Controlled Drinking: More Than Just a Controversy

Michael E. Saladin; Elizabeth J. Santa Ana


Curr Opin Psychiatry. 2004;17(3) 

In This Article

Harm Reduction

Harm reduction in the area of controlled drinking[9] has been conceptualized as an attempt at 'meeting people where they are' with respect to their motivation to change high-risk behavior. Rather than focusing on the elimination of high-risk behaviors, the harm reduction approach tends to favor reducing the harm or risk of harm.[62] While the present discussion will focus on alcohol problems, harm reduction approaches have been used to address a range of public health problems (e.g. methadone maintenance for opiate dependence and needle exchange program to reduce HIV infection among injection drug users.[62,63]) Like GSC, harm reduction is often targeted towards individuals who would, ordinarily, 'fall through the cracks' or never present themselves for treatment.

Harm reduction began in 1980 with the 'Junkiebond' movement in Rotterdam, The Netherlands. This movement evolved into a trade union that was formed to represent the needs and health concerns of Dutch hard drug users. The philosophy of the Junkiebond focused on the understanding that drug users know best what their needs are in terms of health care and housing and so they should be actively involved in deliberations affecting them. As 'junkie' league groups spread throughout The Netherlands, addicts' concerns about dirty needle use among their peers led to the establishment of the first needle exchange program in Amsterdam in 1984. This program provided disposable needles and syringes and collected used needles with the aim of reducing the spread of HIV infection among injection drug users.[64]

Borrowing from the harm reduction philosophy in Europe, advocates of harm reduction began applying its tenets to alcohol misuse problems in the US. Controversy was not far behind as harm reduction approaches did not require commitment to an abstinence goal.[65] Although adherents of the dominant disease model viewed this as a significant weakness, harm reduction proponents characterized their methods as more pragmatic, compassionate and inclusive.[66] Harm reduction rejects the 'all or nothing' abstinence approach based on evidence that alcohol misuse is distributed along a continuum rather than existing as a binary (present or absent) disease state.[67] By lowering the threshold for treatment entry, harm reduction encourages greater numbers of problem users to seek and access treatment.

From a harm reduction perspective, the zero-tolerance message communicated by abstinence-focused treatment programs is unrealistic and impractical.[65] It fails to acknowledge that some problem users (e.g. college students) are unwilling to abstain.[68] Harm reduction accepts this reality and seeks to reduce the negative consequences associated with continued use. By offering a choice of treatment goals, clients are more likely to remain in treatment and do not experience an increased risk of uncontrolled drinking.[9] A likely benefit of remaining in treatment is that it affords more opportunity for problem users to modify their drinking behavior. This point was illustrated well in a recent study[60] in which chronically alcohol-dependent individuals who were given the choice between abstinence and moderation and who initially chose moderation, often changed their goal to abstinence after 4 weeks of treatment. Thus, the harm reduction principle of goal choice can increase treatment retention and foster important changes in drinking, either in the form of moderation or abstinence.

It can and has been asserted that all controlled-drinking strategies could be subsumed under a heading of harm reduction.[65] However, the development of some controlled approaches (e.g. BSCT) significantly predated the presence of the harm reduction movement in the US and Europe. Furthermore, although BSCT is consistent with a harm reduction perspective, it cannot be said that it is a direct conceptual product of it. For these reasons and for general organizational purposes, we elected to present harm reduction approaches as a special case of controlled drinking.

Prevalence data on alcohol use indicate that 82% of 12th graders and 80% of college students drink alcohol,[69] with approximately 20% of the latter group being identified as problem drinkers.[70] As a group, college students are at especially high risk to engage in binge drinking and experience alcohol related consequences.[71] Fifty-four million Americans above the age of 12 years report consuming five or more drinks at least once in the past month (i.e. binge drinking) and 15.9 million report consuming five or more drinks on five or more days in the past month (i.e. heavy drinking).[72] According to a 1992 survey,[73] 11% of American men and 4% of American women met criteria for alcohol dependence or abuse during the past year. While these prevalence data represent clear evidence of substantial high-risk drinking among adolescents and adults, harm reduction interventions that could potentially address the broad spectrum of alcohol misuse in the US have not attracted the level of interest observed in Europe and Australia.[64,74]

Harm Reduction in School-Age Children and Adolescents

As noted above, adolescents and young adults are particularly at high risk for alcohol-related problems and injuries (e.g. unsafe driving, academic problems, and family conflict).[53,75] Historically, few interventions have had a positive impact on alcohol misuse and its associated consequences in young people, possibly because they focus too heavily on consumption and abstinence rather than emphasizing individual choice and risk reduction. The poor outcome of the Drug Abuse Resistance Education Program (DARE) is an unfortunate reminder that 'zero-tolerance' programs sponsored by institutional authorities (e.g. the police) are likely to fail.[76]

However, recent studies have documented the effectiveness of harm reduction approaches in reducing the amount of harm associated with alcohol misuse in primary and secondary school students.[65] For example, the School Health and Alcohol Harm Reduction Project (SHAHRP), conducted in Australia, is a large-scale intervention study aimed at reducing alcohol-related harm in secondary school students.[77] Students in the SHAHRP program received alcohol education, drinking choice information, skills training, assertiveness training, and other activities designed to minimize harm associated with the use of alcohol. Students receiving the harm reduction intervention were compared with a control group that received standard alcohol education classes. Results obtained over a 3-year period showed that students in the SHAHRP intervention exhibited a significantly lower level of alcohol consumption and decreased harm (e.g. hangovers, fighting, and troubles at school) associated with alcohol use compared with students in the control condition. Similar programs administered to children in US schools have reported either sustained reduction in alcohol use from junior high through the end of high school[78] or small reductions in the normative increases in alcohol use during adolescence.[79]

Harm Reduction in College Students

Marlatt and colleagues[80] examined the efficacy of an intervention called the Brief Alcohol Screening and Intervention for High-Risk College Student Drinkers (BASICS). High-risk drinking was defined as drinking at least monthly and at least five to six drinks per drinking occasion in the past month and reporting at least three alcohol-related problems on three to five occasions in the past 3 years. Rather than focusing on abstinence, the BASICS intervention[81] targeted reductions in both alcohol use and alcohol-related negative consequences. High-risk college students were randomly assigned to receive either BASICS or assessment only. Those in the BASICS intervention received personalized feedback based on assessment data containing information about how their drinking levels compared with other college students, information regarding BAC, risk factors, alcohol-related consequences, tolerance, and methods for drinking moderately. BASICS was delivered in a motivational interviewing style[52] that was both non-confrontational and empathic, but geared toward highlighting discrepancies between heavy drinking and achievement of life goals. At 2-year follow-up, the BASICS students showed significantly reduced drinking rates and fewer harmful consequences compared with high-risk, assessment-only students.

To examine the clinical significance of the changes in drinking behavior and related consequences observed in the Marlatt et al.[80] study above, a follow-up study was performed involving both of the previously studied high-risk college student groups (BASICS and assessment-only) and a non-high-risk 'functional' comparison group.[82] Compared with the assessment-only high-risk drinking students, the BASICS students evidenced greater reductions in drinking and alcohol-related problems. According to Marlatt and Witkiewitz,[65] the BASICS program may have altered the trajectory of drinking behavior of the BASICS students such that it more closely resembled the moderation trajectory of the non-high-risk functional control participants. The relatively dissimilar trajectories of the assessment-only group and the non-high-risk functional control participants suggested deterioration in the high-risk group.

A second follow-up report on the high-risk drinkers in the Marlatt et al. study[80] examined the impact of the BASICS intervention on alcohol use and alcohol-related problems at 4-year follow-up.[83] The results indicated that while BASICS had only a modest effect on drinking, it significantly reduced negative consequences 4 years following the initial intervention. Specifically, 67% of the high-risk BASICS students reported good outcomes versus 55% in the high-risk control students. In addition, dependence symptoms were more likely to decrease and less likely to increase for participants in BASICS than for the high-risk controls. This was the first study to demonstrate long lasting benefits of a brief, non-abstinence intervention for high-risk college drinking.

In a randomized controlled trial targeting high-risk college drinkers, Murphy and colleagues[84] compared the BASICS program with an educational intervention and an assessment-only control condition. Although there were no overall significant differences between groups at the 3-month follow-up, the BASICS group showed a significant advantage over the education and control groups for students who were heavy drinkers. Students in BASICS who drank at least 25 drinks per week and engaged in binge drinking at least three to four nights per week showed greater reductions in weekly alcohol consumption and participated in fewer binge drinking days compared with similar individuals in the education and control groups. Heavy drinkers in BASICS also maintained their comparatively large reductions in amount of alcohol consumed and number of binge drinking days at the 9-month follow-up.

Internet/PC-based Harm Reduction

It was noted above that a computer-based version of BSCT could produce substantial reductions in the drinking behavior of heavy drinkers.[31] Although not based on BSCT, Squires and Hester[85] have developed a computer-based intervention called the Drinker's Check Up (DCU). The DCU is a brief motivational intervention designed to assist clients with a goal of moderation or abstinence. This computerized treatment was designed for use with at-risk drinkers and alcohol-dependent individuals that are ambivalent about changing their drinking. The treatment is widely available, either on the Internet as a web-based application (website: or as a Windows (Microsoft Corporation, Redmond, Washington, USA)-compatible PC application.

There are three components to the DCU: assessment, feedback, and decision-making modules. During the assessment component, the user is presented with a choice of questionnaires to complete. The feedback module provides (1) a severity descriptor (e.g. low, medium, high, or very high) showing the user their risk, consumption, and alcohol-related consequences, (2) an indicator as to whether the user might benefit from proceeding further with the program; and (3) quantity/frequency normative data that can be used to compare the users' drinking with population norms. During the decision-making module, users are provided with three options that are tailored according to how ready the user is to make changes. The first option allows the user who is 'not at all ready to change' to obtain a printout of their feedback summary or to view literature on the PC called 'alcohol and you' before exiting the program. The second option allows the user who is 'unsure about change' to complete a decisional balance exercise. This exercise asks users to list the benefits of making a change versus the costs of not making a change. If after completing this exercise, users are still not ready to change, they are offered an option to exit the program. The third option allows the 'ready to change' user to work on a section that will assist him or her to develop a plan of action. At this point, users are given a choice between moderation goals and abstinence. If moderation is selected, the user is given guidelines for moderate drinking including: definitions, contraindications, and an assessment designed to determine the possibility for success with the goal.

Recently, Hester, Squires and Delaney (R.K. Hester et al., in preparation) conducted a controlled clinical trial of the DCU Windows program for 61 problem drinkers randomly assigned to either immediate DCU treatment or to a 4-week wait list control group. Results showed that the immediate DCU group significantly reduced alcohol consumption at the 4-week follow-up, while the delayed control group did not. At 12-month follow-up, alcohol quantity and frequency measures had declined by 50% in both the immediate and delayed DCU conditions. Squires and Hester[86**] have recently published detailed case data and outcomes of three participants from this clinical trial. The reported percent decrease in number of standard drinks from baseline to 12-month follow-up for the three participants were 100 (abstinence), 66, and 18. The results illustrate the full range of treatment effects that can be obtained with the DCU. The results of the clinical trial are as encouraging as those described above for the computer-based version of BSCT, and together they suggest that computerized controlled-drinking interventions have considerable potential in terms of treatment gains, cost, accessibility and efficiency.

In sum, harm reduction approaches to alcohol misuse have successfully impacted the serious problem of alcohol misuse in school age and college students in the US and abroad. Although the emphasis of harm reduction approaches is on reducing harm secondary to alcohol misuse rather than 'moderation' of use per se, the outcomes of these school programs (e.g. SHAHRP) show appreciable reduction in drinking. In high-risk college students, there is evidence that administering a brief intervention based on harm reduction principles can reduce both the drinking behavior and its consequences over a 2-year period. However at a 4-year follow-up, the intervention effects appear to have persisted more with respect to alcohol-related consequences than drinking behavior. Perhaps 'booster' sessions provided every 2 years might promote maintenance of the 'moderation' effect on drinking behavior. Lastly, the internet/PC-based DCU is an excellent example of how to increase the availability of harm reduction procedures that specifically address 'moderation' of alcohol use or abstinence. Although limited, existing research with this and similar PC-based applications demonstrate problem drinkers can moderate their drinking with little or no involvement from health care professionals.