Alcohol abstinence vs. moderation

Degree of dependence predicts which strategy works best.

 A debate that started in the 1960s remains an important one in the addiction field: is it possible to control problem drinking, or must the drinker give up alcohol completely?

Clinicians often find that patients who enter alcohol treatment for the first time say they would like to find ways to cut back on their drinking rather than abstaining. And many people who have not yet developed symptoms of alcohol dependence, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), such as high tolerance or withdrawal symptoms, are nevertheless in danger of crossing the line into dependence.

Yet it may be difficult to encourage people at any stage of a drinking problem to seek help, owing to a combination of denial, stigma, and other barriers to care. Offering counseling on moderation may help convince some problem drinkers to seek help before they suffer painful consequences.

Dr. Thomas W. Irwin, program director of the McLean Center at Fernside, a residential drug and alcohol program affiliated with McLean Hospital, described a standard clinical approach for working with patients to determine whether moderation or abstinence makes the most sense when trying to address an alcohol problem.

Severity predicts relapse

Research into moderate or "controlled" drinking has shown that this strategy can be successful for patients who have not yet developed a pervasive pattern of alcohol abuse, or who have experienced few negative consequences from drinking. It also helps to be young, female, employed, in a stable social situation, and confident about moderating intake. The goal is to help patients set goals and drinking limits before they cross the line into dependence.

But the research shows clearly that moderation is unlikely to be successful for patients who already meet criteria for dependence, whether defined by the DSM-IV or by a variety of assessment tools.

One study, for example, followed the outcomes of drinkers for three to eight years after they participated in behavioral self-control training, a therapy designed to instill moderate drinking behavior. The researchers found that as severity of dependence increases, likelihood of patients' being able to reduce their drinking to moderate levels, and keep it there, goes down dramatically (see table). For the most dependent drinkers, abstinence may be the only option.

Symptom severity predicts alcohol treatment outcomes

As severity of alcohol dependence increases, the likelihood of being able to continue drinking moderately for an extended period decreases, according to a study that followed outcomes three to eight years after treatment.

Alcohol Dependence Scale

The higher the score, the greater the level of dependence

Success ratios

Proportion of former drinkers able to maintain their goal for at least 12 months

0 –14

1 abstainer : 3 moderate drinkers

15 – 20

1 abstainer : 1 moderate drinker

21– 27

11 abstainers : 6 moderate drinkers

28 or more

6 abstainers : 0 moderate drinkers

Source: Miller WR, et al. Motivational Enhancement Therapy Manual (National Institute on Alcohol Abuse and Alcoholism, Project MATCH Monograph Series, Volume 2, 1994), Table 2, p. 33.

Moderation as motivation

Moderation can be used, however, to motivate patients to change.

Many patients are ambivalent about giving up alcohol, even though they recognize that dependence is straining their marriages or jeopardizing their jobs. The sad reality is that alcohol has become so integral to their existence that they can't imagine what life would be like without it. A patient who expresses a desire to start drinking in a more controlled way is indicating a desire to change a behavior. Motivational interviewing can help patients progress toward change. With this technique, clients set the agenda, and the therapist acts as a partner in dialogue rather than an authority.

Demanding abstinence too soon may just end up driving away a patient who is at the brink of dealing with addiction more directly. When a patient expresses a desire to moderate drinking, it can alert the clinician to a teachable moment. Patients who try to limit drinking for a while and find they are unable to do so may then realize that they have already developed dependence. This may be enough to motivate them to try to abstain.

Miller WR, et al. "Long-Term Follow-Up of Behavioral Self-Control Training," Journal of Studies of Alcohol (May 1992): Vol. 53, No. 3, pp. 249–61.

Rosenberg H. "Prediction of Controlled Drinking by Alcoholics and Problem Drinkers," Psychological Bulletin (Jan. 1993): Vol. 113, No. 1, pp. 129–39.

Walitzer KS, et al. "Treating problem drinking," Alcohol Research and Health (1999): Vol. 23, No. 2, pp. 138–43.

For more references, please see www.health.harvard.edu/mentalextra.

Date Last Reviewed: 1/1/2009
Date Last Modified: 1/1/2009
Copyright Harvard Health Publications