It is time for low‐risk drinking goals to come out of the closet

Recovery from alcohol problems includes low-risk drinking outcomes, especially for those not severely dependent. We suggest the failure by alcohol counselors in the United States to offer low-risk drinking goals is due to their being trained through an apprenticeship model rather than an evidence-based academic model, as used to train other health professionals. When we were invited to write an editorial on the topic ‘Should we still be aiming for abstinence only’, we found it ironic that this topic is still an issue for the field. Sixteen years ago, in an invited editorial for this journal, we summarized the literature on low-risk drinking as a route to recovery from alcohol problems 1. That editorial had three main conclusions: Recoveries of individuals who have been severely dependent on alcohol predominantly involve abstinence. Recoveries of individuals who have not been severely dependent on alcohol predominantly involve reduced drinking. The association of outcome type and dependence severity appears to be independent of advice provided in treatment 1. (p. 1149). The journal published eight commentaries responding to our editorial, and while there was some debate about whether low-risk drinking should be a goal of treatment 2, there was broad recognition that low-risk drinking outcomes are an important element of a public health approach to reducing alcohol problems 3. Furthermore, none of the commentaries took exception to our main three conclusions. Since the publication of that editorial, the evidence base has strengthened further. Empirically sound epidemiological studies in both the United States 4 and Canada 5 have demonstrated that when one considers the full spectrum of alcohol disorders and includes people who were not in treatment (i.e. self-change recoveries) low-risk drinking outcomes occur and are common. Considering the full spectrum of people with alcohol problems is important, because as far back as the 1970s, epidemiological studies revealed that there was a large population of individuals whose alcohol problems were not severe. For example, the Institute of Medicine in the United States estimated that the ratio of not severely dependent drinkers to severely dependent was about four to one 6. More recently, results from the National Epidemiologic Study on Alcohol and Related Conditions (NESARC) suggest that over the long term low-risk drinking outcomes are as prevalent as abstinence outcomes, and that such outcomes are more prevalent among individuals whose alcohol problems are less severe 4. Despite decades of mounting scientific evidence showing that low-risk drinking outcomes occur and are common, low-risk drinking is still a closet treatment goal, at least in the United States, the reason is that clinicians largely ignore the evidence. In the remainder of this editorial, we discuss why this state of affairs continues and why low-risk drinking should be offered as a treatment goal by health and mental health professionals and by alcohol treatment programs. While there are several important benefits to recognizing low-risk drinking as a legitimate treatment goal, the most important is that it would lead to targeted efforts to impact individuals whose alcohol problems are not severe and who are not physiologically dependent on alcohol. Such individuals, often referred to as ‘problem drinkers’, view themselves neither as fitting the stereotypes of inveterate ‘alcoholics’7 nor as candidates for the 12-Step treatment offered in most conventional alcohol programs. In fact, there is evidence that the orientation of traditional alcohol treatment programs has been the rationale for many not severely dependent drinkers not seeking treatment or delaying treatment entry 6, 8. In this regard, it is also important to recognize that we currently have no idea how many people might seek treatment or enter treatment earlier if alternative treatment goals such as low-risk drinking and harm reduction were promoted in treatment and supported in the community. In addition, because several epidemiological studies such as the NESARC survey show that many who, at one time, met dependence criteria over time resolved to low-risk drinking outcomes, it may also be the case that if it were known that low-risk drinking outcomes were acceptable, individuals with more serious problems who currently do not seek treatment might feel encouraged to seek assistance. In this regard, early intervention efforts should focus on facilitating self-change 9 and on using societal level strategies to inform people that low-risk drinking outcomes are not only possible, but are common. In terms of disadvantages of recognizing low-risk drinking as a treatment goal, historically some in the field have argued that the acceptance of a low-risk drinking goal would lead to causalities such as some abstinent individuals attempting to drink and heavy drinkers seeking to reduce rather than stopping their drinking 10. Although such outcomes could occur, neither provides justification for failing to meet the needs of a very large population of individuals who could benefit from services. From a public health perspective, if low-risk drinking outcomes are viewed as a legitimate treatment objective this would not only benefit individuals with drinking problems, it would also benefit society as a whole because problem drinkers account for a substantial number of problems involving intoxicated behavior 6, which greatly taxes the health-care system 11. The fact that widespread services targeting problem drinkers are lacking, especially in the United States, is a serious indictment of the alcohol field and does not derive from ignorance, as calls for such services have existed for many years 7. In order to understand more clearly the relative lack of appropriate services for not severely dependent drinkers in the United States, one needs to understand the nature and history of how alcohol treatment services developed. The provision of such services in the United States differs from most other countries in two ways. First, the majority of the work-force in the alcohol field, unlike the mental health field, does not consist of trained professionals (e.g. social workers, psychologists, mental health counselors, psychiatric nurses) 12. This relates to how the work-force first became established following the creation of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in the early 1970s. The establishment of the NIAAA provided substantial funding for public alcohol services, and led to the rapid development of counseling programs staffed mainly by individuals whose background was that they themselves were in recovery, usually related to their participation in 12-Step treatment and/or Alcoholics Anonymous. Thus, the bulk of the initial work-force providing treatment services developed without any professional training standards or credentialing mechanism 12. Later it became apparent that to gain legitimacy standards needed to be developed, and as might be expected, the standards that developed were consistent with the existing values and beliefs of the current work-force. Consequently, in contrast to other health and mental health professions where the training foundation is an evidence-based academic model, training for addiction counselors occurs largely via an apprenticeship model (i.e. specified number of hours working under the supervision of another counselor). For example, even today a Nationally Certified Addiction Counselor does not need a college degree 13. Given this history, it is easy to understand why this training model is a major impediment to accepting low-risk drinking as a successful outcome in the United States. A second difference in service provision is that in the United States services consist of a mix of public and private programs, whereas in many other countries the government is the main service provider. This is important, because when the government is the main payer for services there are incentives to attend to the research literature and not wait until problems become severe and more costly. Because government funding comes mainly from taxes, early intervention strategies play an important role in public policy. It might be said that the addiction counseling profession in the United States is very much like the pre-scientific status of the profession of medicine around the turn of the 20th century. In this regard, Ariely, reflecting on the evolution of medical practice to become evidence-based, has described the kind of inflexibility an apprenticeship belief-based training model can create: Medicine has long been a profession of received wisdom; early practitioners in ancient days worked according to their own intuitions, combined with handed-down wisdom. These early physicians then passed on their accumulated knowledge to future generations. Doctors were not trained to doubt their intuitions nor to do experiments; they relied heavily on their teachers. Once their term of learning was complete, they were supremely confident in their knowledge (and many physicians continue with this practice). So they kept doing the same thing over and over again, even in the face of questionable evidence 14 (pp. 289–290). However, over time the field of medicine adopted evidence-based services, due largely to pressures from those within the profession. This adoption led to the tightening of standards and the eventual exclusion of training programs that were not evidence-based 15. It is difficult, however, to imagine where similar pressures to adopt evidence-based services would come from for addiction counseling, as that training is isolated from other professional training and there are no apparent pressures to become evidence-based. In closing, we would like to dedicate this editorial to the memory of Dr G. Alan Marlatt, who early in his career not only recognized the value of low-risk drinking goals but, some would say, put his career on the line in defending such goals, particularly at the time of the ‘controlled drinking’ controversy 16. It is tragic in the wake of his death that the majority of alcohol treatment programs, particularly in the United States, still refuse to offer low-risk drinking treatment goals to many who might seek treatment if such goals were available. We end this editorial with a question for those who will comment on its content. What will it take for the field and clinicians who purport to help individuals with alcohol problems to offer evidence-based treatments for problem drinkers, the ‘underserved majority’7? Until this happens, providers and the field will continue to force problem drinkers to keep their pursuit of low-risk drinking a private struggle. None.

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