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Vol 2, No 24
19 June 2000
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Csardas Hitting Back
at the Bottle

Combating alcoholism in Hungary
An interview with Dr Mária Holzberger

Gusztáv Kosztolányi

It was with a slight sense of foreboding that I approached the porter at the gate of the National Psychiatric Institute at Lipótmező, a little off the beaten track on the Buda side of the capital. Having laboured my way uphill in the pitiless heat (ironic that after so much destruction was wreaked by the floods earlier in the year, we now should be faced with the prospect of a ruinous drought), I had to ask directions as to how to reach the National Alcoholism Institute (Országos Alkohológiai Intézet). The smartly dressed (and un-perspiring) porter told me to follow the road behind the main building and turn left towards the wooden hut.

So this was Lipótmező, visiting hours 9:00 to 19:00, a haven of dust-free tranquillity in the throbbing metropolis. Here and there, elderly ladies sunned themselves on the park benches, the lawns were tended to perfection, all a far cry from our popular preconceptions ("You're Lipótmező fodder!" we say, Lipótmezőre való vagy, when we wish to call someone's sanity into question, which just goes to prove how much of an institution the hospital is).

The directions were clear, and I soon found the unassuming wooden shack tucked away in the welcome shade of trees. My appointment was with Dr Mária Holzberger, head physician and deputy director of the National Alcoholism Institute, our foremost expert in the field of alcoholism and other forms of addiction. She greeted me with a warm smile and a cordial handshake.

Central Europe Review: Dr Holzberger, perhaps you could begin by telling me a little about the Institute, its tasks and its general role.

Dr Mária Holzberger: There is far more to the National Alcoholism Institute than its name suggests, since its tasks involve examining addictions in general, in other words, its activities cover a much broader sphere of issues than alcohol dependency alone. We are responsible for addictions as a whole, ranging from alcoholism, through abuse of illegal drugs to abuse of medicines, which are legally obtainable but used as drugs, such as tranquillisers and sleeping tablets.

In recent years, behavioural dependencies have been gaining ground. Here I think primarily of gambling, although many experts also talk of pathological eating disorders as well as of addictions related to work and other areas of activity, in which there is a great deal of truth.

The primary task of the Institute is to draft recommendations concerning both diagnosis and therapy for the use of professionals in the health care network specialising in this field. We also keep up a correspondence on methodology, to put it in layman's terms, we pass on information about the most modern diagnostic and therapeutic methods and techniques employed across the world or even simply within Hungary itself.

The main point is that professionals should be trying out these methods and techniques and - with a bit of luck - achieving results in so doing. Drawing up recommendations, then, is one facet of our work. We make these recommendations available to the national network of addiction and health care clinics and, last but not least, we compile statistical data, which allows us to form a picture of the spread of addictions amongst the population at large.

As a widely held trend of opinion would have it, around ten per cent of addicts come into contact with the health care network looking for help. I would multiply the number of addicts seeking health care by ten if I wished to assess the level of what I would in inverted commas refer to as the degree of "contamination" in the general populace, or at least try to discern the trends. This refers to the entire year. It is particularly important for me to apply such a correction factor if I wish to have a clearer idea of how many addicts of a given type of illegal substance are likely to turn up within the health care sector.

The recommendations made by the Institute are destined not only for decision-makers within the medical profession but for the political decision-makers as well. The Institute also deals with teaching, vocational training and further training within the specialist realm of addictology. Within this framework, training is provided for doctors, psychologists, paramedics and the middle ranks within the health service.

The Institute endeavours to focus on certain topics within the network itself, to carry out scientific observations and draw the relevant conclusions from this work. One example of such a topic might be biological therapy, in other words, investigating how effective a certain medicine might be. We studied the efficacy of Neutroxon, a heroin substitute used in the treatment of addicts, to name but one product.

Another possible object of enquiry might be determining the success rate of various psychotherapy or sociotherapy methods in treating individual cases or in group therapy. At the present juncture, very important research is being carried out into the healing effects of therapy communities on drug addicts.

Of course, another important area of research would be to observe alcoholics [I would like to point out for the benefit of readers with a knowledge of Hungarian that Dr Holzberger was consistent throughout in her use of the politically correct term alkoholbetegek rather than alkoholisták] and sufferers of alcohol dependency and draw conclusions based on the results of the study. Such an undertaking would make a valuable contribution in terms of methodology as well as research.

The Institute also attempts to foster close contacts with Hungarian experts in other fields of medicine as well. It is self-evident, for example, that alcoholics fall victim to internal complications such as cardio-vascular diseases and liver diseases, and that they come into contact with doctors specialising in the treatment of such complaints in the cardiological and gastro-entological units. This is why we too need to maintain contacts with colleagues in these fields.

Similarly, we keep in touch with surgeons, since the accidents in which injuries are sustained often happened when the victim was under the influence of alcohol, or - as has increasingly been the case latterly - under the influence of illegal drugs. At the same time, we strive to keep in touch with experts abroad, so there is also an international dimension to our network of relations.

We publish two journals: Network and A Szenvedélybetegségek [Addictions], in which we pass on our experience, our scientific conclusions and other information of importance to the network. Alongside these journals, the Institute produces the so-called Alcohological Mini Dictionary series, which comprise a broad range of subject matter - these are the books you can see on the shelves around you.

Foundations have also been set up alongside the Institute. Their task is to use the instruments at their disposal to bring about the sort of changes in the lives of individual addicts, which cannot be dealt with the way things stand at the moment within the institutional framework.

In this context I could mention the Agape Foundation, which focuses mainly on prevention, the Support Foundation (Támasz Alapitvány), which aims at encouraging addicts to enter into treatment at an early stage as well as organising the Unified Addiction Network (Egységes Addiktológiai Hálózat). The latter entails dealing with the patient according to the condition he is in rather than on the basis of what type of substance he is addicted to, and includes determining whether it would be expedient for him to put him into isolation for a given period of time.

The early treatment programme is the most important, since we have realised that alcoholics or those whose consumption of alcohol has assumed dangerous proportions, as a general rule only turn to specialist doctors once they have already drunk their brains or livers to oblivion, once they have already drunk themselves out of a living and out of a family. Once they have reached this stage, it is extremely difficult to offer them any real help at all. This is why we came up with a programme, the essence of which is that addiction care centres get in touch with GPs. This makes sense, as patients turn first to their GPs when the first slight symptoms and complications begin to appear.

They also contact the social workers, since the type of family problems caused by drunkenness will definitely crop up where these patients are involved. Behavioural counsellors are also contacted, because the inevitable changes for the worst first arise amongst the children. We, or rather the carers, discuss whether the problems reported, such as fluctuating blood pressure or a deterioration in the children's behaviour betray tell-tale signs of the presence of an addiction within the family.

We also discuss, and this is also very important, how to break the news to the patient or client in such a way that he does not take offence and reject the whole proposal out of hand, but accepts that the solutions being broached are in his own best interests.

In some of the cases, a minimum intervention of this type on the part of the GP is enough to nip an impending dangerous over-consumption of alcohol in the bud. If the addiction has already become established, however, expert help is indispensable, but in such cases we request that the GP, the social worker, the behavioural counsellor and other civil and ecclesiastical organisations send the individual concerned to the nearest local Support (Támasz) care centre, where we have established a counselling service and where the expert's task is to take matters further in order to instil motivation in the patient to get better.

The Support Foundation's main source of income for funding the extra work that such services imply is the interest they receive from grants awarded in open competitions. It is beyond all shadow of a doubt that four to six hour sessions are out of the question where the strictures of commerce apply.

Above and beyond this extra work, however, we also compile statistics over longer periods of time, say, over one or two years, to keep track of whether the number of somatic complications is on the decrease or just to gain an insight into exactly what is going on: How many people were referred to the Support care centre? How many have gone teetotal? How many have stayed teetotal? Once we are in possession of these statistics, we hand them over to the care centres in question, to give them ammunition in turning to the local social security fund or the operator in their effort to ensure they are given the increase in the number of hours they need to carry out these activities.

These efforts have been relatively successful, but much depends on the attitude of their local authorities, what their attitude to the problem is, because there are plenty of officials out there who believe that the patients had it coming to them, they richly deserved what has happened to them since it is their own fault. Where such attitudes prevail, we have not been able to achieve very much, but wherever the local authorities have recognised that - as is the case with every human illness - certain propensities are at work and that it is not simply a matter of coincidence that the patients have been propelled along this course.

Wherever they appreciate that once an individual has already become an addict, it is no longer entirely up to him whether he can kick the habit or not, that he has a genuine need for medical and human support because of the terrible withdrawal symptoms he usually receives or what he needs by way of help. This applies equally to the personal, family and psychological problems, which pushed him in the direction of dependency in the first place.

In the last few years in Hungary, about half of the addictology clinics have been modernised to adapt to the Support principles and a substantial proportion of these has succeeded in bringing about further progress.

In my opinion, early treatment is extremely important. A second key issue in the realm of addictions is as follows. Let us suppose that an addict reaches the stage where he decides to give up the substance in question and he has been detoxified. He has managed to go clean and is more or less stable. What he needs at this juncture is for someone to take an interest in him over a longer period of time within the framework of what is termed as "care work."

We experts can like it or lump it, but relapses are part of the nature of the illness and when they occur the tragedy lies not so much in the fact of the relapse itself as in the lack of a properly developed relationship between the addict and the expert carer if the addict does not feel that he can turn immediately to the expert to ask for emergency help because he has, quite literally, hit rock bottom.

What is true of the drug addict is also true of many alcoholics: that longer term care and attention, lasting between six and eighteen months in a rehabilitation institute, rehabilitation workplace or sheltered accommodation is needed. Rehabilitation alone is not enough: resocialisation is also called for. He has to re-establish a proper relation with his surroundings, modify the way he reacts to events, his values. What we are dealing with here is not just enabling a person to work again, but enabling a person to know what to do with themselves in their leisure time.

This is a particularly serious problem amongst opiate addicts: a destructive process laying waste to personality, behaviour, emotional life and values has set in, and the withdrawal symptoms have caused such awful torment that the addict would stop at nothing to feed the habit. These addicts really cannot cope with being at a loose end in their free time, and this is one of the reasons why they slid down the slippery slope of dependency. They could only find the company, the experience - which, by the way, is distorted and morbid but nevertheless pleasurable, imparting a sense of peace and harmony.

We all exist within a given context, a structure, and so we have to ensure that they learn it is possible to live without drugs or substitutes and still be happy or at the very least feel tolerably good.

Civil organisations have a vital role to play in assisting a client, who has either left the network or is still in the network, but who no longer lives within a close-knit therapy community, further along the road to recovery. These organisations provide the client with the community space within which the addicts' social and mental wounds can begin to heal, where there are points of reference and where those former addicts, who now live stable lives, can give them the natural community, which everyone needs. One final advantage is that the clients live in a drug-free setting.

CER: Since when has the Institute been operational?

Dr Holzberger: The Institute was organised in 1986-87. It was previously a methodological centre. Professor Levende who, interestingly enough, was a lung expert, noticed that even modern therapies were of little use in relation to alcoholics and patients who escaped from the wards. He was surprised to discover that an alcoholic was not willing to co-operate even when he suffered from such a serious illness as consumption. Dr Szonya Simeg was also included in the ranks of those, who began pioneering in the very early days at the end of the 60s. She was the head of the methodological centre, by the way.

At the same time, a good few psychiatrists were struck by the numbers of patients in the psychiatric wards whose illness was linked to alcoholism or szipuzás, the abuse of organic solvents or medicines. These days, with the help of modern drugs, many psychiatric patients can be treated as outpatients. There are certain groups of patients, however, who suffer from alcohol-induced hallucinations or alcoholic oeneroid states of consciousness and for whom an intensive course of treatment on a ward is essential.

Alcoholic dementia was also on the increase. From the beginning of the 60s onwards, the quantity of alcohol consumed per capita has doubled, and there has been a corresponding increase in the psychiatric complications caused by alcohol. I mentioned a few moments ago that we maintain contacts with other national institutes.

Together with Lívia Cserhalmi, a university lecturer, we established that the cause of heart diseases in 40 per cent of sufferers could be traced back to alcohol abuse.

CER: Do you think that changes in drinking habits have had an adverse effect on the population's state of health?

Dr Holzberger: One of the major problems these days is precisely the change in drinking habits in Hungary. On the one hand, whilst the village communities still existed there were certain accepted standards and these standards acted as a restraint, deterring people from drinking to excess. If someone broke the rules, it spelled the end of their livelihood, as no one would help out a drunkard. There was a certain ritual element to drinking. If you visited a friend or neighbour, you were offered drinks until you were bound to accept.

The advent of industrialisation altered the situation in Hungary as elsewhere. The standards and their power to hold people back went into decline and there was a shift in consumption patterns from wine to distilled spirits. It is easier to become addicted to pálinka than to wine. You would have to drink three litres of wine to enjoy the effect of two decilitres of pálinka and pálinka is easier to get hold of.

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There is also the question of establishing behaviour patterns. In families where alcohol abuse is a problem, the children are more susceptible to becoming alcoholics themselves in later life. 95 per cent of young drug-abusers grew up in families where alcoholism or heavy drinking was part of everyday life. The origins of addiction are extremely complex. With young people we are not confronted with someone who takes an ecstasy tab and nothing else but with taking an ecstasy tab and smoking marihuana and drinking as well. In even worse cases, the person concerned also sits down at the one-armed bandit and loses all the money that was supposed to be spent on feeding the family.

CER: Would you say then that alcoholism is confined to the middle-aged and older segments of the population?

Dr Holzberger: No, alcohol is a major problem amongst young people as well. Looking at last year's statistics, quite high numbers of young people between the ages of 15 and 19 were heavy drinkers, not to mention the age group of 20 to 34 year olds, amongst whom drinking has been extremely important. The total number of patients registered at the addiction care centres at the end of last year was 46,737. Of these 42,924 were alcoholics, 2396 were drug addicts and 1417 were hooked on both alcohol and drugs.

Remember, these figures date from the end of the year only. There are considerably greater numbers of alcoholics, since, if I take all the other information into account - in other words, if I include patients in psychiatric care centres, in the drug treatment units (drogambulanciák) and in the psychiatric/addiction wards of the hospitals - then the real number of people suffering from alcohol problems and who have turned up for treatment in the network is nearer the 70,000 to 80,000 mark.

As far as drug addicts are concerned, even if I include those who have turned up at the detoxification units and the toxicological wards - and they have almost certainly gone elsewhere too - the actual number is around 10,000 to 12,000, although I cannot find out for certain as the information concerning individuals is sketchier than in the case of alcoholics. The above figure also comprises everyone who has abused tranquillisers, sleeping tablets and solvents. Even if we were to discount the two major detoxification units, then we would still be talking of a total somewhere around 10,000 registered last year for Budapest as a whole.

Please also bear in mind that the figure is slightly misleading, because the numbers of registered patients are slightly higher than the numbers of those, who actually presented themselves at the clinics. The reason for this is that those who turned up at the clinics in 1998 remained in the register for 1999. Even bearing all these considerations in mind, there are still eight times as many alcoholics as drug addicts in Hungary.

CER: Yet all round the world, governments only ever seem to talk about the drug scourge, in spite of the fact that alcoholism is a problem of far more serious dimensions...

Dr Holzberger: In my opinion, this is because the stance adopted on narcotic drugs is quite unequivocal. Narcotic drugs are illegal substances; you are not allowed to consume them in any quantity. This is simply not regarded as open to argument. If I could put it even more pointedly, drug abuse is a crime, full stop and end of story. Although to experts the dividing line between social drinking and drinking to excess is clear, to laymen it is a fairly malleable concept, wouldn't you say? What would the reaction of the man in the street be? He would retort that you addictologists want to stop me from drinking even one paltry glass of beer!

That is not what we are aiming at, but if you look at the phenomenon in general terms, alcohol as such is a legal, socially accepted substance, the consumption of which forms an ancient tradition. It is built into the Judaeo-Christian tradition, and all of this makes it extremely difficult to deal with, even leaving aside the revenue aspect. Virtually everyone has been drunk once or twice in the course of their lives, let's face it, but no one likes to be branded an alcoholic. If something forms part of a culture and is socially accepted, then you cannot go at it hammer and tongs. Trying to encourage everyone in Hungary to be teetotal would be an exercise in futility.

CER: Have you noticed any marked changes in drinking habits over the last few years? Has the fairer sex become more fond of tippling?

Dr Holzberger: Unfortunately, there has also been an increase in alcoholism amongst women in the last few decades. Whereas it used to be far more typical for women to take tranquillisers in the old days and maybe drink on the sly, indulging a craving for sweet liqueurs and so on, they are now much more open about drinking.

This is almost certainly a by-product of emancipation. Women can hold their drink every bit as much as men. It is a Hungarian speciality to regard the ability to hold your drink as a sign of manliness. As you know, there is no shame attached to drinking huge quantities, quite the opposite. You are a real man if you can drink your friend under the table.

Heavy drinking amongst women is a warped form of equal opportunities. Twenty years ago, about eight per cent of the women who turned to the health service for help did so as a result of alcohol-related problems. These days, the corresponding figure is between 20 and 25 per cent. I do not believe either that alcoholism is a problem restricted to a given social stratum.

A great deal of attention has been paid to the phenomenon known as "destitution alcoholism" (nyomor-alkoholizmus). It is beyond all doubt that there are situations in life that are very difficult for certain people to cope with unless they take the edge of their pain by doping themselves up. If we disregard such extreme circumstances for a moment, then the reality is that alcoholism pervades all levels of society.

The difference is one of visibility. If a wealthy, well-situated individual develops an alcohol problem, he will either end up in an institution or he will be given a covering diagnosis. He may, however, end up sliding down the social ladder - this is a phenomenon we are studying amongst psychiatric patients, but the same holds true of alcoholics - thereby giving rise to the impression that alcoholism is more prevalent in the lower segments of society, whereas the reality is that the higher you climb in the social ranks, the easier it is to conceal alcoholism.

CER: I get the impression that there is a certain degree of social indifference about the evil effects of alcohol, which I imagine is hard to fight against.

Dr Holzberger: Truth to tell, it would be possible to do something about it if we were to succeed in putting the message across to the decision-makers and the politicians, if we were to attract their attention to the problem of alcoholism and make them accept that take it from us, fighting against illegal drugs is tilting at windmills unless we combat alcoholism.

In every single article and study we produce as an Institute and in every single statement that we make, we attempt to prove with the data at our disposal that it is of the utmost importance to sort out the problem. The media have a major role to play here too. If some unfortunate young person dies as the result of an overdose, the newspapers are full of articles lamenting this unnecessary waste of life. That so and so many middle-aged people die every year as a result of alcoholic intoxication is not considered to be news: the dog bit the postman, not the postman the dog, as it were.

CER: Would you say the situation has improved or deteriorated since the collapse of Communism?

Dr Holzberger: A great deal of progress has been made within the field of addictology, because the realities of life have forced the health service, the experts and even the politicians to take a look at these problems. A network has been set up. It works, although it has its difficulties to contend with, and much experience has been accumulated, which will prove its worth as further progress is made. One of the reasons for the uncertainty that bedevils our specialist area at the moment is that the entire health service is in the process of being transformed and performance-based criteria are being applied in funding.

To my mind, our area is particularly unsuited to being judged on the basis of performance, since the
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type of patient we are dealing with suffers from long-term personality and behaviour disorders. You cannot compare them with, say, a patient with pneumonia. In the latter case, you can gauge performance. You can determine whether the patient was given the best antibiotic over an appropriate period of time, or whether he was given too much by way of treatment. You can also assess objectively whether someone with appendicitis underwent the appropriate surgical procedure. With addictions, however, you are dealing with a group of illnesses, which originate from such a wide range of causes and which have such long-lasting effects that you simply cannot adopt a narrow-minded approach to them.

CER: Do you look to the future with dread?

Dr Holzberger: I am a born optimist. If I look back over how humanity as a whole has developed, or even if I look back over the history of my profession, it instils in me a sense of progress, even though there have been occasional aberrations here and there. Within psychiatry, for example, new medicines have become available and we have come far enough not to have to chain our patients to their beds. Medical science is objective enough to ensure that sooner or later the truth will prevail.

If we are continually furnished with statistical evidence that so and so many people die of cirrhosis of the liver every year, so and so many of alcohol-induced dementia and so and so many of cardiac problems brought on by alcoholism, if we can demonstrate that alcoholism in the family conditions the children growing up within it virtually predestining them to drug abuse, then sooner or later someone will sit up and take notice.

CER: Thank you, Dr Holzberger.

On my way back to the city centre on the tram, I was struck afresh by the sheer numbers of billboard advertisements for every imaginable brand of beer, both Hungarian and foreign. The catchy slogans (to give one example, "The frothy side of life" - az élet habos oldala) seemed rather hollow after having listened to the doctor's impassioned plea to sanity. Let us hope that hers does not remain a voice crying in the wilderness.

Gusztáv Kosztolányi, 19 June 2000

Author's Note: I would like to express my thanks to Dr Ilona Dobranovics for inspiring this article.

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