Alcohol, its problems and pleasures have been with us for millennia. The dilemma of how to view alcohol has never been better expressed than by Congressman Schwegel of Iowa. He had a standard reply about his views on Prohibition, back when it was an issue:

"If, when you say 'whiskey' you mean the devil's brew, the poison scourge, the bloody monster that defiles innocence, dethrones reason, destroys the home, creates misery and poverty, yea literally takes the bread from the mouths of little children; if you mean the evil drink that topples Christian men and women from the pinnacles of righteous, gracious living into the bottomless pit of degradation and despair, shame and helplessness and hopelessness — then certainly I am against it with all my power.

"But if, when you say 'whiskey,' you mean the oil of conversation, the philosophic wine, the ale that is consumed when good fellows get together, that puts a song in their hearts and laughter on their lips and the warm glow of contentment in their eyes; if you mean the drink that enables a man to go magnify his jciy and his happiness and to forget, if only for a little while, life's great tragedies, heartbreaks and sorrows; if you mean that drink the same of which pours into our treasuries untold millions of dollars to provide tender care for our crippled children, our blind, our deaf, our dumb, our aged and infirm, and to build highways, hospitals, and schools — then, certainly, I am in favor of it.

"This is my stand, and I will not compromise."

The man must have been a great politician.

Our desire to rid our society of "the bloody monster that defiles innocence [and] dethrones reason" was shown when we went so far as to pass the 18th Amendment to the Constitution and ushered in Prohibition. However, Prohibition proved that the majority of the population will not go without "the ale that is consumed when good fellows get together," and the resulting black market for alcohol created even worse problems for society than when it was freely available, and so the 18th Amendment was later repealed.

The problems caused by alcohol remain with us and we need to try new measures to separate "the bloody monster" from the "philosophic wine." Alcohol is directly involved in 50 percent of motor vehicle accidents, 50 percent of domestic violence cases, 50 percent of crimes and 70 percent of child abuse. In addition to its direct effect, alcohol is involved indirectly in much of the remaining percent of the above problems, because children raised by alcoholics grow up ignorant of healthy ways of dealing with life's problems. Although they may decide that they do not want to be alcoholics like their parents and so they do not drink, they still manage their lives in dysfunctional ways (well-described in books such as Adult Children of Alcoholics by J. Woititz, Ed.D.), often involving antisocial or criminal behavior. Patients in my practice who need treatment for anxiety and depression usually have a family history of alcoholism in parents or grandparents. In various studies, 50-70 percent of homeless people are alcohol dependent.

Our current methods of dealing with alcohol abusers are sometimes counterproductive. Oftentimes, they are induced or forced into treatment because of an arrest for driving under the influence. The actual penalty is taking away their driver's license, so we have an alcoholic struggling to get his life back together who cannot drive to his treatment program or to work. Yet, he can still walk down to the liquor store, buy more alcohol and continue to harm himself and others. This is especially true if, in his alcoholic stupor, he decides to drive without a license — an extremely common event. It would be much more useful to let him drive but not drink.

Prohibition failed because it deprived even those who could drink responsibly (70-90 percent of the population) from the pleasures of alcohol. We need to find a way to prevent those who harm others when they drink alcohol (1-5 percent of the population) from getting that alcohol, but let those who drink responsibly have access to it. Because there is no way to do this precisely, we need to approach any restrictions cautiously, minimizing interference with responsible alcohol drinkers in order to evince a wide base of support in the population. We already have a successful and accepted model for reasonable regulation of a useful but potentially dangerous activity — licensing of drivers of motor vehicles. Licensing of alcohol consumers is a reasonable way to approach our goal of reducing the harm to society caused by the use of alcohol.

Factors to be Considered in Developing a Licensing Plan

1) Most people are incredibly ignorant of the nature of addiction, the effects of alcohol or other drugs, and the role of alcoholism in a wide array of social problems. In order to provide information to those especially in need of it and to ensure that they are learning at least a minimally necessary amount, the Alcohol Consumption License (ACL) could be obtained only after passing a test similar to a driver's license test. Instead of knowing traffic laws, the knowledge required to obtain an ACL would be the physical and personality effects of alcohol, interactions with other medicines, the genetics and other risk factors for alcoholism, the nature of and early signs of alcoholism, the role of alcoholism in violent behavior, the effects that alcohol abuse by parents has on children and other family members, and other pertinent information. Although this may sound extensive, it would probably be less than one-hundredth of what is in any state vehicle code that must be learned to obtained a driver's license.

2) The first part of a substance abuse treatment program is education in these matters for both the alcoholic and his/her family. With the education necessary to obtain an ACL, we would essentially ensure that anyone who drinks alcohol would have also entered the first stage of treatment — education.

3) This is a very new concept, so it should be undertaken with the idea of revising and adapting it as new information is acquired. When there is a policy choice to be made, we should always err on the side of public acceptability as opposed to effective prevention, so as not to recreate the errors of Prohibition.

4) Given the regional differences in people and the different sizes and population densities of different states, it is unlikely that one system could be adequately adapted to all states, so the role of the federal government would be minimal.

5) Any time a substance desired by people is banned, a black market develops. In order to minimize the black market, the ACL should be relatively easy to obtain and use, similar to a driver's license. The ACL would only have to be renewed every 10 years or so —just enough so that the photograph looked approximately like the bearer of the license. Since most people drink responsibly, this would minimize the inconvenience to the 90-95 percent responsible drinkers who do not cause society significant problems.

Because of the similarity to driver's licenses, the procedure for obtaining the ACL could be combined with obtaining a drivers' license. In California, even those who cannot drive obtain official state identification cards at the offices of the Department of Motor Vehicles. These cards and licenses are now very hard to forge, with the holder's picture and a holographic state emblem imprinted right on a plastic card. It would be quite easy to add ACL tests to the procedure and have the cards of those that pass imprinted with a pink square in one corner, or some other way of signalling their right to consume alcohol. Clipping off this corner would suspend the ACL.

Variations

How the license is used would vary from state to state — we need to take advantage of our federal system for social experimentation in order to find the best use. Some possible options:

1) An ACL would need to be presented before buying any alcoholic beverage in a store or bar or when more than two drinks or half a bottle of wine (per person) are ordered with food in a restaurant.

2) An ACL would need to be presented before buying any alcoholic beverage anywhere.

3) An ACL would not need to be presented before buying any alcoholic beverage, but anyone found causing a problem, having a positive breath test (or refusing a test) and not having a license would be liable for extra fines, jail time, etc.

Reasons for suspension of the license could also be varied from state to state. The license could be suspended for anyone whose drinking has become a problem to society— driving under the influence, drunk and disorderly, disability due to alcoholism, or any criminal or violent behavior while under the influence (including domestic violence). It could be reinstated in some circumstances for those who complete appropriate treatment and do not repeat their problem behavior for a reasonable amount of time (many recovering alcoholics are perfectly able to be around alcohol and to provide alcohol to guests without relapsing). It could also be suspended for 1 to 6 months or so for anyone furnishing alcohol to someone who is without a license.

If some states wish to be more intrusive and paternalistic, they could be even more restrictive and suspend the license of anyone diagnosed with untreated alcoholism to protect them from themselves and see how effective those measures are. Many alcoholics drink alone, partly to hide their drinking from others. Many others have difficulty finding anyone to buy alcohol for them (their sober friends and family will not do it), but I have been amazed over the years at the number of people who are bedridden and seemingly non-functional at home, but still get alcohol delivered to them until they are actually too sick to lift the bottle delivered to their bedside.

It might be reasonable to make exceptions for parents who serve alcohol to their teenagers at home, e.g., a 19 year-old could have wine with dinner at home with his parents.

The Primary Objection

It is often argued that those whose license had been suspended would just find someone to buy alcohol for them, but that is not likely to be true: 1) A functioning alcoholic who has lost his license would be somewhat shy about asking his friends to buy alcohol for him— what if they ask why he lost his license? There is a reasonable chance that he would wish to maintain his image of normality and do what was required to regain his license or accept its loss as something in his best interest. 2) A responsible drinker would not be inclined to buy alcohol for someone without a license because, through the educative process of obtaining a license, he would know that lack of a license means the requestor has a major problem with alcohol, and "friends don't let friends drive [or get] drunk." 3) Most people, but especially alcoholics would not want to risk losing their own license by buying alcohol for someone without a license — addicts protect their own source of supply above all else.

Certainly, there would be exceptions, but the social pressure preventing.those who cannot drink responsibly from getting alcohol would be vastly increased. As education of the public through the licensing process progressed, the general awareness of alcohol-related problems would enhance compliance with the law by responsible drinkers. Moreover, harmful behavior by those who only act harmfully while under the influence would be greatly decreased. Those who are in treatment would be able to drive to work and to treatment programs, but they would not be allowed to buy alcohol legally.

Problems like those during Prohibition would be largely avoided because the vast majority of consumers would still have easy access to alcohol. Even of those denied legal access to alcohol, only the most socially bankrupt would engage in black market acquisition of alcohol and risk fines or jail — the others would abstain or seek treatment, if only to get back their license.

Consequences of Illegal Consumption

Those who persist in obtaining alcohol illegally should probably be put in a one- or two-year coerced treatment program. First, it has been shown that even coerced treatment helps (California has had good success with pilot programs in two of its prisons). Second, these are the kind of alcoholics that often eventually become public charges because of cirrhosis or Wernicke-Korsakoff syndrome, so we may as well make them temporary public charges early on to try to prevent them from becoming permanent public charges later.

Other suggestions or refinements are welcome to the arena of ideas— we have fifty different states in which to try various permutations. However, we should not wait while we argue and philosophize over the "perfect" program. We need to do something now to bring under control the problems caused to our society by alcohol abusers and it needs to be acceptable to the vast majority of the populace. Alcohol consumption licensing is a reasonable step to take.

If the ACL program proves to be successful at reducing the harm from alcoholics, it could create public and political support for expansion to other drugs, the first of which should probably be tobacco. With every addictive drug for which use could be made legal while minimizing social harm, there could be increased tax funds for treatment programs, decreased black market, less money needed for enforcement and overall less social harm from crime as well as direct effects of the drugs.

James T Hamilton, MD, FAAFP, Diplomate, American Board of Family Practice, can be contacted at 1401 Avocado Avenue, Suite 403, Newport Beach, CA 92660, (714) 721-6788.