If you are among those who think that your father or mother or husband or, heaven forbid, yourself cannot be an alcoholic because an alcoholic is somebody with a dirty overcoat and a beard who smells bad and sleeps under newspapers on a park bench, you've got another think coming.
There are an estimated 10 to 12 million alcoholics in the United States, and the roster includes executives, children, doctors, bus drivers, lawyers, factory workers, secretaries and others who look and act just like you.
Alcoholism costs the United States $117 billion a year in lost work time, family breakups, illness and premature death, estimates the National Council on Alcoholism (NCA).
Just under half the population -- about 100 million Americans -- drink alcohol, NCA says, and 10 to 12 million of these drinkers are alcoholic. Only 15 percent of them are receiving treatment.
And for every alcoholic, NCA says, four other people directly suffer consequences.
In the metropolitan area, there are about 350,000 alcoholics, says Joe Wright, director of the Washington Area Council on Alcoholism and Drug Abuse (WACADA). Of every 100 alcoholics, 40 may brush up against a form of help, he says, including medical treatment, membership in or a skirmish with Alcoholics Anonymous (AA), or counseling from a clergyman.
Half of these 40 who receive help will continue drinking and are likely to become ill or die prematurely, Wright estimates. Ten will make it to three to five years of sobriety in AA, and the other 10 will vacillate in AA for several years. Half of those "vacillators" eventually will achieve measurable sobriety.
An alcoholic, says the NCA, is someone whose drinking causes a continuing problem in any area of his or her life. The council defines alcoholism as a chronic, progressive and potentially fatal disease characterized by tolerance and physical dependency on alcohol or internal changes from alcohol ingestion, or both.
Each year, about 95,000 Americans of all ages die as a direct or indirect result of alcohol, says Christine Lubinski of the NCA in Washington. Cirrhosis of the liver kills 30,000 yearly. Alcoholism and alcoholic psychosis cost another 5,000 lives. Accidents, homicides and alcohol-related suicides kill 60,000 a year.
There's a lot of chicken-and-egg argument about alcoholism and behavior connected with it, but some general agreement: It is not a moral infirmity or a weakness; it is a disease, and it is treatable.
But it is not curable, says Dr. George Kolodner, a psychiatrist who heads Washington's Kolmac Clinic, an outpatient treatment center for alcoholism. And because there is no cure, Kolodner advocates abstinence.
"It's not like a broken leg that you can stay off for a while and then walk again," he says.
"I also tell people that there'll be a 'cure' in the newspapers every six to eight months, but that you ought to hold off taking that cure until the person who has devised it has won the Nobel Prize. You can bet that if a cure is ever discovered, the person who does it will get the Nobel Prize."
Unlike social drinking, Kolodner says, alcoholic drinking tends to be self-perpetuating. "I had a guy walk in this morning," he said recently, "who said he didn't think he was an alcoholic because 'I don't drink every day, but once I start I can't stop.' I said, 'Right, you've got the disease of alcoholism.'
"It's not what you drink or when, but what happens after you take the first drink, and that's what separates the alcoholic from the nonalcoholic."
It's not surprising that alcoholism treatment is big business. Americans spend about $1.3 billion each year on such programs, says John Noble, deputy director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in Rockville. Treatment programs typically fall into three categories: programs within hospitals, residential programs at specialized treatment centers and outpatient programs -- or some combination of those.
Examples of these treatment options in the Washington area -- where there are scores of programs -- include Seton House at Providence Hospital, CompuCare and Recovery Centers of America.
Seton House in Northeast -- part of the nonprofit Providence Hospital, which is owned and operated by the Daughters of Charity -- offers both inpatient and outpatient alcoholism treatment, plus detoxification. Known as "detox," detoxification is a process in which the body rids itself of the immediately dangerous levels of alcohol in the system under clinical supervision to monitor unpleasant side effects, such as convulsions.
The outpatient program costs $600 for 10 weeks of therapy in two 2-hour sessions a week, plus 15 weeks of follow-up care that includes individual, group and family activities and counseling. There is a counseling session after six months.
Detox costs are based on the fee for a hospital bed at $600 a day. The average detox stay is three to seven days -- with the longer stays for extreme cases involving severe symptoms such as hallucinations, delirium tremens and convulsions.
Seton House also has a 40-bed inpatient treatment center that offers a 21-day program at an average cost of $6,000 to $7,000, says Jean Genson, program coordinator. This includes 15 weeks of follow-up care and a session with counselors after a year.
Another kind of treatment option is offered by Comprehensive Care Corp., known as CompCare, which controls 27.3 percent of the alcoholism and drug treatment in the private sector, according to spokesman Ken Estes.
Headquartered in Newport Beach, Calif., CompCare has contracts for more than 110 treatment programs in community hospitals in the United States, plus 17 hospitals owned outright and used solely for the treatment of alcoholism. In the last fiscal year, CompCare grossed $114 million and had profits of $14.1 million, Estes said. This is from 5,000 treatment beds nationwide, including some for psychiatric care.
CompCare's programs run 28 days, plus detoxification. The cost is the daily room rate of the hospital in which the program is operated -- so if the hospital charges $200 a day, the 28-day stay costs $5,600.
The charge at CompCare-owned hospitals varies by location, but generally is in the $185- to $275-a-day range, Estes said.
Another large treatment conglomerate is Recovery Centers of America Inc., which is headquartered in Georgetown and is a wholly owned subsidiary of National Medical Enterprises Inc. of Los Angeles. RCA treats chemical dependency under the name New Beginnings, including one at Washington's Psychiatric Institute.
There are 30 of these New Beginnings, says Dick Kessler, vice president for operations in RCA's Eastern Division. They include both in-hospital programs, like that at the Psychiatric Institute, and free-standing centers, such as The Meadows at Gambrals, Md., and Hidden Brook at Bel Air, Md. The costs is similar to those of CompCare's treatment centers, and treatment, again, is 28 days.
Although the magic number seems to be 28 days, that is about two weeks short of an optimum treatment time, says Herbert W. Winstead, chief of the Alcoholism Program of the Montgomery County Health Department. But it is the time period for which most insurance companies will pay, he says.
Insurance reimbursement is currently in a state of flux, largely because of changes in Medicare coverage for alcoholism treatment. New Medicare regulations were issued two weeks ago and will become effective in October. They are expected to become the bellwether for private insurance coverage. Between now and October, the insurance interests will hammer out their own rules. Currently, most private insurance will pay at least a part of the cost of treatment in facilities approved by the Joint Commission on Accreditation of Hospitals (JCAH). Most treatment centers have some provision for adjusting payment according to ability to pay.
Between the relatively inexpensive outpatient programs, such as Seton House, and the residential treatment centers are such programs as the Kolmac Clinics in Silver Spring and downtown Washington and Primavera of Arlington and Culpeper, Va. They offer outpatient programs whose treatment plans fall somewhere in the middle.
Psychiatrist George Kolodner started the Kolmac Clinic in 1973, when, he says, the mood of the country was largely apathetic about alcoholism.
"A lot of hospitals were not admitting patients with alcoholism as the primary disease," he says. "And a conviction for driving while intoxicated was almost impossible to get."
The pendulum then swung to the other extreme, Kolodner says, with alcoholics being catered to, treatment centers springing up everywhere and insurance companies providing payment -- which contributed to the rising cost of medical care.
"Now," Kolodner says, "I feel some rumblings of neo-temperance, and that is unfortunate. To control the substance -- as in drunk driving laws and prohibition and the drinking age -- is not the answer."
The answer, he says,is educating young people about exactly what alcohol is and does.
The Kolmac alternative costs $3,120 for the "intensive" part of the program, which includes 30 visits of three hours each over two months. The "recovery" phase costs $4,672 and involves one visit of two hours each week for 16 months. This totals $7,700 plus change. (Kolmac includes "ambulatory" detox in its price, and if hospitalization is necessary will put the patient in Georgetown or Holy Cross hospital, and the patient pays the regular hospital detox fee.)
The advantage to this not-so-low-cost alternative is that it keeps the patient functioning in society. This may be advantageous, Kolodner says, to a company that wants an employe treated but can't really spare him or her for the duration of a full inpatient treatment regimen.
On the other hand, Montgomery County's Winstead prefers inpatient treatment where possible.
"A lot of the time," he says, "part of the problem is the job, the wife, the kids, the dog, whatever. You've got to get the drunk out of the environment and get him to concentrate on what is the real problem, which is alcohol."
Whatever the treatment, all centers have this in common, Winstead says: The goal of breaking down the alibi system of alcoholics so that they can not only admit to alcoholism but go on to accept and deal with it.
"And that's the biggest reason for going into treatment," he says. "The time from early morning until late at night is spent talking about and listening about alcohol. Twenty-four hours a day, all they hear is alcohol and what it does."
Treatment, in a typical four-week program, includes: one-on-one sessions with a counselor, group therapy with other alcoholics, trips to outside AA meetings to teach the patient how to go to meetings and where they are, AA meetings in the treatment center, lectures, films and family counseling. The good centers, Winstead says, make provisions to bring in family members at least once a week.
The program, he insists, must be oriented toward abstinence, not control, and the good ones get the patient at least familiar with the steps of Alcoholics Anonymous. Most insist that he or she complete the fourth step of AA's 12-step recovery plan before being discharged: The taking of a "fearless and searching moral inventory" of him or herself.
Besides this total immersion in the didactics of sobriety, Winstead says, the treatment centers are staffed by medical professionals and are able to respond to medical emergencies, either associated with withdrawal or detoxification or other nonrelated ailments.
Most treatment centers are big on vitamins and nutrition, he says, trying to introduce good eating habits to people who perhaps for decades have been surviving on the empty and deleterious calories provided by alcohol.
In the end, some alcoholics find themselves uncomfortable with any treatment center. Some find that steady attendance at AA -- which is 50 years old this month -- plus faithful adherence to the 12 steps of the AA program and a daily set of prayers helps them get sober and stay that way.
But the best advice seems to be: "Whatever works for you."