Everything in Moderation? Not All Problem Drinkers May Need Abstinence

John Watson

December 06, 2019

For most Americans, sharing a bottle of wine over dinner or heading to happy hour after work is an unremarkable experience. Social drinking is part of our cultural fabric, especially during the holidays. But these moments can be decidedly more troublesome for those struggling with unhealthy drinking habits.

Bonnie, 66, counts herself among this group. "Alcohol was my go-to pretty much when I had any type of emotion: happiness or sadness, pleasure or pain, anger or anxiety."

After years of what she described as out-of-control, near-daily drinking, Bonnie feared the moment when its toll on her health would become clear and irreparable.

"I was scared every year when I had my physical. I would hold my breath to see what the liver values were, what my bone density was."

Those visits would have been an ideal time for a clinician intervention, but experts say that many physicians fail to seize such opportunities.

"At the moment, we're not very good at screening and counseling patients about unhealthy alcohol use," said Alex Krist, MD, MPH, a professor of family medicine and population health at Virginia Commonwealth University, in Richmond. "Clinicians can make a difference to close a gap to improve the health of Americans."

But do they even know what to say? Contrary to the prevailing view, experts say, some people who engage in risky drinking practices may not need to completely abstain from alcohol. Instead, for appropriate patients, moderation strategies can be successfully implemented, even for those who've exhibited potentially hazardous tendencies.

In order to guide appropriate patients to moderation, clinicians must first move beyond an outdated either/or view of unhealthy drinking, said Keith Humphreys, PhD, a professor of psychiatry and behavioral sciences at Stanford University and coauthor of the book Edwards' Treatment of Drinking Problems: A Guide for the Helping Professions .

"That's a big misconception, that everybody is either an alcoholic or fine," Humphreys said.

Instead, many experts now believe that a person's relationship with alcohol falls on a spectrum. On the one end are outright teetotalers and the low-risk users who never exceed consumption recommendations; on the other end are those who meet the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition definition for alcohol use disorder (AUD), including signs of physical dependence.

In the middle are those whom the National Institute on Alcohol Abuse and Alcoholism (NIAAA) places in the category of "risky use." The NIAAA defines this as exceeding the recommended limits of four drinks per day or 14 drinks per week for healthy men aged 21 to 64 years, or three drinks per day or seven drinks per week for all adult women of any age and for men aged 65 years or older.

Humphreys said it is a mistake to assume that alcohol-related health and societal problem derive predominantly from those on the extreme end of the spectrum.

"We have a population of people who have drinking problems that is three times as large as people who are thought of classically as alcoholic. In fact, they cause more population harm than alcoholics because they are just so numerous."

We have a population of people who have drinking problems who are three times as large as people who are thought of classically as alcoholic… Dr Keith Humphreys

From 2001 to 2013, high-risk drinking practices increased by 30% and are now estimated to affect upwards of 30 million Americans. Binge drinking ― or having more than four drinks per occasion for women and five for men ― is now reported by 17% of the US adult population, including 1 in 10 of those 65 years of age or older.

Such statistics paint a troubling picture of alcohol's progressively deleterious role in American life. Risky drinking practices can undoubtedly lead to AUD ― but it is far from inevitable. Indeed, evidence suggests that as many as 90% of excessive drinkers do not meet the criteria for alcohol dependence.

Experts say this makes those "risky drinkers" an ideal target group for behavioral interventions to achieve moderation. Although some clinicians may reasonably be apprehensive about recommending such strategies, Humphreys said the opposite approach also has risks.

"If all you offer is abstinence, you turn people away that you could help," he said. He gave as an example someone in his or her early 20s with risky drinking tendencies who pushes back against the idea of abstaining from alcohol for the rest of their life.

If all you offer is abstinence, you turn people away that you could help Dr Keith Humphreys

"They may continue with their drinking problem, wreck their car, or have some other kinds of problems," he said. "So you're dismissing a chance to help people cut back or change their drinking in some way that reduces harm. It would be a shame to give that up if you have basically a 'my way or the highway' kind of approach to abstinence."

Ignoring the problem altogether isn't a real option either, he says.

"A lot of docs say, 'I don't want to treat substance use disorders,' and the myth is that you can make that decision and practice medicine," Humphreys said. "If you don't ever address it, you'll be treating the sequelae of it all the time, and in a frustrating way because you will fail frequently...you're not getting at the root cause."

Identifying which patients can potentially return to moderate drinking is perhaps best served by those medical professionals who know them best: their primary care physicians.

In 2018, the US Preventive Services Task Force (USPSTF), for which Krist served as a vice chair, updated their 2013 recommendations on screening for unhealthy alcohol use in adults in primary care settings, including pregnant women.

There are a variety of brief screening tools for use by primary care providers, most prominently the abbreviated Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and the NIAAA-recommended Single Alcohol Screening Question (SASQ). These can be administered in as little as 1 minute. For patients who are identified as engaging in risky alcohol use, the USPSTF recommends following up with more in-depth assessments, which can typically be given in less than 5 minutes.

For patients who are identified as engaging in risky or hazardous drinking, the USPSTF recommends providing them with brief behavioral counseling interventions to reduce unhealthy alcohol use. There are a variety of such interventions available; 30% of those that were reviewed by the USPSTF are Web-based. They can be given over a median of one 30-minute session.

"On average, doing very basic counseling like that results in people drinking about 1.6 less drinks per week, and about 14% of people who are engaging in risky drinking to stop doing so," Krist said.

He also recommends that primary care physicians keep an eye as to what patients are drinking. For beer in particular, the landscape has changed greatly in recent years. The NIAAA considers a standard beer to be 12 oz with 5% alcohol by volume. However, consumer research has found that the number of beers available in North America from 2011 to 2014 that had more than 6.5% alcohol increased by 319%.

"It involves not only how much they're drinking but also specifically what they're drinking, and thinking about how it might be impacting their lives," he said. "Knowing that can be important to differentiate risky drinking from AUD, and identifying that group is probably one of the more effective things that primary care clinicians can do."

Humphreys noted that those most likely to benefit from moderation have the greatest social capital: they are employed and have a higher-level education and a support system of friends and family. Conversely, the greater the signs of physical dependence (eg, cravings, blacking out while drinking), the less likely it is that moderation can be achieved.

Strategies for moderating drinking overlap with those used for achieving abstinence. Krist recommends asking patients to identify when, what, why, and with whom they drink. These questions can uncover important factors that drive people to excessive alcohol intake, such as the enabling drinking buddy or the siren call of Friday night after a grueling work week.

"The difference for moderation is that you talk about strategies for during the drinking episode, which is not relevant to abstinence," he said.

The difference for moderation is that you talk about strategies for during the drinking episode, which is not relevant to abstinence. Dr Alex Krist

Patients should be given tactics for avoiding excessive consumption, Humphreys said, such as ensuring they eat before drinking, having a water or soft drink in between alcoholic beverages, and moving away from drinks with high alcohol content.

Patients also should be encouraged to engage in activities that do not depend on alcohol.

"You're having them learn other coping skills and developing alternative activities incompatible with drinking, like joining a basketball league, going back to their church, synagogue, or mosque, and just getting reinvolved."

Such skills can be further honed in social support groups, which offer the structure, accountability, and behavior modeling that have clearly been shown to be effective at altering other health practices, such as smoking and overeating, Humphreys said.

One such group is Moderation Management, which holds sessions throughout the country to help give habitual and risky drinkers the necessary skills to keep their alcohol consumption in check. It was through her participation in this group that Bonnie said she was finally able to manage her alcohol consumption, despite several initial relapses.

"I've really been working the program, reading whatever I can get my hands on," she told Medscape Medical News. "The switched got flipped on, and it's been great."

Moderation Management recommends that new participants initially take a break from drinking.

"It's suggested that you do a 30-day abstinence period to help you recalibrate and gain some clarity about why you're drinking," Bonnie explained.

After that, participants select their goals for drinking in the future; pinpoint triggers and work toward managing them; identify more-rewarding activities; and use the group structure to deal with the relapses and frustrations that may come along the way without fear of judgment.

Moderation Management's groups are led by facilitators who are also members. Dianne Drake Foss, MS, LPC, the facilitator of the group in Granby, Colorado, said that how long people participate in the program varies considerably.

"There are some like myself who have attended meetings for several years and plan to continue for many years to come. There are some who only come a few times and either decide the program is not for them or do it on their own. Being in an active support group that meets regularly seems to be the most effective way to learn to be a responsible drinker."

Andrea, a 56-year-old member of a Moderation Management group in Ontario, Canada, credits her participation with turning 3 decades of almost daily drinking into what is now a healthier relationship with alcohol.

"It wasn't easy at first, and at times I felt like all I did was think about what and when I was or wasn't going to drink, but eventually, when I started feeling the physical benefits of my reduced consumption, it really became my new normal," she wrote in an email. "I started looking forward to my sober nights and having a plan for what I would do those nights instead of drinking."

Although the volume of published data on Moderation Management pales in comparison to research into an abstinence-based group such as Alcoholics Anonymous (AA), it does suggest it is effective at reducing alcohol-related problems and consumption. Humphreys and a colleague conducted a survey of the moderation group's members, from which they concluded that most people were not simply delaying an inevitable transition to abstinence.

"Our data showed that people were very good at sorting themselves into that group," he said. "They were overwhelmingly people who had a college degree, had a job, and did not have many dependent symptoms. In short, they were the kinds of people you would bet could succeed as becoming moderate drinkers."

How successful AA is at helping participants achieve abstinence is a subject of debate. A widely promoted statistic from the 1990s that indicated that the organization only has a 5% success rate is likely inaccurate. A 2014 analysis of randomized controlled trials concluded that "for most individuals seeking help for alcohol problems, increasing AA attendance leads to short and long term decreases in alcohol consumption." One longitudinal study reported that approximately 50% of AA participants remained alcohol abstinent at 8 years, compared with 25% of those who went without treatment. A survey conducted by AA itself reported that the average duration of abstinence of its members approached 10 years.

However, there are clear obstacles to designing studies of a group whose therapeutic model depends on privacy and in using abstinence as a marker of success when relapses inevitably occur but do not significantly derail members' progress and so may not be reported. Such factors make a comparison between successful abstinence and moderation all but impossible.

Foss said the Moderation Management program is designed to offer different paths forward for those who may only be able to address their drinking habits with abstinence.

"There have been a few people I told after the meeting they were welcome to continue coming, but based on what they revealed, they may not be candidates for a moderation program," Foss told Medscape Medical News. "I encouraged them to seek out several other groups to look at besides just AA, such as Smart Recovery and Life Ring."

Bonnie said that lately she's noticed an increase in the number of people who attend Moderation Management meetings at the recommendation of their therapist. The growing acceptance by the medical establishment is an encouraging sign for a group that many members say they had to Google their way to discovering. However, as with all behavioral health interventions, it ultimately falls to the person struggling with these problems to put forward the effort necessary to make them successful.

"If you can make that commitment and say it out loud to other people, I think it helps you stick to that," said Bonnie. "People fail, they slip up, they relapse. But if it's important to you, you get right back in the saddle again."

John Watson is a writer living in Philadelphia, Pennsylvania.

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