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Looking at the Facts on Moderate Drinking

May 1, 2006
by root
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Carlton Erickson's column on moderate drinking in the January/February 2006 issue makes personal-opinion statements in the guise of science, and I find that unfortunate at best. His assertions that (1) “some scientists advocate that some ‘alcoholics' can return to ‘moderate drinking' or ‘social drinking'” and (2) that “‘alcoholics' (as defined by AA and most neuroscientists) should not try to drink ‘socially,' since to do so might lead to a downward spiral of addiction” are neither scientific nor supported by research evidence.

First, I know of no researcher or scientist who advocates moderate drinking. The data are clear that people with severe drinking problems (whether or not they self-label as “alcoholic”) can and do return to moderate drinking. Not all do, but the data are as clear on this as they are about any other outcome in the alcohol treatment field. In fact, when we look at treatment outcomes following abstinence-focused treatment, we see moderate, nonsymptomatic drinking outcomes occurring at least as often as prolonged abstinence.

Second, “should not” is not science. It is a value judgment and smacks of the paternalistic, doctor-knows-best attitude that much of medicine has begun to abandon in favor of an approach based on informed consent and open discussion of alternatives. It also smacks of a hubristic assumption that somehow AA and neuroscientists have an inside track on what people with alcohol problems should do about them. If brain function were destiny, no one would ever overcome severe alcohol problems without assistance—because their brains would not allow them to! Yet we also know from research that nonassisted positive outcomes are common.

We should be moving the field past personal supposition, preference, and belief into a reliance on what the data accumulated over the past several decades actually show. One would hope that someone with a PhD would be able to tell the difference between data and personal preference and belief. I have no problem with personal belief being written about. I do have a problem with personal belief being hidden under the mantel of science, and that is what Dr. Erickson does in this column.

I challenge Dr. Erickson to show us evidence that his assertions are correct. Who are these evil scientists who advocate moderation for all problem drinkers, including the most severely affected? Where are the data showing that people who self-define as “alcoholics” are unable to moderate?

Frederick Rotgers, PsyD, ABPP, Associate Professor of Psychology, Philadelphia College of Osteopathic Medicine
Dr. Erickson's response:

Dr. Rotgers' letter disappoints me, because he failed to get the point I was making. I asked in my commentary, for those who are alcohol-dependent, “Why is it important even to suggest that drinking alcohol might be beneficial?” He doesn't reply in his letter. I also suggested in my commentary that we should develop a unifying message, which Dr. Rotgers apparently doesn't care to consider.

Dr. Rotgers does not realize that the “mainstream, respected alcohol-research literature” I mentioned in my commentary includes not just his favorite problem drinking studies, but also the pharmacologic, genetic, neuroscience, and brain imaging literature. Such studies not only assume that chemical dependence is a brain disease, but also hypothesize the brain dysregulations involved. The “disease” relates to alcohol dependence (not alcohol abuse). It appears that Dr. Rotgers is not enamored with the DSM diagnostic definitions that make such a difference in our understanding of types of problem drinkers (I wrote about this in the January 2003 issue of this magazine). When used properly, these definitions can help us understand why, as stated on page 76 of the third edition of the Clinical Textbook of Addictive Disorders (The Guilford Press), some drinkers “are more likely to benefit from controlled drinking strategies and be able to return to nonpathological use of alcohol, [compared to] the person who reaches criteria for dependence, where abstinence would be the preferred treatment goal.”

It is antithetical to suggest that individuals who have “loss of control over alcohol use” (NIAAA and DSM definitions of dependence) should attempt controlled drinking. Most people who are in serious trouble with alcohol have tried to control their drinking, unsuccessfully. For those problem drinkers who are never assessed for dependence (most are not) and for those drinkers who do not wish to attend AA, learning to drink in moderation is a reasonable first option. But for those people who are assessed via accepted criteria as being alcohol-dependent and for those already in AA or in recovery, the first and only reasonable recommendation for overcoming the illness is abstinence.