This article is featured in the June 2017 issue of the Substance Dependence Treatment Review
Controlled drinking (CD) is part of the harm reduction approach to alcohol dependency, and also a type of Alcohol Dependence Treatment (ADT). The method of treatment has been around since the 1970s, and can be an effective method. However, even with repeated studies, the treatment has endured a controversial history among therapists, popular media, and in the research literature.
Clinical studies and peer reviewed research have demonstrated that controlled drinking is possible, and various moderation-based treatment could be preferred over abstinence-based treatment. Nevertheless, especially in the United States, zero tolerance has remained the treatment approach most popular among the public and professionals.
The History and Controversy of Controlled Drinking Research
In the early 1970s, the husband and wife team, Mark and Linda Sobell, led PhD students in a study conducted at Patton State VA Hospital located outside of San Diego.1 They took a total of 40 chronic alcoholics and divided them into two groups. One group was given Individualized Behavior Therapy for Alcoholics (IBTA). This treatment is now referred to as Controlled Drinking Therapy (CD). The second group of 20 patients underwent the standard 12 step/minnesota model abstinence-only program at the hospital. After two years of research, the Sobells reported significantly better outcomes for the patients who underwent Controlled Drinking.
While this study was happening, Mary Pendery, a 12-step, abstinence-only advocate who also worked at Patton State as an alcoholism counsellor, closely monitored the Sobells research and outcomes. For most of the 1970s, even after the study was completed, Pendery tracked the Controlled Drinking patients.
Her work caught the attention of Irving Maltzman, a UCLA psychology professor, and L. Jolyon West, who was the head of the psychiatry department at UCLA. These three published a paper in the July 1982 edition of The Science Journal. The paper accused the Sobells of fraudulent research. They claimed that four of the Controlled Drinking patients died in the following decade, and some had also relapsed. Their argument made media headlines and created a rift in the addiction community.
At this time The Sobells had been working at the Addiction Research Foundation (ARF) in Toronto. The ARF quickly established a commission to review the study, the dispute, and the allegations of fraud. Over the next several years, the Sobells made immaculate correspondence and notes of all patients in the research program, their relapses, and their deaths. What was revealed led the committee to clear the researchers of all claims.
Pendery and her team had made a crucial mistake. They had not followed up the abstinence group, as they had the controlled-drinking group. The ARF committee had found six of the abstinence-only group had died in the same period, while others had relapsed. What this ultimately suggested was that both treatments were not 100% effective, but the Controlled Drinking treatment did have a better overall outcome. In fact the final, most prominent result of the Sobells research was that in the last six months of the study, the 20 Controlled Drinking patients drank minimally or not at all for 160 out of 183 days. The 20 patients who were being taught the standard model of abstinence-only, typically functioned well for 80 days, before relapsing.
Decades later, the findings of the commission remain little-known to the public, as well as treatment institutions, and professionals. In the United States, abstinence, and nothing less, is still seen as the only legitimate method of treatment. The result of which is: there are very few facilities that integrate some kind of controlled drinking methods into alcohol dependence treatment.
A burst of successful controlled drinking studies happen every decade or so. Since the mid-2000s professionals are slowly beginning to accept that abstinence is not a realistic or achievable goal for every person. In fact, an insistence on the total and irrevokable discontinuation of drinking, not only does not always work, but may hinder an individual into getting help in the first place. Estimates suggest that between 60 and 95 percent of patients entering a 12 step program either drop out or fail to remain abstinent.2
Understanding Harm Reduction
Harm reduction is directly associated with controlled drinking treatment methods, but has been also incorporated into needle sharing programs, sexual protection programs and so forth. The method of treatment is aimed at reducing negative consequences associated with drinking, thereby improving the patients' quality of life. It is considered to be a non-judgmental approach for social justice, in that it respects the rights of people who choose to drink or use drugs. It also is seen as more realistic for people who live and work in a culture where (some) drinking is a part of social behavior.
In terms of alcohol consumption, potential harms that might be reduced include chronic health problems, acute injury, familial problems, job loss, mental health issues, social upheavals, etc. Most of these harms can be explained by:
- Context: Where the drinking takes place,
- Population: Who is drinking, and
- Behavior: The patterns of drinking that result.
By identifying these three factors, possibly harmful outcomes can also be given the necessary attention. With this in mind, a strategy or plan which targets these issues can be developed and put into place.
The Main Goal of Controlled Drinking is Not Abstinence
With controlled drinking, the main goal is not abstinence. Nor is complete sobriety forced upon someone who does not wish it. Rather, as in the name, controlled drinking attempts to reduce the consumption of alcohol through setting limits for any drinking occasion. These limits can include: the duration of the event, the amount consumed, and the associated behavior and/or consequences. The overall goal is to reduce the total consumption of alcohol to a safer, controllable level, and thereby to improve the patient's life in several areas.
Reduce Harm and Improve Health
Alcohol consumption has been linked to a broad range of health issues high blood pressure, heart disease, breast, esophagus and colon cancer, liver disease, B12 or folate vitamin deficiency and more. Heavy drinking can also lead to heightened levels of stress or anxiety as well as cause symptoms of depression or other mental health disorders. Apart from a direct physical impact alcohol could have on a person's health, there is a greater risk for injury, assault, or STD while under the influence of alcohol.
A reduction in alcohol consumption, as studies show, suggest a patient's health can be significantly improved. In one study on the effects of alcohol reduction and blood pressure, carried out by leading researchers and the American Heart Association (APA), it concluded out that less consumption did indeed act as a treatment and preventative measure for hypertension.3 The results of this study could also lead to a decrease in the risk of a stroke, heart attack or cardiovascular disease. Further research suggests reduction can:
- Assist in maintaining a healthier weight and appearance,
- Improve sleep patterns, and
- Balance hormones and the patient's mood.
Reduce Harm and Improve Relationships
Alcohol dependency can have a drastic effect on relationships not limited to a spouse, parent, and children, but also friends, co-workers, and society as a whole.4 Without addressing these problems, the relationship can be damaged or broken all together. Controlled drinking will assist the patient to identify relationship problems which were caused, or partially caused, by the consumption of alcohol. Healthier behaviors can be taught in conjunction with tools that help to repair a relationship. Overtime, stronger, healthier and sober connections with loved ones and friends can be restored.
Reduce Harm and Improve the Workplace
Alcohol's effect on an employee's work performance can include poor decision making, damaged relationships with clients, absenteeism, inefficiency, procrastination, and frequent mistakes. Intoxication on the job can jeopardise the safety of the patient, and also their co-workers, because of a likelihood in making errors due to a loss of coordination, and/or poor judgement. These concerns reflect an International Labor Organisation statistic which estimated up to 40% of workplace accidents are associated with alcohol use.5
With the guidance of a controlled drinking therapist, key predictors for problematic drinking in the workplace can be identified. These may include both individual and workplace predictors such as educational level, relationship status, self-worth, long working hours, high physical or emotional demands, monotonous work, job insecurity, lack of supervision, etc. A further prediction, which must also be considered, is a workplace environment that tolerates or encourages drinking as a means of socializing or bonding. Once the predictors are understood, a coping strategy and plan of action can be developed to hinder the desire to drink.
Treatment Components for Controlled Drinking
Controlled drinking incorporates several different components to help a patient reduce their consumption. Determining how best to treat a person will be individually based upon various factors such as his or her goals, level of intake, past events and high risk situations (also known as triggers). A controlled drinking therapist will help the patient to recognize these things and provide them with the skills needed to effectively deal with them without having to resort to drinking. The number of controlled drinking therapy sessions can range between 6 and 12 or more; one time per week, and lasting for 50 - 90 minutes. A Controlled Drinking therapist may also ask the patient to implement some or all of the following strategies:
- Keep track of how alcohol much is being drank
- Count and measure the drinks using the 'Standard Drinking Sizes
- Decide how many days per week alcohol can be consumed, and how much
- Implement slow, or paced, drinking
- Eat before and/or whilst drinking
- Avoid triggers
- Have a plan in place to deal with urges or triggers
- Find healthier, sober alternatives
- Learn, and feel comfortable with, drink refusal skills
Psychological and Psychosocial Interventions
Structured psychological interventions can be used in congruence with controlled drinking therapy. This method of treatment traditionally makes use of the interaction between a therapist or counsellor, as well as computer programs, self-help manuals, books and other material. The term 'psychological intervention' is considerably broad, and can be further classified into behavioral, cognitive, systemic, psychodynamic, and social therapy. The objective of the therapy will reflect the theoretical principles of the approach. For example, behavioral therapy is based on the idea that alcohol dependence is a learned habit and influenced by a patient's behavior.
The idea of this therapy is to teach a patient new behavior patterns that lead to a reduction in drinking and any resulting harm. On the other hand, cognitive therapy places an emphasis on the role of thinking just prior to drinking. It is also used to prevent or avoid a relapse. Theoretical psychological frameworks used to treat dependency has been articulated in various studies; however, there is no solid evidence that suggests one is superior than another.6 For this reason, each one of the therapy options can be examined and chosen based upon the patient' preference, need and objectives.
Motivational techniques are structured and intensive forms of interventions which are based upon motivational interviewing principals.7 Motivational interviewing is patient-centered, and aims to rapidly change internal motivations through exploring and resolving ambivalence towards behavior. The treatment is not based upon a set model of techniques or steps, but rather attempts to take advantage of the patient's current psychological resources. It is also employed as a treatment add-on or co-therapy with pharmacological intervention, controlled drinking therapy, and/or psychological therapies.
Brief interventions are part of motivational techniques. These are time limited intervention strategies that focus on an alcohol reduction in a non-dependent or at-risk drinker.8 Guided by a therapist, counsellor or medical practitioner, the idea is to influence positive motivation which will lead to a behavioral change. Behavioral skills or attempts to change the environment of the patient are not included in brief intervention treatment.
Prior to beginning the intervention, a short interview and assessment may be performed which is then followed by feedback from the therapist. Thiss can include personal risk factors, motivational change, goals or principles and advice on how to adjust the current drinking habits so the overall consumption is decreased.
Treatment goals typically encompass a reduction in drinking rather than abstinence. Whereas feedback may help a patient become aware of the negative consequences surrounding the drinking habits or behavior. A strategy may also be developed to help the patient cut down on their drinking. Together, these techniques assist in mobilizing the patient's coping mechanisms while stimulating positive lifestyle changes.
Assisted pharmacotherapy can also be incorporated into a controlled drinking patient's treatment strategy. In general, naltrexone, acamprosate or nalmefene may be prescribed to people who would like to reduce their drinking, but struggle to do so. Nalmefene, in particular, has been a conduit in several studies most notably out of Europe where the medication has caught the eye of doctors and addiction specialists. The drug can be taken just prior to drinking and helps a patient to reduce their desire to drink.
Moderation Management Meetings
Moderation management (www.moderation.org) is a behavioral change program and worldwide support group for people who are concerned about their drinking and wish to make healthier, more positive changes in their life. The meetings provides an alternative to abstinence or 12 step based programs which are not always a right match for a patient. Guided by a leader in a group environment, members can discuss strategies that help a person to manage negative emotion, alte behaviors, find moderation or balance between sobriety and drinking.
Controlled Drinking is Not for Everyone
Just abstinence is not an ideal form of treatment for everyone, controlled drinking will not be a suitable approach for some people. A culmination of the studies on controlled drinking suggests the method of treatment:
- May be more appropriate for younger people who have not been significantly impacted by alcohol, financial strain or legal troubles.
- Is not always so effective on older people who have been dependent on alcohol for many years.
- Might not be a suitable approach for those who have serious health issues related to alcohol (i.e. cirrhosis).
- Should not be implemented when the patient is pregnant or has a mental health disorder which is triggered or worsened when drinking alcohol.
There may also be other contributing factors to take into consideration before a patient begins controlled drinking therapy. For these reasons, it is recommended to speak with a doctor or medical professional for further advice.
Differences in European and North American Treatment Models
The European and North American treatment models for alcohol dependency (addiction) are significantly different. Each has a different history, and definition of addiction, and from this different treatments follow: Abstinence and Controlled Drinking.
North American Alcohol Dependency Treatment
The North American model of treatment originates from the Minnesota Model, an approach created in the 1950s inside a state mental hospital.9 The Minnesota Model advocates complete abstinence, a prohibition on drugs and alcohol.
The core objective of the treatment is to maintain complete abstinence from all drugs and alcohol, as well as to provide guidance in dealing with everyday ups-and-downs and hardships, and become part of a therapeutic community. Today this model is popular and has been expanded in various ways at different rehab facilities to include other types of complementary treatment.
European Alcohol Dependency Treatment
Up until the 1960s, there was little to no official model of treatment in Europe.10 It was around this time, psychiatrists in the UK and Czech Republic (formerly Czechoslovakia) started to develop a democratic, user-led therapeutic environment which consisted largely of group therapy, social interaction, collective education and behavioral alterations. This flourished into a common model that treated addictions based upon underlying reasons, or core conditions which may include factors stemming from social, financial, relationship, childhood or mental health problems. Controlled drinking, or even drug use (i.e. heroin clinics), is often included in this model, and one that works for many patients in the EU. Abstinence on the other hand is not necessarily a goal, but rather an option best suited to patients who are ready and willing.
Reducing the consumption of alcohol over a set period of time is not a widely accepted form of treatment for those with a dependency problem. Rather, abstinence, or the complete cessation of alcohol consumption, is considered to be one of the only methods to halt dependency. A broad range of studies are providing evidence for the effectiveness of methods to reduce alcohol consumption in a person, eventually leading to a total elimination of the desire to return to drinking in an uncontrolled way.
Many ongoing studies, particularly those out of Europe, are implementing medication that helps patients to reduce and control their drinking. One such medication, Nalmefene or Selincro, has been the subject of clinical trials and medical conferences, and is now available to the public in certain countries.
At the same time, the North American Minnesota Model of abstinence has also become popular in Europe, though not as exclusively as in its native location.
Advantages and Drawbacks of the Controlled Drinking Treatment
The accepted orthodoxy of a large segment of alcohol dependency treatment focuses solely on abstinence. However, there are a significant number of alcohol-dependent drinkers for whom complete abstinence is negatively perceived, and impractical. Controlled drinking, on the other hand, offers an acceptable treatment method for certain kinds of alochol-dependent individuals, and can be an effective approach to reducing alcohol intake, reducing harm, and improving outcomes.
Advantages of the Controlled Drinking Treatment Method
- Dependent drinkers may not feel completely out of control or overwhelmed when opting to moderate their own consumption.
- Various studies have been able to show a decrease in alcohol consumption and positive consequences.
- For people who are not ready to quit drinking, this strategy might help to reduce health problems and make improvements in their daily life.
Drawbacks to the Controlled Drinking Treatment Method
- Controlled drinking works best when other types of treatment such as therapy or counselling is included.
- People who are unable to quit on their own, or who lack control because of an acute problem, may not benefit from controlled drinking.
- Controlled drinking will take a precise mindset and wilful determination from the dependent person. Lacking this could prove the treatment to be unsuccessful.
This article is featured in the June 2017 issue of the Substance Dependence Treatment Review