Why can’t alcoholics learn to drink in moderation?

October 11, 2013

Dear Cecil:

I have a dear friend who’s an alcoholic. When he came out of treatment, I told him I couldn't see why he wasn’t able to condition himself to have, say, a single glass of beer and stop at that. He said it didn't work that way, but never got specific. Why can't an alcoholic learn to drink in moderation?

Cecil replies:

Because alcoholics, by definition, are incapable of drinking in moderation. Sorry if that seems like a kiss-off answer, but research and experience tell us that’s how it is.

Alcoholism is no trivial problem. The estimated 75 million or more alcoholics worldwide cost society from 1 to 5 percent of its gross domestic product. In Russia, where the problem is especially acute, male life expectancy is only 60 years, 15 years less than for U.S. men, largely due to alcohol abuse.

The question of how to control heavy drinking — abstinence or moderation — has been surprisingly controversial for something like 60 years. I say surprising because the basic facts have never been in dispute.

The dominant school of thought favors abstinence, arguing that alcoholics are too fragile ever to resist temptation and that a single drink can trigger a binge. Alcoholics Anonymous, founded in 1935 and at something like 2.1 million members the largest alcoholism support and treatment organization in the world, is a strong proponent of abstinence.

Abstinence has an impressive success rate, researchers have found. But some say it’s not the only way.

Investigation into alternative approaches was kicked off by a study of 97 English heavy drinkers in the 1950s, who were tracked for several years and generally found to be able to control their alcohol consumption without abstinence. In 1978 a Rand Corporation followup of U.S. heavy drinkers who’d received abstinence treatment found that 18 months later 22 percent could drink in moderation without problems, and after four years 18 percent were still doing so. Other work in the 1970s found that some with seemingly severe alcohol issues could be successfully trained to drink moderately, and had better life outcomes than those who stuck to abstinence.

These findings aroused bitter argument, for an obvious reason: if 18 percent of heavy drinkers can learn to drink in moderation, 82 percent presumably can’t. Nonetheless, over the years strategies were developed to teach heavy drinkers to control but not necessarily halt their consumption.

An approach that became a lightning rod in the 1990s was Moderation Management, a nine-step self-help program. “Prominent figures in the treatment and research communities denounced MM as a ‘dangerous temptation to alcoholics’ that was ‘built on the illusion’ that alcoholics could return to controlled drinking,” writes Stanford addiction researcher Keith Humphreys in a 2003 review of the program’s effectiveness.

Exhibit A: MM’s founder, Audrey Kishline. She “left MM, joined AA, and several months later caused the deaths of two people in a horrific car accident while severely intoxicated,” Humphreys reports.

But he points out the MM and AA crowds don’t fundamentally disagree. MM participants are told initially to abstain from drinking for 30 days, then switch to moderate consumption. If moderation fails, then a return to abstinence is recommended. The implication is that some heavy drinkers can control their habit and some can’t.

AA, he notes, says the same thing. Both groups “make explicit distinctions between problem drinkers who are able to return to controlled drinking and alcoholics. Both [groups] also concur that failure at the goal of moderate drinking indicates that a drinking problem is serious and is best addressed by abstinence.”

Research supports a two-pronged approach, finding that the most out-of-control drinkers generally get better results with abstinence, while those with less severe drinking issues often do OK with moderation.

So what’s the dispute about? A key element in AA theory is alcoholics’ capacity for denial, and its advocates see only the potential for tragedy in a system that lets drinkers decide they’re capable of drinking on occasion.

Humphreys, though, says his research showed people who sought help for excessive drinking for the most part were pretty clear-eyed and tended to correctly self-sort. AA members were more likely to be older males with severe alcohol-related problems — recent episodes of binge drinking, things like that. No doubt partly for that reason they had a greater chance of being jobless or otherwise socially and economically unstable. (Other research suggests they’re also more likely to be minorities.)

MM participants, on the other hand, tended to be younger, female, and white, with fewer indications of severe alcohol abuse.

But not all of them. About 15 percent of MM members, Humphreys reports, had major alcohol problems — “shaking when not intoxicated, delirium tremens, blackouts, convulsions or fits after drinking, and cravings for alcohol upon waking,” plus alcohol-related job issues. These people, he says, fit the profile for alcoholism — they just don’t admit it.

Thus your friend’s response. You don’t say whether he was in AA, but the first of the 12 steps is to acknowledge you’re powerless over alcohol. The research suggests no one arrives at this stark conclusion unless it’s true.

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References

Heather, Nick, et al. "Initial preference for drinking goal in the treatment of alcohol problems: I. Baseline differences between abstinence and non-abstinence groups." Alcohol and Alcoholism 45.2 (2010): 128-135.

Humphreys, Keith, and Elena Klaw. "Can targeting nondependent problem drinkers and providing internet-based services expand access to assistance for alcohol problems? A study of the moderation management self-help/mutual aid organization." Journal of Studies on Alcohol and Drugs 62.4 (2001): 528.

Humphreys, Keith, et al. "Self-help organizations for alcohol and drug problems: Toward evidence-based practice and policy." Journal of Substance Abuse Treatment 26.3 (2004): 151-158.

Humphreys, Keith. "Alcohol & drug abuse: A research-based analysis of the Moderation Management controversy." Psychiatric Services 54.5 (2003): 621-622.

Kellogg, Scott H. "On “gradualism” and the building of the harm reduction-abstinence continuum." Journal of Substance Abuse Treatment 25.4 (2003): 241-247.

Saladin, Michael E., and Elizabeth J. Santa Ana. "Controlled drinking: more than just a controversy." Current Opinion in Psychiatry 17.3 (2004): 175-187.

Sobell, Mark B., and Linda Carter Sobell. "Obstacles to the adoption of low risk drinking goals in the treatment of alcohol problems in the United States: A commentary." Addiction Research & Theory 14.1 (2006): 19-24.

Walters, Glenn D. "Behavioral self-control training for problem drinkers: A meta-analysis of randomized control studies." Behavior Therapy 31.1 (2001): 135-149.

Witkiewitz, Katie and Marlatt, G. Alan. “Overview of harm reduction treatments for alcohol problems” International Journal of Drug Policy 17 (200285–294.

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