When you’re sober, it’s so easy to tell yourself you’ll have just one drink. Or if you’re trying to be honest with yourself, you say you’ll stop at two; maybe two is enough to feel it, but not enough to have any consequences. But what happens when you finish that second drink? How do your sober intentions hold up against the reality of that buzz waiting just inside the fridge or on the shelf? In short, can you really stop at one or two or does that one drink wreck any willpower you had earlier in the evening until you finish the rest of the alcohol in the house...and go looking for more?
This question is the backbone of a major debate in addiction research and treatment: can people addicted to alcohol go back to moderate drinking? For years, the answer was assumed to be an unequivocal no: programs based on the 12-Step models dominated treatment and there is no room for “just one drink” in AA.
But now these traditional programs are being influenced by modern research to create new and sometimes very much improved strategies of addiction treatment. We are questioning everything and in the process we’re discovering what works and what doesn’t. This reexamination of the truths we once thought absolute opens the debate on moderation.
So which is it? Is the 12-Step-based model of absolute abstinence still scientifically accurate or does the “moderation management” approach championed by ModerateDrinking.com and elsewhere have a place in modern addiction care?
The answer comes down to what kind of drinker you are – why do you drink, how much do you drink, and how long have you been in this pattern? That’s because the longer you have been in an aggressive drinking pattern, the more your consumption changes the physical characteristics of your brain.
“Problem drinkers” may still be purely motivated by emotion or association or coping or opinions about alcohol’s desirable effects. In other words, their drinking may have a purely cognitive cause. There’s fairly strong evidence these “non-dependent problem drinkers” can retreat from addiction into moderate drinking. For example, this clinical trial by the major proponent of moderate drinking, Dr. Reid Hester, shows that even among non-addicted problem drinkers, lighter drinkers benefit more than heavy drinkers from moderation management.
But there seems to be a tipping point after which problem drinkers can no longer moderate their drinking.
When problem drinking becomes addiction, cognitive causes aren’t the only reasons to drink. Instead, long-term dependence on alcohol creates changes to the physiology of the brain, resulting in complications like memory loss and even stunting the brain’s ability to grow new neurons. Over time, a brain chronically exposed to alcohol also loses its ability to produce and use dopamine, one of the main chemicals that makes humans feel “good” or euphoric. The addicted brain is addicted. And it’s not one or two drinks the addicted brain wants.
Writing in the journal Psychiatric Services, Dr. Keith Humphreys makes a similar point, showing that, “The vast majority of Moderation Management members have low-severity alcohol problems, high social stability, and little interest in abstinence-oriented interventions.” In this setting of low-severity problems, moderation management has shown to be moderately effective and in Humphrey’s opinion, “the inclusion of MM in the array of options for people attempting to resolve drinking problems seems on balance a benefit to public health.”
But Humphrey joins almost all reasonable researchers in the field of addiction, agreeing there is a huge difference between the brain of a non-dependent problem drinker and the brain of a person addicted to alcohol. For these addicted brains, the only real option remains abstinence. One drink gives the brain the leverage it needs to force the addicted person into many.
During April’s Alcohol Awareness Month, I hope you’ll join me in the real, inward-looking experience of discovering what kind of drinker you are. If the answer is “non-dependent” you may have the choice of moderation management. But if the answer is alcoholism, your best goal has been and remains abstinence.
Richard Taite is founder and CEO of Cliffside Malibu, offering evidence-based, individualized addiction treatment based on the Stages of Change model. He is also co-author with Constance Scharff of the book Ending Addiction for Good.