Is Moderate Drinking The Answer?
By: Judy Foreman
12/19/2000

Until four months ago, Paul Robert, a hard-working, 42-year-old Connecticut businessman, would get home from work and knock back six drinks a night - 45 drinks a week. Sometimes wine, sometimes beer, sometimes the hard stuff.

"It was the stress," he says, and alcohol "absolutely" helped. He didn't think he was a true alcoholic. His job was going great, he says, and his family life - he has a wife and two  children,  ages 7 and 10 - was, too. He'd never been arrested for driving drunk. Even his liver showed no damage from all the alcohol it processed night after night.

Deep in his heart, though, Robert knew he was drinking far too much, and he wanted to cut back. What he did not want, however, was to go the Alcoholics Anonymous route and quit completely.

Today, Robert gets counseling and a daily dose of a drug called naltrexone to reduce his craving for alcohol, allowing him to cut back to12 drinks a week. His goal is "to go back to leading a normal life, so I can go out and have a couple of drinks. I am already there."

But Robert's treatment at Charles River Hospital in Wellesley raises one of the most controversial questions in medicine. The idea that excessive drinkers can safely return to moderate drinking contradicts the most famous alcohol abuse program, AA, and researchers fear it gives false reassurance to alcoholics.

However, advocates of moderate drinking believe that many alcohol abusers don't get help because they fear they'll have to stop drinking altogether. They say moderation could significantly reduce the nation's most pervasive substance abuse problems.

An estimated 14 million Americans either abuse alcohol - meaning they're impaired, but not physically dependent - or they are outright alcoholics prone to uncontrolled drinking, tolerance for high doses, and withdrawal symptoms when drinking stops. All told, about 40 million Americans drink more than the recommended moderate levels - one drink a day for women, and two for men, with a drink defined as  5 ounces of wine, 1.5 ounces of spirits or 12 ounces of beer.

So, can a heavy drinker really cut back without quitting totally? Yes, but the odds of success depend on the severity of the drinking problem, and on whether you have a family history of alcohol problems. If you're an alcohol abuser but not yet alcohol-dependent, your chances are better; if you're truly alcohol-dependent, they're almost zero. In fact, doctors at Charles River don't offer the moderate drinking program to people who are physically dependent on alcohol.

The good news is that most people with alcohol problems are not dependent, according to a 1997 analysis published by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.

The bad news is that the line between abuse and dependence "is in no way a clean distinction," says University of New Mexico psychologist William R. Miller, a leading alcoholism researcher. In fact, he says, mental health experts are reconsidering whether it makes sense to maintain this distinction at all.

The problem is that people with drinking problems tend to self-diagnose, to think their problem is less severe than it really is, and to avoid seeking help. That's one reason why the famous 12-step meetings of AA are filled with people who have tried for years and failed to control their drinking rather than quit.

The research studies on controlled drinking are both encouraging and sobering.

A series of studies by Miller's team at the University of New Mexico shows that people without alcohol dependence can indeed return to more moderate drinking. In these studies, about two-thirds of heavy drinkers managed to reduce their drinking substantially and to maintain their success for two years. When followed for up to eight years, the success rates decline - just 15 percent had maintained moderate, problem-free drinking, 25 percent had abstained completely for at least a year, 23 percent had cut back but still had some drinking-related problems, and 37 percent were no better than when the study started. Other studies in 1980, 1984, 1988, and 1992 showed similar results.

In a pivotal study of true alcoholics - published 15 years ago in the New England Journal of Medicine but still considered noteworthy by other researchers - Dr. John Helzer, a psychiatrist at the University of Vermont Medical School, showed that only about 2 percent were able to have an occasional drink without becoming dependent again. Curiously, noted Helzer in a telephone interview, a successful return to more moderate drinking was four times more likely in women. Other studies in 1979, 1989, and 1996 also suggest that women may be more successful at cutting back than men.

Cognitive-behavioral techniques, in which people are taught to recognize and change the thinking patterns that underlie their drinking, clearly help people cut back on alcohol intake. In fact, they are among the most successful approaches for people with less severe drinking problems, according to a 1999 review of the data in Alcohol Research & Health, the journal of the Alcohol Abuse and Alcoholism Institute. Cognitive behavior also works for true alcoholics - not to help them cut down but to help them remain abstinent - according to project MATCH, a large federal study in1996.

Brief interventions, in which a doctor or nurse schedules several short appointments to teach a patient about ways to reduce intake, also reduce consumption in people who are not alcohol-dependent, according to the same1999 review. In fact, in Seattle, a 1999 study of people who wound up in the emergency room after alcohol-related accidents showed that 30 minutes of alcohol counseling from a psychologist before discharge reduced the likelihood of readmission for other alcohol-related trauma. But nationwide, many doctors and nurses have yet to incorporate this technique into their practices.

On the more discouraging side, research in 1996 by Dr. George Vaillant, director of research in psychiatry at Brigham and Women's Hospital, tracked more than 700 college-educated and less-educated male heavy drinkers for more than 50 years. Vaillant found that men who tried to control their drinking usually relapsed while those who managed to stay sober for five years rarely did.

Yet, despite the evidence that moderate drinking leads to relapse for most alcoholics, the idea of controlled alcohol consumption is a powerful lure for alcoholics.

"Nothing is more appealing to a lot of alcoholics than the idea that if they could just figure out how to control their drinking, that would do it," says Dr. Roger Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont.

Dr. Richard K. Fuller, director of clinical and prevention research at the National Institute on Alcohol Abuse and Alcoholism, agrees. With true alcoholics, he says, its very unusual for them to return to moderate drinking. "The reason this is so sensitive, why some alcoholics become livid about this, is because they feel their own recovery was delayed for many years because they struggled, kept chasing this will of the wisp. "Most people can have a drink or two and stop. The alcohol-dependent person can't," Fuller added.

The limits of moderate drinking were illustrated dramatically not long ago with the tragic story of Audrey Kishline, who founded a program called Moderation Management in 1993 on the premise that heavy drinkers who are not yet alcoholics can cut back without abstaining altogether.

Last March, Kishline went on a drinking binge and killed two people in a car crash. Afterward, she reportedly called her program an example of "denial in action," and  pleaded guilty to two counts of vehicular homicide.

Even so, Stanton Peele, a Morristown, N.J., psychologist, lawyer and former board member of Moderation Management, points out that it is ironic that Kishline's accident happened after she joined AA and tried to abstain. It wasn't just moderation that failed her, he says, "everything failed her."

Advocates of  moderate drinking like Anthony Martignetti, an addiction specialist who runs the Alcarrest program at Charles River Hospital, insist that, for selected people, reduced drinking programs work.

In fact, says Martignetti (whose family, ironically enough, owns the Martignetti companies, the New England liquor distributor), it's the fear of abstinence-only programs that keeps many people from seeking traditional treatment. So far, about 200 problem drinkers have completed Martignetti's program, and by one year after treatment, 70 percent say they've reduced their drinking by 70 percent.

The bottom line? For Paul Robert, at least, things look good. He's optimistic he can continue to drink moderately.

For others, well, let's put it this way: If you find yourself saying"Bottoms up!" too often, see a doctor or alcohol counselor to evaluate your drinking. Trying to diagnose yourself is likely to be fraught with denial.

Then, if you and your counselor agree your problem is not severe, try a program aimed at cutting back. However, if your alcohol problem is severe, total abstinence remains the best answer.

SIDEBAR:

There are a number of medications that can help people control or cut down on their drinking, says Dr. Shelly Greenfield, medical director of the alcohol and drug abuse ambulatory treatment program at McLean Hospital in Belmont.

Antabuse (disulfiram) is a so-called "aversive" drug that causes nausea and other unpleasant symptoms if alcohol is also consumed. At high doses, the combination of  Antabuse and alcohol can be dangerous. The idea is to make the drinking experience so unpleasant that a person doesn't drink, but this only works if people take the drug.

Naltrexone (ReVia) is an opiate-blocking drug long used to combat addiction to drugs such as heroin. In 1994, it was approved by the US Food and Drug Administration to curb craving and prevent relapse in people with alcohol problems.

Acamprosate is a drug that has shown promise in European studies to curb craving for alcohol and help maintain abstinence. It is not approved in the United States, but studies are underway.