In Debate
Are Attempts at Moderate Drinking by Patients With Alcohol Dependency a Form of Russian Roulette?
Nady el-Guebaly, MD1
(Can J Psychiatry 2004;49:736-742)
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In 1962, Davies reported on 7 male patients who showed normal drinking habits, out of a total of 93 “alcohol addicts” as defined by the WHO at the time (1). All 7 patients had achieved a period of complete abstinence ranging from a few months to a year before taking up “normal” drinking for a period ranging from 7 to 11 years. Follow-up included out-patient attendances, contact by a social worker, and correspondence with relatives. Davies’ paper received 17 critical commentaries in the same journal. They included the following statements: “in many years of practice, we never encountered a true alcoholic recovering the ability to drink normally,” “drinking resumption was a freak anomaly of human biochemistry or psychopathology,” “these patients may have been genuine alcoholics but not genuine normal drinkers,” and “their drinking was simply a prelude to full relapse.” While Davies was not the first to report this phenomenon, he was the first to give it prominence in the paper’s title, hence, the widespread reaction.
In 1981, Heather and Robinson marshalled the related evidence in their book Controlled Drinking (2). The notion of normal drinking by previously identified individuals with alcoholism essentially contradicted the dominant concept of alcoholism as an irreversible disease characterized by loss of control, that is, by the inability to stop once drinking commenced, as described by Alcoholics Anonymous (AA, 3)—a trait later adopted by Jellinek as a characteristic of the gamma alcoholic (4). In Heather and Robinson’s view, loss of control described rather than explained alcoholic drinking.
Throughout, a conceptual dichotomy differentiated between individuals suffering from the disease of alcoholism and those whose drinking might be abnormal in quantity and harmful but who were not diseased. Modern versions of this dichotomy have been adopted by Edwards and others in their delineation of the alcohol dependence syndrome as part of a range of alcohol-related disabilities (5). In its criteria for alcohol dependence vs alcohol abuse, the DSM-IV TR nosology reflects a similar range (6), as does the ICD-10 differentiation between dependence and harmful use (7).
The Debate Today
Fast-forwarding some 25 years, the professional debate in the field does not, in my opinion, seem to elicit as much passion as it once did, owing to several developments. The first development is recognition that the terms used required further definition. Heather and Tebbutt proposed that the definition of controlled drinking (CD) should include some limit on the amount and frequency of consumption (that is, a maximum of 3 oz of alcohol daily) and the condition that the drinking does not result in signs of dependence (that is, withdrawal syndrome) or social, legal, and health problems (8). At present, the term “problem drinker” is increasingly replaced by the nosological dichotomies (based on DSM and ICD criteria) of abuse or harmful use and dependence.
The second development is increased consensus that abstinence remains the preferred, safer outcome for individuals with alcohol dependency. However, several studies report resumption of controlled drinking, with prevalence estimates ranging from 2% to 30%, depending on definitions. Miller undertook a comparative analysis of 4 samples (n = 140) of media-recruited problem drinkers who self-referred for behavioural self-control training (9). Of the original 140 cases, 99 (71%) were accounted for as follows: at 3.5, 5.0, 7.0, and 8.0 years, respectively, 23 were abstinent, 14 reported controlled and asymptomatic drinking, 22 were improved but still impaired, 35 were unremitted, and 5 were deceased. Most of the long-term controlled drinkers had established their pattern within the first year of follow-up, but maintenance of this pattern could not be reliably predicted (9). Related to abstinence is the so-called “dry drunk” syndrome. Dry drunk is a lay term used by AA to describe an individual with alcoholism who has stopped drinking but who may still be suffering many of the emotional symptoms common to actively drinking alcoholism sufferers (3). Being dry drunk is a cause of relapse, but could it act as a motivator for CD? From the published work, the goal of CD also appears to be somewhat more acceptable in the UK than in North America (10).
The third development is investigation of the factors predicting those individuals most likely to achieve CD. Two patient characteristics have received the most attention. One is the severity of dependence. Several studies tend to show that a less severe drinking problem, measured in various ways, predicts an association with CD (9,11)—a finding supported by the occasional clinical difficulty of delineating the categories of abuse and dependence. A second characteristic is personal persuasion combined with the individual’s belief system: Studies tend to support the hypothesis that outcome is influenced by the degree to which an alcoholism sufferer believes in the necessity of abstinence, together with the degree to which the person is persuaded that CD is attainable. Other potential predictors studied have included lower frequency of treatment; lack of participation in AA; continuous pretreatment drinking styles; higher psychological and social stability; and younger age, employment status, and female sex. Many of these results are based on self-reports, albeit with collateral confirmation. A minimum follow-up period of 2 years is also recommended, as significant changes in drinking may occur over time. Individual drinking courses are shaped by an interactive combination of characteristics, but none fully predict the potential for CD.
This section should conclude with Vaillant’s report on a unique 60-year follow-up of men with alcoholism. By age 70 years, 54% of the 72 successfully followed alcohol-dependent men living in the city core had died, 32% were abstinent, 1% were controlled drinkers, and 12% still abused alcohol. By the same age, 58% of the 19 successfully followed college-educated alcohol-dependent men had died, 21% were abstinent, 10.5% were controlled drinkers, and 10.5% abused alcohol. The concept of the inexorable progression of alcohol abuse may be correct only in its initial stage. As with tobacco abuse, some smokers progress to 2 packs daily in a few years, whereas others maintain a habit of one pack daily for decades (12).
The fourth development is the concept of pathways to recovery and the “harm reduction” option. Most individuals with drinking problems do not enter formal treatment. In a 3-year longitudinal study of 135 attendants at a detoxification centre who had never received professional treatment, almost one-half (48.3%) of those for whom outcome could be clearly determined became moderate drinkers or stably abstinent. At baseline, those who became abstinent (n = 28) were of low socioeconomic status, had severe drinking problems, and believed their drinking was a serious problem. Once they began their recovery, they relied heavily on AA as a maintenance factor. In contrast, individuals who became moderate drinkers (n = 29) had high socioeconomic status and more social support at baseline. In this study, it was possible to predict through a logistic regression which natural recovery pathway an individual drinker would follow (13).
Over the last 25 years, a harm-reduction strategy emphasizing the outcome of reduced harm and improved psychosocial function as an alternative to a sole focus on abstinence has gained prominence (14). As an example, a harm-reduction outcome is often an initial pragmatic strategy for individuals with alcohol dependence and severe psychiatric comorbidities. A goal of abstinence is often perceived, at least initially, as forbidding. Hodgins and others reported that, when given a choice of outcome at the initial assessment, 46% of 106 subjects with chronic alcoholism chose abstinence, 44% chose moderate drinking, and 9% were unsure (15). After 4 weeks of treatment, two-thirds of the subjects chose abstinence.
A fifth development is the “brain switch” hypothesis. The National Institute on Drug Abuse (NIDA) findings (16) of major pervasive differences between the brains of individuals with and without addiction have advanced the hypothesis of a metaphorical switch in the brain to be thrown as a result of prolonged drug use. Drug use, initially a voluntary behaviour, transforms itself into compulsive drug seeking and, hence, to a state of addiction. The addicted brain experiences changes in metabolic activity, receptor availability, gene expression, and responsiveness to environmental cues. A reasonable standard of treatment success would be a significant decrease in drug use and long periods of abstinence with only occasional relapses (16).
The sixth development is a mutual help experience, “Moderation Management (MM).” In the 1990s, a mutual help organization began to gain notoriety by attracting persons with problem drinking who were not dependent on alcohol and not interested in abstinence-only organizations. Many 12-Step advocates predicted that this approach would simply reinforce alcohol denial, described as a “grandiose penchant for estimating one’s ability to control drinking.” A survey of the MM membership confirmed that members scored a full SD below AA members on measures of alcohol dependence and were more likely to be women, under age 35 years, and currently employed (17). However, at least 15% of the members did meet the criteria for alcohol dependence. MM’s founder, Audrey Kishline, was to leave MM, join AA, and unfortunately cause the widely publicized death of 2 people in a drinking-while-impaired accident (17). Whether a mutual help approach to nondependent drinkers attempting moderate drinking would benefit public health is worthy of investigation.
Conclusion
The question remains as to why people want to continue drinking when they know it causes them harm. In my opinion, a harm-reduction strategy has currently subsumed the CD movement. For many, the harm-reduction option is an opportunity to embark on the arduous process of recovery that appears, at least initially, forbidding. It is also recommended that, when a CD approach fails, the patient is to be persuasively counselled to adopt a goal of abstinence. Of interest, the DSM-IV diagnostic course specifiers do not recognize CD.
Recovery is supported by the belief that one cannot drink. This belief is reinforced by AA’s membership, wherein the new member demonstrates where not to go and the old-timer shows what is possible with abstinence.
Representation of both advocate and skeptic views of CD in a clinical team can be clinically useful. “Keeping each other honest” is important and provides balanced options to our patients. With more treatment options, the range of severity among individuals accessing treatment is much broader than in the past, hence the need to individualize treatment goals.
Acknowledgement
I gratefully acknowledge the thoughtful commentary of Dr WG Campbell.
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