A man in his fifties sits across from his doctor hearing the words he has been dreading, that his liver tests show serious damage, that if he does not stop drinking he will not see his grandchildren grow up. He wants to stop. He has wanted to stop for years. But wanting and stopping are different things, and every time he has tried, the shaking starts within hours, the anxiety becomes unbearable, and by nightfall he is at the liquor store telling himself this is the last time, knowing it probably is not. A woman hides bottles around her house in places her husband has not yet discovered, drinking just enough to function through the day, dreading the mornings when her hands shake until the first drink steadies them. She knows she has a problem. Everyone knows she has a problem. But when she looked into treatment, she found programs designed for people who could take weeks off work, and she cannot take weeks off work, so she manages as best she can, which is not very well at all. A university student drinks the way everyone around him seems to drink, heavily on weekends, sometimes through the week, blacking out occasionally, waking up with regrets frequently, telling himself this is normal, this is what being young is, even as something whispers that normal should not feel this desperate and this out of control. A retired woman whose wine with dinner became wine instead of dinner has finally stopped after a hospitalization scared her into sobriety, but now she sits in her quiet house not knowing what to do with evenings that once organized themselves around the ritual of the glass, the bottle, the slow numbing that made loneliness bearable. Alcohol is the most commonly used addictive substance in Canada, embedded in social rituals, marketed relentlessly, available everywhere, and normalized to a degree that makes problem use difficult to recognize and harder to address. Whether the systems meant to help people with alcohol problems actually reach them, and whether those systems understand what help requires, remains a question that affects millions of Canadians directly and millions more who love them.
The Case for Alcohol-Specific Treatment Focus
Advocates argue that alcohol use disorder deserves dedicated attention and resources distinct from other substance use disorders because of its unique characteristics and prevalence. From this view, treating alcohol as one substance among many obscures the specific challenges it presents.
Alcohol withdrawal can be medically dangerous in ways that withdrawal from most other substances is not. Severe alcohol withdrawal can cause seizures, delirium tremens, and death. Medical management is often necessary. Treatment systems must be equipped for this specific medical challenge that alcohol presents more acutely than most other substances.
The social embeddedness of alcohol creates recovery challenges that other substances do not present to the same degree. Alcohol is legal, widely available, and socially expected in many contexts. Recovery from alcohol use disorder means navigating a world saturated with alcohol, where declining drinks requires explanation and abstinence marks one as different. This social context requires specific attention in treatment and recovery support.
The prevalence of alcohol problems dwarfs other substance use disorders. More Canadians struggle with alcohol than with opioids, stimulants, or other drugs combined. Treatment systems scaled for less prevalent substance issues cannot serve the volume of people with alcohol problems. Investment should reflect prevalence.
From this perspective, improving alcohol treatment requires: expanded medically supervised withdrawal services; treatment programs designed for the social context of alcohol recovery; investment proportional to the prevalence of alcohol problems; specific attention to alcohol in prevention and early intervention; and recognition that alcohol is not just another drug.
The Case for Integrated Substance Use Treatment
Others argue that separating alcohol from other substance use disorders is counterproductive and that integrated approaches better serve people who often use multiple substances and share underlying vulnerabilities. From this view, substance-specific silos fragment care that should be unified.
Many people with alcohol problems also use other substances. Polysubstance use is common. Treatment systems organized by substance force people into categories that do not reflect their reality. Integrated treatment addressing substance use comprehensively serves people better than alcohol-specific programs that ignore other substance use.
The underlying factors driving alcohol use disorder overlap substantially with those driving other substance use disorders. Trauma, mental health conditions, social isolation, and genetic vulnerability affect risk for all substance use disorders. Treatment addressing these underlying factors rather than specific substances may be more effective than substance-focused approaches.
Creating separate treatment streams for alcohol creates access barriers and inefficiencies. Someone seeking help should not have to navigate different systems depending on which substance they use. Unified substance use treatment improves access and enables comprehensive care.
From this perspective, improving alcohol treatment requires: integrating alcohol services within comprehensive substance use treatment; addressing common underlying factors rather than substance-specific symptoms; eliminating separate silos that fragment care; and recognizing that the person matters more than the substance.
The Medical Model of Alcohol Treatment
Alcohol use disorder is classified as a medical condition in diagnostic systems, but whether and how medical treatment should dominate the response remains debated.
From one view, the medical model appropriately recognizes alcohol use disorder as a brain disease requiring medical treatment. Medications can reduce craving and support sobriety. Medical supervision manages withdrawal safely. Viewing alcohol problems as medical conditions reduces moral stigma that prevents people from seeking help. Medical treatment should be first-line response.
From another view, over-medicalization of alcohol problems may obscure social, psychological, and spiritual dimensions that medical treatment does not address. Medications help some people but not all. The disease model may encourage passivity rather than agency. Effective response requires more than medical intervention.
Whether alcohol treatment should be primarily medical or incorporate other approaches as equals shapes treatment philosophy.
The Role of Mutual Aid
Alcoholics Anonymous and other mutual aid groups have helped millions achieve and maintain sobriety, but their role in the treatment landscape remains debated.
From one perspective, mutual aid should be central to alcohol recovery. Peer support from those who have achieved sobriety provides something professional treatment cannot. The availability, accessibility, and no-cost nature of mutual aid groups makes them irreplaceable resources. Mutual aid works for many people.
From another perspective, mutual aid is not treatment and should not substitute for it. The spiritual emphasis of twelve-step programs does not fit everyone. Claims of effectiveness are based on self-selected participants who succeed, ignoring those who do not. Professional treatment should not defer to mutual aid or require participation in it.
Whether mutual aid should be integrated into treatment, recommended alongside it, or treated as separate pathway shapes how people are directed toward recovery resources.
The Moderation Question
Traditional alcohol treatment assumes abstinence is the goal, but whether some people can achieve controlled drinking rather than requiring total abstinence remains controversial.
From one view, abstinence is the only safe goal for people with alcohol use disorder. The nature of addiction makes controlled drinking impossible for those who have crossed into problematic use. Suggesting moderation is possible gives false hope and undermines recovery. Abstinence should be the clear and consistent message.
From another view, insisting on abstinence excludes people who might reduce their drinking if moderation were presented as acceptable goal. Some people do achieve stable moderated drinking. Offering only abstinence may prevent harm reduction for those who will not accept total abstinence. Individual goals should be individually determined.
Whether treatment should promote abstinence exclusively or support moderation for those who choose it shapes treatment philosophy and engagement.
The Early Intervention Gap
Most people with alcohol problems do not seek treatment until significant consequences have accumulated, raising questions about whether earlier intervention could prevent the progression to severe disorder.
From one perspective, screening and brief intervention in primary care can identify risky drinking before it becomes severe. A few minutes of physician advice can change drinking patterns. Early intervention is more effective and less costly than treating advanced alcohol use disorder. Systems should emphasize upstream intervention.
From another perspective, screening everyone for alcohol problems medicalizes normal behavior and may not be effective for those who do not perceive a problem. Brief intervention works for some risky drinkers but not for those with established alcohol use disorder. Resources should focus on treating those who are ready rather than screening those who are not.
Whether early intervention should be prioritized or whether resources should focus on treatment for those with clear problems shapes prevention and treatment investment.
The Stigma Barrier
Stigma against people with alcohol problems prevents many from seeking help, but how to address stigma is contested.
From one view, disease-model messaging reduces stigma by framing alcohol use disorder as a medical condition rather than moral failure. People do not choose to have a brain disease. Emphasizing the medical nature of alcohol problems encourages help-seeking and reduces shame.
From another view, disease messaging may reduce personal agency and suggest that recovery is not within individual control. Some research suggests that disease framing actually increases stigma. Alternative approaches emphasizing recovery and change may be more effective than disease rhetoric.
Whether stigma is best addressed through disease framing or other approaches shapes public messaging about alcohol problems.
The Access Challenge
Treatment for alcohol use disorder is theoretically available but practically inaccessible for many who need it.
From one perspective, treatment access is primarily a coverage and cost issue. Publicly funded treatment has limited capacity. Private treatment is expensive. Expanding public funding would expand access. The barrier is resources, and resources can be provided.
From another perspective, access barriers go beyond funding. Treatment programs require time away from work and family that many cannot afford. Programs may not be culturally appropriate. Previous negative experiences with treatment may discourage return. Addressing access requires more than expanding funding.
Whether access barriers are primarily financial or whether other barriers matter equally shapes strategies for improving access.
The Family Impact
Alcohol problems affect not just individuals but families who live with the consequences of drinking and often struggle to know how to help.
From one view, families should be integrally involved in treatment. Family members can support recovery. Family therapy can address relationship damage. Al-Anon and similar programs help families regardless of whether the person drinking seeks help. Treatment should be family-centered.
From another view, involving families in treatment can be complicated when family relationships are part of the problem or when confidentiality is important to the person seeking help. Family involvement should be offered but not required. Individual recovery should not depend on family participation.
Whether family involvement should be central or optional in alcohol treatment shapes program design.
The Canadian Context
Canada's alcohol policies and treatment systems reflect provincial responsibility for healthcare and liquor control, with significant variation across provinces in both alcohol regulation and treatment availability. Canada's Guidance on Alcohol and Health provides evidence-based low-risk drinking guidelines, though these have been contested.
From one perspective, Canada should strengthen alcohol policies including pricing, availability, and marketing restrictions that reduce population-level consumption alongside treatment expansion.
From another perspective, policy measures that restrict the majority should not substitute for treatment that serves those who need it.
How Canada balances population-level alcohol policy with individual treatment shapes the overall response to alcohol problems.
The Question
If alcohol is both a normal part of Canadian social life and a substance that causes enormous harm to millions of individuals and families, if treatment exists but those who need it often cannot access it or do not recognize they need it until tremendous damage has been done, if recovery is possible but the path to recovery remains unclear and the systems meant to support it remain fragmented - how should a society that both celebrates alcohol and suffers from it respond to those who fall into the gap between casual use and catastrophic use? When someone wants to stop drinking but cannot, when withdrawal is dangerous but medically supervised withdrawal is not available, when the choice presented is total abstinence or no help at all - is the system serving the people it is meant to serve, or has it created conditions that ensure many who need help will not receive it in forms they can use?