end up," she says. "On a regular day I consider myself a law-abiding, respectful person. But when I drank I was a totally different person."

In the end she became so disappointed in herself, she stopped trying. Six months before she stopped drinking, her boyfriend admitted he didn't know if he could handle her drinking anymore. In a moment of honesty she told him she wasn't going to make him another empty promise. "That messes with your self-esteem," she says. "You can't trust yourself."

Her parents never entertained the idea she was severely addicted to alcohol. To them it was just a stage they were desperate for her to grow out of.

Emma didn't realise either. "There's this huge disconnect," she says. "A female who is an intelligent, sweet, loving daughter doesn't fit the stereotype. She can't be an alcoholic. So she doesn't get help."

She has come across these misconceptions again and again. Last December, she and her colleagues were seated in the private room of an upmarket Auckland restaurant, enjoying their Christmas function. It was a welcome treat after a big year. One of her managers leaned over to her, bottle in hand.

"Wine?" he offered.

"No thanks, I don't drink," she smiled.

"You don't go to those bloody meetings, do ya?" he shot back.

Any stigmatisation says more about the other person than it does about me. It's a lack of understanding of what alcohol addiction really is.
Simone Barclay

The group exploded with laughter. It was a standard ribbing, and an absurd idea. How could such a nice girl need the meetings washed-up drunks go to?

Three years earlier, just after her 32nd birthday, Emma had done just that: gone to a meeting of Alcoholics Anonymous. "I walked into this room and there were so many strong women," she says. "Professional women. I wanted what they had."

In a moment of clarity she had seen that if she didn't stop drinking, it was going to kill her. She had tried everything else - treatment centres, Antabuse (a drug that makes the body temporarily allergic to alcohol), counselling, hypnotists. She was out of options.

She hasn't drunk since. AA, like all addiction interventions, is no cure - medicine has not achieved that yet. But it has helped her learn how to stay well.

So what is the best treatment for severe alcohol addiction? While mild and moderate alcohol addiction can be addressed by cutting down on drinking, severe addiction usually requires stopping altogether.

And while there are reports of those who naturally grow out of their addiction, for most severe addicts, stopping drinking will require long-term help.

This is because chronic heavy alcohol consumption changes the neurological processes of the brain so that it is "primed" to become addicted in a way the "naive" brain is not.

Research suggests this priming is irreversible, and causes a homing pigeon instinct - an obsession with returning to alcohol despite being unable to control it once started, and despite the probable severity of consequences.

Long-term support also helps to manage the personality traits that made the person vulnerable to addiction in the first place, the skill deficit addiction can cause, and the emotional damage to self-esteem created by the addiction.

Dr Doug Sellman, director of New Zealand's National Addiction Centre, says the good news is recovery causes new changes in the brain, which with repetition can become stronger than the original addictive changes.

He says Emma's choice to use AA makes sense. "Some of the most dramatic recoveries I've seen in the severely addicted have been those engaged with the 12 steps of AA," he says.

Lembke agrees the best recovery she sees is from people involved in AA. "It is a tried and true and potentially life-saving intervention for those who actively participate," she says. "The truth is, the science is still trying to catch up with what AA intuitively figured out in 1936."

However, both Lembke and Sellman point out that AA is not for everybody, and that several other solutions are effective, from individual therapy, to group therapy, to meditation - provided it is continued long-term.

Emma still gets support. And she can see, looking back, why people are so wary of alcoholics. She likens alcohol addiction to a tornado in the lives of those around you. "You really hurt people," she says. "You appear to be very selfish. How can you give someone sympathy when they constantly let you down, constantly destroy themselves?"

The reason it took Emma until she was 32 to go into recovery was because she knew, somewhere deep down, it would mean stopping drinking. She desperately wanted a solution, but she was terrified to give alcohol away. It had become an obsession.

Now it seems a long way behind her, and she is used to feeling content. In the outside world though, she is cagey about why she doesn't drink. She wishes she were braver. She worries that if she isn't honest, how will the next person get help?

But the fear of being misunderstood keeps her quiet. "I've worked so hard to build up my reputation," she says, "and I don't want to risk that."

Beyond AA
For the severely addicted, much of the recovery industry cites quitting drinking through Alcoholics Anonymous as the best fix.

But it's not the only way. Live-in and out-patient rehabilitation centres offer a great boost in getting alcoholics started on the path of recovery.

Post-rehab there are several methods of recovery to choose from: therapy, self-help groups, education programmes, meditation, spiritual practices, or just a complete lifestyle makeover putting health at the top of the list, can work.

The basic rule applies that the chosen method needs to be used long-term to effectively treat severe addiction.

Dr Anna Lembke of Stanford University says: "I recommend trying all available methods until you find one that works. If that means climbing Kilimanjaro, then go for it."

There is also a handful of medications which can aid recovery, among them Antabuse, Topamax, Campral, Gabapentin, Baclofen, and Naltrexone.

Naltrexone, which blocks the brain's opiate receptors, thereby removing the
pleasurable and euphoric feelings associated with drinking, is attracting a lot of controversy. Dr Roy Eskapa, author of The Cure for Alcoholism, and other proponents of Naltrexone, have shined fresh light on this decades old medication.

The drug claims to extinguish alcohol addiction by returning the patient's cravings for alcohol to a pre-addiction state. The Sinclair Method, developed by Dr David Sinclair based on his research in Finland, recommends taking Naltrexone one hour before drinking, for the rest of the patient's life, to reduce cravings to drink too much. The method promises a 78 per cent success rate at the one-year mark, and claims around a quarter of patients stop drinking altogether.

Dr Charles O'Brien, chairman of the Substance-Related Disorders Work Group for the DSM-5, supports Naltrexone, saying the drug fails because it is usually not prescribed according to the Sinclair Method, but instead is taken once a day while abstaining from alcohol. Stories have surfaced from those for whom no other treatment worked, saying Naltrexone set them free from alcohol addiction.

It sounds too good to be true - a pill that can render all the blood, sweat and tears of a more traditional recovery path redundant. The reality, as reported by doctors at the coal-face of recovery medicine, points to exactly that - in most cases, it is too good to be true.

Lembke says the idea that Naltrexone can cure a complex biopsychosocial illness like addiction is incorrect. She regularly prescribes Naltrexone, always in conjunction with other treatments, and says some patients find it helpful - but most find it only marginally so, or not helpful at all. While Naltrexone can ease physical cravings in some, it leaves all other aspects of addiction untreated.

The sobering fact, says Lembke, is that long-term recovery requires ongoing maintenance work, whatever form that takes.

Dr Doug Sellman of New Zealand's National Addiction Centre agrees it is naive to think any of the drugs currently available can cure addiction, especially considering the brain changes that occur once addiction is established. In his experience there is no silver bullet.

- Canvas

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