Abstinence Is Not the Only Option

I can't even think of how many times I've heard the notion that complete, total, abstinence should be the only goal for all people who abuse drug or alcohol. This idea is so pervasive that most addiction treatment providers actually expel clients for relapsing, a notion that makes no sense to me especially if you believe in the idea that addiction is a chronic disease. In fact, even most research institutions and well-informed providers use total abstinence as the marker for addiction treatment success.

The thing is that the amount of alcohol or drug use per se is not a part of the definition of addiction or abuse (other than in the "using more than intended" factor but even there an absolute amount isn't introduced) and I don't think it should be a necessary part of the solution either.

When I first set about writing this article, many of the issues I was going to bring up had to do with research on alcohol relapse patterns, my own story, and other evidence I've already introduced on All About Addiction.

Fortunately for us, some recent research about Moderation Management and a newly developed website application component introduced me to some new evidence regarding moderate alcohol drinking that will allow us to look even more deeply into the problem. And now there is even a treatment center focused on moderation as a treatment goal.

Moderation Management: Drinking Alcohol Like a Gentleman

In case you've never heard of Moderation Management (MM), you should check out their website. Moderation management offers face-to-face and online meetings, a listserv, a forum, online alcohol drinking limit guidelines, a self-help book that can be ordered through the site, and an online calendar where users can report their drinking.

The population of people who use MM is pretty well educated and is made up for the most part of problem drinkers rather than those meeting full-blown alcohol dependence criteria. The idea is to teach problem drinkers more responsible drinking habits so that they don't devolve their habits into all-out alcoholism.

Not only is there evidence that the moderation approach works, but with the addition of a new website application that helps problem drinkers through an interactive web experience, it seems that moderation management may be a real option for people who want to learn how to control their alcohol consumption instead of going into full abstinence. For all we know, it might also be an option for people who do meet criteria for alcohol dependence but since the study we're about to assess didn't talk about it, we'll leave that for later.

Can Moderation Management Work for Heavy Drinkers?

This recent study assessed the effectiveness of using the Moderation Management approach alone or along with an interactive website that help people monitor their drinking and make changes towards moderation. The idea was simple: Use technology to guide behavioral change in interested individuals along MM rather than abstinence principles.

The 80 people who volunteered for the study were around 50 years old and were drinking alcohol pretty heavily: They were consuming around 35 drinks a week at an average of about 5 drinks per day, meaning they were essentially all daily drinkers. But the range was pretty big here with some people drinking more than 50 alcoholic drinks a week or almost 10 drinks a day. They were managing about 16 percent of every month without drinking (approximately 5 days) but again the range here was wide with some reporting essentially no abstinence and others being abstinent for half of every month on average.

The researchers used a baseline assessment and then followups at 3, 6, and 12 months. There was no inpatient treatment component, just use of the MM website alone, or in conjunction with the new interactive web application.

Most of the information collected was self-reported by the participants, which is known to be somewhat problematic, so the researchers also contacted significant others who were used to corroborate the drinking behavior reported by the participants.

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The results were pretty interesting:

Participants who used the Moderation Management website alone drank a little less in each of the followups and were able to raise their average percent abstinence from 16 percent to a little over 20 percent. They were also able to reduce their scores on instruments assessing problem associated with drinking alcohol and their overall drinking problem severity. All changes lasted throughout the 12 month study period. Importantly, even on drinking days, these participants reduced their blood alcohol content (BAC) levels by almost 50 percent.

Results were even better for the group that used the interactive site. This group achieved 40 percent abstinence days, essentially doubling those of the moderation management group alone, while keeping all the other benefits mentioned earlier including reduced BAC average on drinking days and reduced problem drinking overall. For the 30 participants in the combined experimental group, drinking had taken on a much less troublesome form now — non-daily moderate alcohol drinking that resulted in a reduced number of problems associated with drinking.

Conclusions, Limitations, and Thoughts on Moderate Drinking

I'm a big supporter of the idea that improvements in quality of life, in addition to or instead of measures of abstinence, need to be incorporated broadly into addiction treatment research. The way I see it, our goal in treating addiction is to help a client improve their functioning, which is often being hampered by substance abuse but that is not necessarily completely dependent on it.

Following that logic, it makes a lot of sense to me to include the idea of moderation as another option in the addiction treatment arsenal. This is especially true in light of the fact that moderate drinking might be good for health and intervention research shows us that changing behavior is possible.

It is very important to note that this study specifically excluded people who had previously been admitted to alcohol or drug treatment as well as those who had symptoms of severe alcohol withdrawal at any point in their life (like delirium tremens and such). This means that the participants likely did not include some of the most severe alcoholic cases.

Still, when it comes to looking at entire population, most individuals that abuse alcohol are specifically NOT those more severe cases, which means the results might actually be more generalizable.

The sample size used in the study also leaves something to be desired and I would hope that further research would examine these effects with a bigger cohort and a more variable participant group.

Lastly, this being a study, it is very possible that participants were better motivated, more informed, and more likely to put in the effort required to use the moderatedrinking.org program. Future work would need to assess the effectiveness of this tool in the field without such interference.

Nevertheless, it is hard to ignore the fact that significant improvements in participant functioning including a reduction in the frequency of drinking alcohol, amount of alcohol consumed, and negative consequences associated with drinking alcohol were observed in the Moderation Management and Moderate Drinking groups.

Such reductions are very often the goal of treatment and as such, show some possible promise for the treatment of individuals with alcohol abuse problems. Indeed, the participants in the study are what I would consider very heavy drinkers and are likely more representative of common drinking problem behavior than the really severe, chronic, poly-substance dependent patients that often present to residential treatment.

As such, I think these results are very encouraging in terms of offering another possible solution for individuals who are looking to reduce their alcohol consumption and the problems that keep creeping up along with it.

© 2011 Adi Jaffe, All Rights Reserved

You can read Dr. Jaffe's book, The Abstinence Myth, and connect with him on Facebook, LinkedIn, and Instagram, as well as his website and podcast.