Are Greater Levels of Treatment Producing Better Social Outcomes?

Given the substantial growth in treatment for alcohol and drug abuse and the relatively greater exposure to such treatment of the unemployed and drop-outs from the labor force, we could expect that the least well-off Americans are being prevented from dropping out of the social net. Instead, during a period of rapidly expanding provision of alcohol treatment, probably the number of homeless alcoholics—which had already begun to climb—continued to grow rapidly. A survey of Baltimore homeless in the 1980s (Breakey et al., 1989) found that, while major mental illnesses were very prevalent (42% of men; 49% of women), alcohol disorders were more so (among men 68%; 38% of women).

In the 1950s through the 1960s, in many urban centers, such alcoholics were privately handled through a series of SRO (single-room-occupancy) hotels and through "flop houses." Income from federal assistance programs and even panhandling were sufficient to gain a berth in these establishments, which were highly tolerant of their clientele's drinking habits (think of Charles Bukowski's novels and the film Barfly). But the 1960s and 1970s saw urban renewal and "yuppification" eradicate such housing in many urban centers. There is no longer, for example, a Bowery in lower Manhattan. The idea that those on the public dole or panhandlers could afford to live in this district today is impossible to imagine. At the same time, charity institutions in the United States charged with housing the poor and/or homeless, including both private groups such as the Salvation Army and homeless shelters, typically exclude drinkers or intoxicated residents.

In other words, there is no existing basic subsistence "harm reduction" structure in place in the United States. This is not because there are not abundant AA chapters or Salvation Army units and other religiously-oriented missions willing to assist the street alcoholic, or because there aren't many homeless shelters (although perhaps not enough to handle all potential clients). But continued drinking by many street alcoholics runs afoul of the ground rules of such institutions, which are steeped in a no-use moralism which dictates that help can only be offered to those willing and able to stop drinking.

The Growth in Alcohol Dependence Problems

Along with the growth in bottom-of-the-barrel alcoholics and their experience of more serious negative social repercussions, Table 3 reveals that growing numbers of Americans of all types were reporting serious alcohol problems in the 1980s. That is, in 1984—at the tail end of the upsurge in private treatment of alcoholism reported in Table 2—the number of American men reporting alcohol dependence symptoms more than doubled, while growing one-and-a-half times for women, compared with the 1967 survey (Hilton and Clark, 1991). Yet, at about this time, overall American alcohol consumption had begun to drop steadily. Hilton and Clark found consumption did not increase among their respondents between 1967 and 1984, nor did actual patterns of drinking change (except for an increase in abstainers!). Thus, without drinking more, and while undergoing much more treatment, Americans reported far more alcohol dependence symptoms (the most severe symptoms of alcohol abuse) beginning in the 1980s. Although the increase in alcohol dependence problems was more evident among less well-educated and younger respondents, the increase was nonetheless apparent across the population—for example, both higher- and lower-income groups.

One last finding to note from Hilton and Clark was that physicians' advice to cut back drinking became less common in 1984 compared with 1967. Minimal physician efforts at reducing drinking have been shown to be the most effective means for ameliorating drinking problems (see Table 4). However, as formal medical treatment for the "disease" of alcoholism rose, such existing "harm-reduction" efforts that may have helped to keep excessive drinking in check disappeared.