Can Patients with Alcohol Use Disorders Return to Social Drinking? Yes, So What Should We Do about It?

Polemics on the issue of whether people with alcohol use disorders can learn to moderate their alcohol use have existed for decades (1). On one side of the debate are advocates of the disease, or 12-step, model of alcohol problems, who argue that individuals suffering from the disease will inevitably lose control of their use if exposed to any amount of alcohol. According to this model, abstinence is the only way to arrest the disease's development. From the alternative perspective, several related arguments are mounted. Some proponents argue that folks require different strokes-that different types of alcohol problems require different types of responses, such as abstinence for some problems and moderated drinking for other types. Other clinicians focus on the benefits of adopting a harm-reduction orientation toward alcohol problems. This approach focuses less on the amount of alcohol consumed and more on helping individuals decrease the harms related to alcohol use. Although abstinence may be desirable, it is not the primary measure of successful outcome. In this paper, I briefly review the arguments supporting the feasibility of nonabstinent drinking outcomes and argue further that we should shift the debate from whether nonabstinent goals are feasible to how we can best integrate such a perspective into our treatment systems. If we expand the range of our treatment options, we may encourage more people with alcohol use disorders to seek treatment. Finally, I discuss what interventions are appropriate to incorporate in this expansion, if we accept that nonabstinence goals are appropriate for some people. Several lines of evidence point to the validity of nonabstinence treatment goals for some people with alcohol use problems. First, as early as the 1940s, follow-up studies of individuals suffering from alcoholism have revealed that a proportion of patients, albeit a small group, describe successful and sustained nonabstinence outcomes (2). The most widely cited of these studies is the Rand report from the mid-1980s, which followed up a large US national sample of patients from abstinence-oriented inpatient alcohol treatment programs. Remarkably, about 18% of these patients were described as drinking in a problem-free fashion after 4 years (3). A second line of evidence comes from treatment evaluation studies that have included nonabstinent drinking goals. Amborgne recently reviewed these studies (2) and identified 12 that consistently found that some patients were able to sustain posttreatment nonproblem drinking over follow-up periods ranging from 1 to 8 years. Several patient characteristics are found to predict successful nonabstinent outcomes. These include younger age, relatively better social and psychological stability, being employed, being female, and having less severe alcohol dependence (4), as well as having a stronger belief in one's ability to moderate drinking (5). Several medical factors, including pregnancy and liver disease, preclude a nonabstinent goal. Why, then, have our treatment systems not fully embraced these data and promoted interventions that allow nonabstinent outcome goals? The diverse political and economic barriers to system change have been discussed elsewhere (6) and are not limited to the substance abuse field. However, one relevant factor is, of course, the experience and intuition of individual clinicians. As clinicians, we are uncomfortable with incorrectly predicting an individual's outcome. Unfortunately, none of the patient characteristics that predict successful moderation are robust enough to be used by clinicians planning individual patient treatment. Rather, a probabilistic model fits-the more indictors present in an individual, the more likely it is that the goal is appropriate. Even so, the prediction is not perfect: a particular patient with all the right indicators for successful moderation (for example, a younger, socially and psychologically stable woman with a mild alcohol problem) might better quit than cut back on her drinking. …

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