In Debate
Can Patients With Alcohol Use Disorders Return to Social Drinking? Yes, So What Should We Do About It?
David Hodgins, PhD, CPsych1
(Can J Psychiatry 2005;50:264–265)
Click here for author affiliations.
Polemics on the issue of whether people with alcohol use disorders can learn to moderate their alcohol use have existed for decades (1). On one side of the debate are advocates of the disease, or 12-step, model of alcohol problems, who argue that individuals suffering from the disease will inevitably lose control of their use if exposed to any amount of alcohol. According to this model, abstinence is the only way to arrest the disease’s development. From the alternative perspective, several related arguments are mounted. Some proponents argue that “different folks require different strokes”—that different types of alcohol problems require different types of responses, such as abstinence for some problems and moderated drinking for other types. Other clinicians focus on the benefits of adopting a harm-reduction orientation toward alcohol problems. This approach focuses less on the amount of alcohol consumed and more on helping individuals decrease the harms related to alcohol use. Although abstinence may be desirable, it is not the primary measure of successful outcome. In this paper, I briefly review the arguments supporting the feasibility of nonabstinent drinking outcomes and argue further that we should shift the debate from whether nonabstinent goals are feasible to how we can best integrate such a perspective into our treatment systems. If we expand the range of our treatment options, we may encourage more people with alcohol use disorders to seek treatment. Finally, I discuss what interventions are appropriate to incorporate in this expansion, if we accept that nonabstinence goals are appropriate for some people.
Several lines of evidence point to the validity of nonabstinence treatment goals for some people with alcohol use problems. First, as early as the 1940s, follow-up studies of individuals suffering from alcoholism have revealed that a proportion of patients, albeit a small group, describe successful and sustained nonabstinence outcomes (2). The most widely cited of these studies is the Rand report from the mid-1980s, which followed up a large US national sample of patients from abstinence-oriented inpatient alcohol treatment programs. Remarkably, about 18% of these patients were described as drinking in a problem-free fashion after 4 years (3).
A second line of evidence comes from treatment evaluation studies that have included nonabstinent drinking goals. Amborgne recently reviewed these studies (2) and identified 12 that consistently found that some patients were able to sustain posttreatment nonproblem drinking over follow-up periods ranging from 1 to 8 years.
Several patient characteristics are found to predict successful nonabstinent outcomes. These include younger age, relatively better social and psychological stability, being employed, being female, and having less severe alcohol dependence (4), as well as having a stronger belief in one’s ability to moderate drinking (5). Several medical factors, including pregnancy and liver disease, preclude a nonabstinent goal.
Why, then, have our treatment systems not fully embraced these data and promoted interventions that allow nonabstinent outcome goals? The diverse political and economic barriers to system change have been discussed elsewhere (6) and are not limited to the substance abuse field. However, one relevant factor is, of course, the experience and intuition of individual clinicians. As clinicians, we are uncomfortable with incorrectly predicting an individual’s outcome. Unfortunately, none of the patient characteristics that predict successful moderation are robust enough to be used by clinicians planning individual patient treatment. Rather, a probabilistic model fits—the more indictors present in an individual, the more likely it is that the goal is appropriate. Even so, the prediction is not perfect: a particular patient with all the right indicators for successful moderation (for example, a younger, socially and psychologically stable woman with a mild alcohol problem) might better quit than cut back on her drinking.
What are the implications of assuming the “wrong” goal for an individual? A small group of treatment studies have randomly assigned individuals to either abstinence or nonabstinent drinking goals (2,7). These studies that compare drinking goals do not find differences in outcome, which suggests it is not harmful to allow individuals to attempt to moderate their drinking instead of abstaining (2). In fact, it may be advantageous to allow patients to make their own goal choice. Goals change over time, and treatment can provide experiences that will encourage patients to reconsider and revise their initial goals. In one Canadian study in which we allowed goal choice among people with severe alcohol dependence, participants choosing moderation initially tended over time to change their goal to abstinence, presumably following lack of success with moderation (8). Choice of abstinence by these patients ultimately predicted better outcome at 1-year follow-up. In short, the appropriateness of a patient’s goal will declare itself over time and, usually, in short order.
There is also indirect evidence that individuals can make good choices for themselves. Humphreys (9) examined the characteristics of people attending Moderation Management, a self-help group that allows goal choice. Almost all attendees choose a nonabstinent goal. As a group, attendees had characteristics similar to the characteristics that predict success with nonabstinent goals. In particular, they reported less severe problems than do individuals who attend formal abstinence-oriented treatment programs. It appears that the right people are choosing this treatment approach.
Humphreys argues that groups like Moderation Management extend the traditional treatment system by attracting people who would not attend traditional treatment. Allowing a choice of goal may be one effective way to increase the numbers of people willing to enter alcohol treatment. It is estimated that as few as 10% of individuals with alcohol use disorders attend treatment (6); more flexible goals may appeal to a wider range of these people.
There is also evidence that therapy can move people toward choosing a realistic drinking goal for themselves. In a recent New Zealand study that allows participants to choose their drinking goal (7), participants assigned to Motivational Enhancement Therapy (MET) were more likely to choose abstinence than were those assigned to nondirective counselling. This suggests that nonconfrontational clinician therapist interaction that encourages patients to examine the effects of alcohol on their lives facilitates a realistic goal choice. This finding is consistent with clinical practice. I often point out to trainees that it is extremely easy to get people to leave your office and discontinue treatment when they are uncommitted to change. The real challenge for clinicians is to instead have the defensive and ambivalent patient engage with the treatment process and move toward making appropriate decisions. From a stage-of-change perspective, it is easy to push people back to the precontemplation stage of change but more difficult to keep them in the contemplation and action stages. However, more systematic research is warranted on the effect of treatment on the process of making and revising drinking goals.
In conclusion, clear evidence supports the feasibility of nonabstinent drinking goals. Several writers (for example, 10) have noted that even the “Big Book” from Alcoholics Anonymous (AA) acknowledges the “different strokes for different folks” perspective: “A certain type of hard drinker” (11, p 39) is seen as able to moderate alcohol use. In fact, throughout the AA writings, multiple categories of alcohol disorders are assumed, with the AA program being aimed at those with disease-type alcoholism. Given the feasibility of nonabstinent drinking goals, which treatment approaches allowing flexible drinking goals have empirical support? Certainly MET is an approach that is entirely suited to flexible drinking goals. In a comprehensive review of the evidence base for alcohol treatment, Miller identified MET as having the largest number of studies and strongest support for effectiveness (12). Also high on the list are approaches such as behavioural self-control training and behavioural contracting, which have been evaluated with nonabstinent drinking goals. As Miller’s review points out, these approaches are not commonly available across North America. Our challenge is to allow our experiences to move us beyond the debate concerning moderation as a treatment goal (our contemplation stage) to designing and implementing treatment systems that integrate diverse evidence-based interventions (our action stage).
References
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3. Polich JM, Armor DJ, Braiker HB. The course of alcoholism: four years after treatment. New York: Wiley; 1981.
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7. Adamson SJ, Sellman JD. Drinking goal selection and treatment outcome in out-patients with mild-moderate alcohol dependence. Drug Alcohol Rev 2001;20:351–9.
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11. Alcoholics Anonymous. Alcoholics Anonymous. 3rd ed. New York: Alcoholics Anonymous World Services Inc; 1976.
12. Miller WR, Wilbourne PL, Hettema JE. What works? A summary of alcohol treatment outcome research. 3rd ed. In: Hester RK, Miller WR, editors. Handbook of alcoholism treatment approaches. Boston (MA): Allyn and Bacon; 2003. p 13–63.
Author(s)
Manuscript received and accepted in December 2004.
1. Professor, Department of Psychology, University of Calgary, Calgary, Alberta.
Address for correspondence: Dr D Hodgins, Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4
e-mail: dhodgins@ucalgary.ca
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