Ned Presnall
Executive Director
Clayton Behavioral
Adjunct Professor, Washington University
"The idea that somehow, someday he will control and enjoy his drinking is the great obsession of every abnormal drinker. The persistence of this illusion is astonishing. Many pursue it into the gates of insanity or death." (The Big Book of Alcoholics Anonymous, Chapter 3)
Heavy drinkers that are able to moderate their drinking may be more like people with early-stage heart disease. Characterizing heart disease in stages allows physicians to match treatment with severity. It is not difficult to imagine how alcoholism might be characterized in a similar way and how treatments could be calibrated to the appropriate stage of the illness.
Imagine, for example, if a large proportion of persons with Stage II alcoholism were prescribed naltrexone, a daily medication that makes alcohol less pleasurable and has been shown in dozens of studies to decrease episodes of heavy drinking. Treating alcoholism by stages might prevent many people from progressing to more severe and debilitating stages of the illness.
Among the 1% of Americans (2.8 million) who receive treatment for an alcohol use disorder each year, there are probably very few people with early stage-alcoholism.
Entering treatment is a strong correlate of problem severity. But among the 6% of Americans (15.7 million) who show some need for treatment and the 11% (29.4 million) who do not need treatment but say they wanted to cut back on their drinking in the past year, there are probably quite a few people with early-stage alcoholism. In fact, 30% of all Americans who drank alcohol in the past year either demonstrated a need for treatment or reported wanting or trying to reduce or stop their drinking. It’s a safe bet that not all of these 45 million Americans suffer from severe alcoholism but they might benefit from treatment aimed at moderating their drinking. (National Survey on Drug Use and Health, 2014)
We are getting more and more evidence that chronic heavy drinking even in people without an alcohol use disorder is associated with increased risk for illness, including heart disease, cancer, and dementia. Making people more aware of these risks could have a profound effect on alcohol overuse in the U.S. In 1980, about half of French adults were daily wine drinkers. Drinking wine was part of French culture and considered innocuous. As it became clear that daily alcohol consumption was associated with serious health risks, French habits changed. Today, only about 17% of French people drink alcohol daily and the number of French people who don’t drink at all has nearly doubled.
So, how can a person with early-stage alcoholism change his or her drinking habit without committing to abstinence? There is very detailed guidance on the Moderation Management website—a group founded in 1994 as an alternative to Alcoholics Anonymous. What I’d like to offer is a more basic, philosophical point: For people that have developed an unhealthy drinking habit but believe they have caught the problem early, committing to the principle of abstinence may not be necessary, but committing to the principle of moderation almost certainly will be.
A principle is something I commit to before I consider any of the fluctuating particulars of my life. If I’m committed to abstinence, I don’t say: I won’t drink unless it’s a special occasion or unless it’s a stressful week at work. I act on principle in the face of the ever-changing landscape of my life. A good friend of mine is 8 years sober and reminds himself every morning before his “feet hit the floor” that no matter what happens that day–whether he experiences a personal loss, a stressful event, or just the general annoyances and celebrations of life–there will be nothing that is worth using over.
Principles do not survive on willpower alone. If I am committed to abstinence, I do a hundred things to prevent myself drinking alcohol. I don’t keep alcohol in the house; I don’t spend time in bars; I call my sponsor every day; I make sure to get good rest; I process my anxiety or anger with friends or a professional; I engage in fun sober activities; I take anti-craving medication. Over time, these things become normal parts of my life and don’t take much effort; but the principle of abstinence continues to guide and shape my everyday choices.
Moderation is a more ambiguous principle. To make it effective, a person must do four things: 1) define it clearly; 2) commit to behaviors that support it; 3) stick it out long enough to develop a new habit; 4) maintain the change.
The man who drinks 3 to 4 drinks per night might commit to the principle of abstaining from alcohol during the week. Now, if he drinks three to four drinks on Friday and Saturday, he has decreased his alcohol use by 70% and is within the CDC’s recommended limits for men. The woman who binges one night each week might commit to drinking no more than 3 drinks on any occasion. Now she has eliminated binge drinking and the acute and chronic effects that often accompany it.
To adhere to these principles, each type of drinker will have to make changes to his or her routine. The man who drinks daily may want to avoid keeping alcohol in the house during the week; this change can decrease the decision fatigue that comes with easy access. He may also want to exercise in the evenings or engage in some alternate pleasurable activity. The woman who typically binges may want to alternate alcoholic drinks with non-alcoholic drinks to slow down her drinking; she may want commit to going home at a certain time on the weekend or not hanging out with certain friends. Both people might benefit from an accountability partner. They might also benefit from naltrexone therapy, as discussed above.
A heavy drinker that is moderating their drinking will typically feel like they are breaking a bad habit. If the attempt doesn’t feel like dieting or exercise, it’s probably not an honest attempt. However, once we adhere to a new behavioral principle for a significant period of time, we tend to re-habituate. The person who drank alcohol daily but now abstains during the week may eventually stop thinking about alcohol during the week. The person who binged on the weekends but now drinks moderately may eventually get accustomed to that change and have a decreased urge to over-drink.
Once you form a new drinking habit, you’ll want to maintain it. Most of us can look back to a period when we’d developed a healthy exercise routine or improved our diet only to lose momentum and regress to old patterns of behavior. Maintaining a habit takes less energy than habit formation, but it can’t survive without some nurturing. A drinking diary is one simple way to prevent unconscious slippage. Sharing that diary with a trusted friend can be even more powerful.
The founder of Moderation Management, Audrey Kishline, eventually wrote an open letter to her supporters explaining that she had come to realize that she suffered from severe alcoholism and that only abstinence could help her break her addiction. While she attempted to achieve lasting sobriety in AA, she killed a man and his son in a drunk driving accident. She spent some time in prison and never fully recovered from alcoholism.
Ms. Kishline’s story is a cautionary tale, but it is not definitive. After all, she had already been to residential treatment when she devised the notion of moderation management. There is no doubt that the fantasy of every person with severe alcoholism is to moderate their drinking and that overcoming that fantasy is crucial for achieving long-term sobriety. The writers of The Big Book recall their principled but failed attempts at controlled drinking:
They jokingly prescribe controlled drinking to their reader: “Step over to the nearest barroom and try some controlled drinking. Try to drink and stop abruptly. Try it more than once. It will not take long for you to decide, if you are honest with yourself about it. It may be worth a bad case of jitters if you get a full knowledge of your condition.”“Here are some of the methods we have tried: Drinking beer only, limiting the number of drinks, never drinking alone, never drinking in the morning, drinking only at home, never having it in the house, never drinking during business hours, drinking only at parties, switching from scotch to brandy, drinking only natural wines…”
But the writers of The Big Book were writing for people with severe alcoholism–the 1% who come to treatment each year, possibly the 6% who demonstrate a need, but not the 11% who just want to cut back a bit. If you are unsure which group you fall into, try an honest, principled attempt at moderation. Try two or three. If you’re successful, you will be healthier over the long term. If not, you may develop increased awareness of the need to commit to an alcohol-free way of life.
Resources for people interested in moderation
Moderation Management
The Drinker’s Checkup
NIAAA: Rethinking Drinking
Ned Presnall is the Director of Clayton Behavioral and Adjunct Professor at Washington University in St. Louis, Missouri. He presents widely on the topics of addiction, mental health, and medication assisted treatment. Ned is passionate about reducing the stigma against persons with addiction and against medication assisted treatment through discourse and public engagement.
This post was originally published on planyourrecovery.com on June 14, 2016.
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