Harm Reduction or Total Abstinence in Treating Alcoholics?

By: Garry Cooper, LCSW
 

 

Parts of this article originally appeared in the July/August, 2006 Psychotherapy Networker Magazine and are reprinted with permission and copyrighted by Psychotherapy Network, Inc.

Researchers and policymakers in the field of alcoholism are catching up to what many clinicians have long been doing: encouraging some clients to deal with alcohol problems by learning to control, not completely stop, their drinking. For some people this can be a more effective strategy than encouraging total abstinence.

For many years, agencies and researchers used complete drinking cessation as their primary measure of effectiveness in evaluating treatments. But at the December, 2005 convention of the American Association of Addiction Psychiatry, several presenters urged researchers to evaluate treatment study outcomes in terms of a reduction of the amount of alcohol a person consumes daily or in the number of drinking days, arguing that this provides a more realistic measure of success. However, for total abstinence die-hards, measuring effectiveness in terms of controlled drinking seems akin to the federal government lowering the standards for clean air and then claiming success at cleaning up air pollution.

But increasingly, the new direction in research and treatment lies in figuring out which clients can control their drinking and which need to abstain completely. At the convention, University of Connecticut psychiatrist Henry Kranzler used the emerging paradigm to point out that two common medications for treating alcoholism have different benefits. Disulfram, no more effective than placebo in achieving complete abstinence, is highly successful in harm reduction, cutting the number of heavy drinking days in half, while Campral has a good success rate in helping drinkers to achieve abstinence. Under the new paradigm, the goal of treatment—abstinence or controlled drinking—can help determine which medication to use.

The trick in treating clients with alcohol problems, whether using medications, therapy, or a combination, may lie in determining which clients can effectively sustain a reduction in drinking and which need to abstain altogether. That research is starting to trickle in. Kranzler thinks the decision may rest upon the severity of an individual’s alcohol dependence, although other researchers have found no correlation between drinking severity and effectiveness of controlled drinking. Kranzler’s other theory, better supported by other research, is that people who have demonstrated a capacity to drink at reduced levels for a reasonable period of time may be better candidates for controlled drinking. (See article 4)

A small study of drinkers in the February, 2006 journal Addiction Research and Theory (Booth, 2006) finds that people who managed to maintain controlled drinking for five years had abstained from drinking initially. They then started drinking small amounts of alcohol, considerably under the recommended limits, and avoided distilled spirits and solitary drinking. This suggests that for some people, stepping off the wagon may not necessarily be a harbinger of disaster. Another study of alcoholics and their families in the same issue (Vellernan, 2006) finds that the most successful controlled drinkers are those in established, positive relationships who have a spouse and/or family.

Perhaps the most promising research for determining which treatments work best for which people comes from a study led by Howard Moss of the National Institute on Alcohol and Alcoholism, presented in the December, 2007 journal Drug and Alcohol Dependence. By culling 1,484 people across 48 states from a population-based sample of 43,093 Americans, rather than using a sample based upon people who have already sought treatment, Moss’s study captures the widest representation of alcohol dependence (AD). After studying the responses to the National Epidemiological Survey on Alcohol and Related Conditions, the researchers discovered five subtypes of people with AD. This classification system carried some surprises for the researchers, and may eventually help clinicians decide which kinds of treatments work for which people. The classification system is based upon family history, age of AD onset, DSM alcohol use disorder criteria, and the presence of comorbid psychiatric and substance use disorders.

The types, in ascending order of severity, are:

Type 1, young adult (31.5 percent of people with AD) is the most prevalent kind. This was one of the biggest surprises to the researchers, who had expected the most common type to be the older, chronic recurring group (see type 5). Onset comes at around 19 years old, and the mean age is 24.5. They are the least likely to have comorbid psychiatric disorders or legal problems, a moderate probability of being cigarette smokers or marijuana abusers, and 2.5 times more likely to be male than female. Although they drink less often than the other types, when they do drink, they drink more. They are also the least likely to seek help; only 8.5 percent did so, and when they do seek help, it’s most likely through 12-step programs rather than from private professionals.

Type 2, functional (19.4 percent of people with AD) averages 41 years of age. They began drinking at about 18.5 years of age, slightly higher than other types, and have AD onset at about 37. Nearly 50% of are married, 62% work full-time, and about 26% have a college degree or higher. They have a moderate likelihood of having another family member with AD, a moderate probability of major depression, and a low likelihood of anxiety and other substance abuse disorders. Type 2 has the highest proportion of retired individuals and a mean total family income of $59,576, the highest among the AD types. They tend to drink alcohol every other day and consume an average of 5+ drinks when they do. They report an average of 10 drinks as being the maximum number consumed on drinking days. Only 17 percent of them have sought help for their drinking, and they tend to seek 12-step groups or private health care professionals.

Type 3, interfamilial (18.8 percent of people with AD) averages about 38 years old, began drinking at about 17 and first showed signs of AD at about 32 years of age. They’re more likely to have family members with AD, to smoke cigarettes, and suffer from major depression or bipolar, obsessive-compulsive, and/or generalized anxiety disorder at some time in their lives. They also have elevated probabilities of marijuana and/or cocaine use disorder. About 38% are married, and 21% are divorced. Nearly 20% have a college degree or higher and 68% work full-time, giving this cluster the highest level of employment among the AD types. Almost 27 percent have sought help for their drinking, usually from self-help groups, specialty treatment programs, detoxification programs, and private health care professionals.

Type 4, young antisocial (21.1 percent of people with AD) averages 26.4 years old, began drinking the earliest (15.5 years on average), and have the earliest onset of AD (18.4 years). They have the highest probability of antisocial personality disorder (54 percent) and a high degree of multigenerational AD. They have an elevated probability of bipolar disorder, social phobia, and obsessive-compulsive personality disorder. As a group, they have the highest probability for a major depressive episode prior to age 15 years. They’re likely to suffer from other forms of substance abuse, with the highest probability among the types of being regular smokers and of suffering from cannabis, amphetamines, cocaine, and/or opioid use disorders. They’re the most likely of all five types to endorse their own drinking or drug use. 76 percent are males and 24% females. Only 15.3 percent are married, and 64 percent never married, and fewer of type 4 than any other type have received a college degree. They also report the most drinks on their drinking days, averaging just over 17. Despite their high likelihood of endorsing their own behavior, almost 35 percent have sought help for their drinking, usually through self-help groups, specialty treatment, and detoxification programs. They are also more likely than the other types to seek treatment with individual private health care providers.

Type 5, chronic severe (19.2 percent) average 37.8 years old, began drinking at about 15.9 years, and has a relatively late onset of AD, at about 29 years. They have a 47 percent probability of having antisocial personality disorder and the highest probability among the types of having both first and second degree family members with AD. They’re more likely than all other types to suffer from lifetime major depression (55%), dysthymia (25% ), bipolar disorder (34%), generalized anxiety disorder (24%), social phobia (26%), and panic disorder (17%), with elevated probabilities for regular smoking and for cannabis, cocaine and opioid use disorders. As befits their chronic severe classification, they’re most likely to report persistent efforts to cut down, drinking larger/longer amounts than intended, significant periods of time spent recovering from alcohol, reduced activities due to drinking, and drinking despite problems. About 65 percent are males, 28.7 percent are married, and they have the highest divorce rate among the five types (25.1 percent divorced and 8.6 percent separated). They have the lowest employment rate, the greatest number of past year drinking days of any of the types (247.5 days), and an average maximum number of 15.4 drinks on any drinking day. Their drinking is too severe to foster denial. Nearly 66 percent of them have sought help for their drinking problem, the most of any type, through self-help groups, specialty rehabilitation programs, and detoxification programs. They have the highest rate of receiving inpatient treatment, and the highest rate of emergency room visits for drinking-related issues.

Currently, Moss suggests using these types as a guide for thinking about different levels of interventions. He already has some hypotheses about levels of interventions. An article in the September 21, 2007 Psychiatric Times quotes Moss as saying that type 1 may benefit from screening and brief intervention techniques “rather than much more expensive approaches to therapeutic intervention.” He speculates that certain medications could also be an effective intervention for type I in order to get an early jump on stopping the reinforcing effect of alcohol, though he stresses that further research is needed on this. Moss says that treatment for type 2, the functional, might better focus on helping them recognize how the impairment affects them and then working on either abstinence or controlled drinking. Because the antisocial types (4 and 5) have the worst prognosis, he says, the treatment focus should probably be on complete abstinence and on behavioral interventions that will help integrate them back into society. The chronic severe type, he says, need the most intensive treatment and should focus, among other things, on relapse prevention.

Moss is continuing his studies on alcohol disorder types and wants to track the types over a period of time instead of taking one snapshot. He’s interested in seeing whether people move from one type to another, for example, whether type 4’s become type 5’s. Equally important: when type 4’s don’t become type 5’s, why not? The information could help develop or fine-tune interventions and may also give insights into the strengths which clients themselves bring to the process of change and healing. He’s also interested in type 1, the most common type. He suspects that many of these young drinkers stop, without professional help, what we might ordinarily assume an inevitable deterioration. Once young adults marry, get a job, and take on other social responsibilities from parenting to community work, he thinks, “These responsibilities may become a significant protective factor, and some may just drop out of the AD diagnostic category altogether,” he says.

Psychologist William Miller of the University of New Mexico, suggests another approach to deciding whether to go for controlled drinking or total abstinence. “The patient’s own stated goal is a pretty good predictor of outcome,” he says. That belief is a cornerstone of Miller’s Motivational Enhancement Therapy (MET), one of the treatments recommended by the National Institute on Alcohol Abuse and Alcoholism. Instead of insisting on total abstinence, MET’s principles reflect what usually constitutes effective therapy in general: developing empathy with the client, doing more listening than talking, allying therapy with what motivates each individual client to change, and letting clients set their own agenda. “We may have aspirations about what we’d like clients to do,” Miller says, “but it’s not a goal until the client chooses it.”

Motivational Interviewing (MI), which has evolved from MET, has shown success with teenage drinkers. Like other strategies that don’t push for total abstinence, MI provides teens with objective information about the effects of alcohol and what their peers are doing. This kind f neutral information allows teens to consider the risks and consequences of their actions and to compare their behaviors and symptoms with those of their peers. Crucial to MI, says psychologist Allan Zuckoff of the University of Pittsburgh, is to present the information with complete neutrality. Scare tactics might be satisfying to the presenter, but they’re largely ineffective, especially with teenagers, who are often impulsive. After presenting the information, MI invites the teen to say what he or she thinks about the information. If the teen doesn’t accept it, he says, don’t insist that the information is true or important, and above all, don’t accuse the teen of being in denial. Doing any of those, says Zuckoff, just leads to an escalating cycle of confrontation and denial.

Resources

Arehart-Triechel, Joan (2007). “Clinical features point to five alcoholic subtypes,” Psychiatric News, 42 (18), 15.

Booth, Peter, G. (2006). “Idiosyncratic patterns of drinking in long-term successful controlled drinkers,” Addiction Research and Theory, 14 (1), 25-33

Moss, Howard, Chen, CM and Yi, H. (2007). “Subtypes of alcohol dependence in a nationally representative sample,” Drug and Alcohol Dependence, 91 (2-3), 149-158.

Vellernan, Richard (2006). “The importance of family members in helping problem drinkers achieve their chosen goals,” Addiction Research and Theory, 14 (1), 73-85

For more information on Motivational Interviewing, see www.motivationalinterviewing.org