By 2013, Steve Harbin’s alcohol problem was plain to nearly everyone.
Once a prosperous salesman in the construction industry, he’d lost his job and health insurance. Gone were the dream house he’d designed in Albuquerque’s foothills and many of the motorcycles he’d owned. The last one, a Kawasaki W650 with a peashooter exhaust, sat in his garage in disrepair.
His marriage had been disintegrating for years, and now the stepdaughters he’d helped raise despised him, the way Harbin hated his own dad, who he’d sworn to never become.
He was draining two bottles of Irish whiskey a day. More of his Social Security check went to booze than anything else.
But the person with whom Harbin spoke most openly about his drinking and should have helped him cut back was the last to notice the problem: his doctor.
The clinician had known Harbin for decades but never diagnosed his drinking disorder nor referred him for treatment.
He was quick to shrug off his patient’s risky behaviors, as Harbin recalled it, content to leave the patient to help himself.
His plight was strong but not uncommon. According to the state Department of Health, over 73,000 residents who could benefit from treatment to reduce their alcohol consumption are not getting it, more than people addicted to all other substances combined.
State officials, physicians and patients offer varied explanations for this gap. Treating alcohol dependence is not easy: Addressing it means changing lifelong habits. Plus, New Mexico has too few psychiatrists, behavioral health providers and social workers, and only a handful of doctors specializing in addiction medicine. The state’s poverty aggravates the challenge.
But problem drinking also often goes unrecognized. The latest survey data show that of New Mexicans who had a drink in the previous month, more one in four meet criteria for an alcohol use disorder, among the highest proportions in the country.
And again and again, clinicians and even patients lay responsibility on the person with the addiction. “I firmly believe that unless someone wants to make the change themselves,” Harbin said, “they’re not going to quit.”
William Miller, a professor emeritus at the University of New Mexico and one of the world’s foremost experts on the psychology of change, respectfully disagrees. “Waiting for people to ‘hit bottom’ is a pernicious myth,” he wrote in an email.
Working with problem drinkers in New Mexico nearly
40 years ago, Miller and colleagues developed “motivational interviewing” — a form of counseling that helps patients change their drinking habits by exploring and resolving their own ambivalence — that is now applied around the world.
It’s unethical for doctors to delay treatment for patients with asthma, diabetes or heart disease until they are sufficiently motivated, and Miller said alcohol disorders should be no different. “Helping people find their own motivation for change is an important and early part of our job, and there is solid science that it’s possible.”
Harbin’s drinking was rooted in his fraught relationship with his father, low self-esteem and depression, but he was better off than many New Mexicans in similar straits.
He was professionally successful. His wife, Angie, was committed to the soft-spoken man who had charmed her and fallen in love with her girls. Originally from the Midwest, she was raised to believe if you work hard enough, you will succeed. She looked at her relationship with Steve that way.
“I’m a person that doesn’t throw in the towel very easily,” she said.
“You see it out till you see that you have nothing left to give.”
More than a decade into their marriage, she’d pushed Harbin to enter treatment, moving in with her sister until he agreed to enroll in a multi-week program at Presbyterian’s Kaseman Hospital. But Harbin thought the sessions were awful. “It was more of a shaming process than it was anything positive about it.”
The health system could have done more to meet him where he was at.
Harbin had been seeing the same primary care doctor for over 20 years, a man in private practice around his age.
When Harbin lost his health insurance, the doctor retained him as a patient.
“He was really one of the most caring doctors I’ve ever known,” he said.
They often spoke about Harbin’s drinking and the harmful effects of alcohol on mental and physical health, he said. But when Harbin struggled with debilitating anxiety about work, the doctor prescribed a benzodiazepine, a class of drug that can be addictive and dangerous to mix with alcohol.
Harbin became dependent on that, too.
“He would keep prescribing them for me, and he would just say, ‘You’re not drinking too much while you’re taking these.’ ”
Harbin’s plight wasn’t unusual, recent research shows. Seventy percent of people with alcohol disorders report a doctor asking them about drinking in the last year.
But only 12 percent say they were counseled to cut down, and just 5 percent say the doctor offered information about treatment. That simple approach — what is called screening, brief intervention and referral to treatment, or SBIRT for short — is effective at reducing alcohol consumption among heavy drinkers, studies show.
For decades, Harbin’s doctor missed the seriousness of his drinking problems, he said, and never recommended anywhere to seek help.
“He told me one time that ‘I don’t really think you’re an alcoholic,’ and that always made me feel odd — because in the long run, I was an alcoholic.”
That sort of thinking — of good and bad drinkers — can also be a blind spot. It’s appealing to believe doctors can sort drinkers into those unable to control their habit and those who can, Miller said, but the science of addiction has moved away from that dichotomy. In 2013, the American Psychiatric Association did away with categorical distinctions of alcohol “abuse” and “dependence,” replacing them with a spectrum from mild to severe disorder.
This recognizes patients like Harbin exist on a continuum and can benefit from interventions meant to reduce alcohol consumption, even without necessarily eliminating it.
And primary care doctors who identify an alcohol disorder often push patients toward specialists and in-patient care, in spite of evidence they can help immediately.
A landmark trial found patients who were counseled by their doctors and prescribed naltrexone, a medication used to treat opiate disorders that has also been shown to reduce many patients’ cravings for alcohol, fared as well as patients receiving more intensive counseling from specialists.
“That’s one of the big misconceptions I see in the field,” said Dr. Snehall Bhatt, chief of addiction psychiatry at UNM.
The mantra of Bhatt and others, who are trying to counsel patients wherever they seek care, is every door is the right door.
A rollercoaster ride
In his late 50s, Harbin was drinking upon waking to numb hangovers and didn’t stop until he passed out.
He was recalled at his best on visits with his grandkids, his youngest stepdaughter Meredith Boles, when she saw a glimmer of the person who had helped raise her. “At one point, he was this lovely man, and I remember bits and pieces of him,” she said. “And he just slowly became this thing.”
Boles saw her stepfather’s behavior as increasingly delusional. He’d bought a gun and once left it on the bed for her mom to discover it, she recalled. On multiple occasions, he called Boles’ sister, telling her he was contemplating suicide, keeping her on the phone for hours as she talked him out of it.
Boles put some distance between her family and Harbin, moving to Colorado in 2010. “I didn’t know how to help him other than to set boundaries for us,” she said. Angie followed, filing for divorce.
What finally saved Harbin was a lucky accident. He stumbled on the number of a little-known substance abuse clinic for the psychology department of the University of New Mexico runs out of a tiny on-campus residence. The clinic offered state-of-the-art treatment, and his lack of health insurance was no obstacle: They charged him $1 per session.
His progress took years — “a real roller coaster ride,” he called it — but with the counselors, he finally began to unpack the root causes of his drinking and to treat an underlying depression. The clinic eventually referred him to UNM’s Addiction and Substance Abuse Program, where his treatment continued and clinicians prescribed him naltrexone.
“It’s life-changing,” said Harbin. “I just never think about drinking, which is incredible for me.”
Despite its effectiveness, naltrexone is underused: Nationwide, just 1.6 percent of people with alcohol disorders have received medication for them. And in New Mexico, more than 100,000 people with any type of substance use disorder, fewer than 4,000 people have a prescription, according to the Legislative Finance Committee.
Harbin has been sober more than 1½ years, the longest period in his adult life he has gone without a drink.
His success is not an aberration: Treated according to best practices, people with addictions respond better to treatment and experience less frequent recurrence of symptoms (in their case, relapse into substance use) than those managing high blood pressure or asthma, studies show.
“If you have to have a chronic illness, addiction is not a bad one,” Miller said. “Most people do get far better over the course of treatment.”
Most patients at the Addiction and Substance Abuse Program are self-referred, and it surprised Harbin the program wasn’t more widely known. “The medical community doesn’t seem to be aware of the resources,” he said. “A whole lot of medical people that are in the UNM system [don’t know about it]which is really crazy.”
New Mexico’s medical community could do more to change this.
In 2004, with funding from the state Health Department and the Robert Wood Johnson Foundation, the New Mexico Medical Society created a handbook for the state’s physicians about screening and counseling patients on problem drinking. But the organization stopped distributing it in 2010 when the grants ran out and has not done further alcohol education since.
The Greater Albuquerque Medical Association has never offered any educational programs about counseling patients with alcohol disorders or prescribing them medications, according to executive director Sylvia Lyon. The failure to counsel even a single patient who needs it can have far-reaching consequences.
Harbin’s alcohol disorder hurt the people around him: Years after their divorce, Angie said she still has difficulty trusting people and will never remarry. “The focus is usually on the person that is suffering with the addiction, but the ripple effect is so broad, down to not only spouses and mothers and fathers and brothers and sisters, but the next generation.”
Indeed, Harbin’s relationships with his stepdaughters and his grandchildren seem beyond repair. In Al-Anon, the support group for families of people struggling with alcohol, they advise to detach with love, but by the end, Boles said she felt total indifference. “I just don’t see him as that person that I did love. The person that I did love … I can hold a different space for that person.”
Nowadays Harbin’s life is stable and quiet. He doesn’t have many friends and age is slowing him down. But he takes satisfaction from cleaning his front yard and he’s got a 20-pound mutt to take care of.
And having cleaned the carburetor of his Kawasaki motorcycle and recharged the battery, once or twice a month he will go on a ride. Years ago, he liked looping north on NM 14 behind the Sandias to Pojoaque, stopping in Jemez Springs to see a friend before completing the four-hour loop.
Now he mostly takes the bike to sessions at the clinic.
“I don’t know what it’s like for other people, but when I’m riding a motorcycle, I don’t think of anything else,” he said. “It’s kind of a mindfulness exercise. It wipes my mind clean.”
This reporting was made possible by support from the USC Annenberg Center for Health Journalism, the McCune Charitable Foundation, the Con Alma Health Foundation, and a fellowship from the Association of Health Care Journalists supported by The Commonwealth Fund.
Status quo has the inside track.