People with alcohol use disorders (AUDs), especially in cases of heavy or long-term drinking, are almost always advised to be abstinent. But randomized controlled trials (RCTs) have documented outcomes such as reductions in the number of heavy drinking days or drinks consumed as successes.

The official standpoint of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is that the safest path for someone with an AUD is abstinence, said Robert B. Huebner, Ph.D., acting director of the NIAAA Division of Treatment and Recovery Research, who along with NIAAA Director George Koob, Ph.D., talked to ADAW on May 14 about the viability of treatment goals that fall short of abstinence.

“The safest course is to remain abstinent,” said Huebner. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) supports that, he said. Participants who were interviewed there years after their remission, who remained abstinent, were at much lower risk of returning to alcoholism than those who returned to low-risk drinking after remission, he said.

NESARC, a study of alcoholism and related disorders conducted by NIAAA researchers in two waves (2001–2002 and 2004–2005 on the same respondents), found that many people with AUDs reduce their drinking, even without any treatment.

“But there may be a proportion of patients who meet the criteria for AUDs and who can return to low-risk drinking,” said Huebner. “We need to be open-minded about this.”

There have been studies comparing patients over a two-year period, and finding that those who were low-risk drinkers were “not appreciably worse on a number of personal and social consequences,” said Huebner. “These are hints that there may be subgroups of alcoholics who are candidates for this.”

No carte blanche

NIAAA does not recommend that alcoholics return to low-risk drinking after they have recovered. “One has to be extraordinarily careful,” warned Koob. “A carte blanche that says everybody can return to low-risk drinking is not appropriate based on what we know,” he said. “There are many people who tried that and failed in disastrous ways.”

But that doesn’t mean patients who want to reduce their drinking should be told they have to accept abstinence. “If a patient has a goal of reduced drinking, we should not show them the door,” said Huebner. “We should engage them, and if necessary reevaluate it on a regular basis.” In some cases, he said, when patients experience the benefits of reduced drinking, they go on to abstinence.

“That’s why we take all comers,” said Koob. “If you reduce heavy drinking, that is so much better” than continuing heavy drinking. “You can have a goal of complete abstinence, and for most of my closest colleagues and friends who have alcoholism in their family, that’s the goal they advocate for their loved one,” he said. “But stigmatizing a slip can be devastating,” he said. “We have to have a more realistic view of behavior and pathological behavior.”

Letting the patient choose

Tom Horvath, Ph.D., is president of Practical Recovery, a for-profit corporation that provides treatment that allows patients to make their own choices about whether they want abstinence or moderation, with the exception of patients in residential treatment, who are required to abstain while they are there. “The fundamental problem in addiction is motivation,” Horvath told ADAW. “You can get clients to do something, but ultimately they’ll do what they want.” Outpatient clients are “free to moderate or abstain,” he said.

About half of the patients in Practical Recovery choose abstinence, said Horvath, adding that most have already attempted the moderation route. “By the time they get to treatment, they’re more inclined to have discovered that moderation isn’t working for them,” he said.

Practical Recovery is based in San Diego and has 12 residential beds, amounting to about 140 admissions a year, said Horvath. The outpatient program is mostly one-on-one — no groups — and there are a “few hundred” patients, he said.

Improving engagement

Offering moderation as an option helps both engagement and retention, said Horvath. “If the treatment threshold is very high, people don’t want to do it. So this is the come-as-you-are harm-reduction approach — just show up because we want to be in contact with you.” This gives the clinician the chance to start motivational interviewing, helping guide the patient.

Moderation is a good option “for people who can accomplish it,” said Horvath. “From a clinical standpoint, if you’re drinking 20 drinks a day, your chances aren’t great to lower that.” But the fundamental barrier, he said, is that people don’t want to be told they can’t have even one drink. “When I try to infringe on your freedom, you become highly motivated to prove me wrong,” he said. “Step 1 of AA doesn’t work.”

Horvath is also president of SMART Recovery, a not-for-profit organization that has abstinence-based self-help groups around the country that do not have the religious or anti-medication aspects of Alcoholics Anonymous.

“There is an enormous amount of research” on controlled drinking, said Horvath. “It is one of the most well-researched subjects in the field of addiction treatment, but it’s not much discussed outside of academic circles.” Many of the studies took place in the 1970s and 1980s when psychologists were grappling with addiction issues, he said.

Personalized medicine

Who is best suited for moderate drinking? That question is important to NIAAA, as is the whole concept of personalized medicine and tailoring treatment to the individual, based on genetics and other factors. “We are developing a nice repository of clinical trial findings,” said Huebner, citing Project MATCH, COMBINE and NIAAA’s Clinical Investigations Group (NCIG). “We ask whether the treatment goal is abstinence or a reduction in drinking.” Mining these databases for outcome data can provide insights into the viability of different treatment goals.

NIAAA officials stopped short of calling a return to low-risk drinking “harm reduction,” saying instead it is “health promotion.” But the label isn’t what’s important, they said. And they do not believe that people have to “hit bottom” before getting treatment. “We don’t agree with that approach,” said Koob of hitting bottom. “The earlier one starts a conversation about changing drinking behavior, the better.”

Early intervention is more likely to be done by the primary care physician than the specialty treatment provider, who usually doesn’t see patients unless they are very sick. “We are trying to facilitate the interaction between primary care physicians and the specialized treatment facilities,” said Koob. “That’s an area I’m going to be putting my nose into a lot more.”

The trend for the treatment of AUDs is for more integration between specialty treatment and primary care, said Huebner. “Both can learn from each other, and working together they will have a more effective approach,” he said.

Quality of life

And insurance companies, while they may prefer the abstinence approach, don’t require it, and welcome any treatment that can improve health outcomes. John P. Emerick, M.D., chief medical officer of New Directions Behavioral Health, told ADAW “the model we use is abstinence.” But that doesn’t mean the insurer doesn’t pay for treatment if the patient isn’t abstinent. “We provide coverage for treatment of people who are dependent on or abusing alcohol,” Emerick said. So, for example, New Directions would pay for treatment with medication, such as Vivitrol, and if the main effect was to reduce drinking, that would still be worthwhile.

“The abstinence model is based on AA, and there are people who don’t like AA because of the spiritual aspect,” said Emerick. The bottom line: reducing drinking also reduces health consequences.

“There is a dose-response relationship between reducing heavy drinking days and a lot of things — health, work life, family life,” said NIAAA’s Huebner. “Reducing drinking improves the quality of life.”

Whether a patient chooses abstinence or controlled drinking, medications like acamprosate or naltrexone, or others (except for disulfiram, which cannot be used for controlled drinking) can help, said Koob, who called attention to the study published in the Journal of the American Medical Association last week showing that naltrexone and acamprosate are underutilized in the treatment of AUDs, and that both medications reduce drinking. “We want to make it clear that there are multiple ways to eliminate an excessive alcohol problem,” he said. “They’re not all abstinence.”

Bottom Line…

The safest goal for someone with an alcohol use disorder is abstinence, but even reduced drinking has health, personal and societal benefits, and can be an easier way for patients to engage in treatment.