Judy Foreman’s syndicated column HealthSense appears internationally every other week. She is a fellow in medical ethics at Harvard Medical School and a visting research associate in women's studies at Brandeis University. Her past columns are available on her website www.myhealthsense.com.
Reprinted with permission of the author.

Until four months ago, Paul Robert, a hardworking 42 year -old Connecticut businessman, would get home from work and knock back six drinks a night -  45 drinks a week. Sometimes wine, sometimes beer, sometimes the hard stuff.

“It was the stress,” he says, and alcohol “absolutely” helped. He didn’t think he was a true alcoholic. His job was going great, he says, and his family life  he has a wife and two kids, aged 7 and 10  was, too. He’d never been arrested for driving drunk.  Even his liver showed no damage from all the alcohol it processed night after night.

Deep in his heart, though, Paul Robert knew he was drinking far too much. Yet he didn’t want to go the Alcoholics Anonymous route and quit completely. What he wanted was to reduce,  not eliminate, his drinking.

And thanks to a program at Charles River Hospital in Wellesley in which he gets counseling and a daily dose of a drug called naltrexone to reduce his craving for alcohol, he thinks he has. “I’m down to 12 drinks a week,” he says. His goal is “to go back to leading a normal life, so I can go out and have a couple of drinks. I am already there.”

The issue of whether people who drink too much can return to moderate drinking is one of the most contentious in medicine - and one with enormous social impact.

 An estimated 14 million Americans have an alcohol use disorder, either abuse (impairment but not physical dependence) or dependence (alcoholism), which is characterized, among other things, by uncontrolled drinking, tolerance for high doses and withdrawal symptoms when drinking stops. All told, about 40 million Americans drink more than the recommended “moderate” levels - one drink a day for women, and two for men, with a “drink” defined as five ounces of wine, 1.5 ounces of spirits or 12 ounces of beer.

So, can a heavy drinker really cut back without quitting totally?  Yes, but the odds of success depend on the severity of the drinking problem, and on whether you have a family history of alcohol problems. If you’re an alcohol abuser but not yet alcohol-dependent, you chances are better; if you’re truly alcohol-dependent, they’re almost zero.

The good news is that most people with alcohol problems are not dependent, according to a 1997 analysis published by the National Institute on Alcohol Abuse and Alcoholism, part of the National Institutes of Health.  The bad is that the line between abuse and dependence “is in no way a clean distinction,” says University of New Mexico psychologist William R. Miller, a leading alcoholism researcher. In fact, he says, mental health experts are re-considering whether it makes sense to maintain this distinction at all.

The problem is that people with drinking problems tend to self-diagnose, to think their problem is less severe than it really is, and to avoid seeking help. That’s one reason why the famous 12-step meetings of AA are filled with people who have tried for years -and failed- to control their drinking rather than quit.

The research studies on controlled drinking are both encouraging and sobering.

• A series of studies by Miller’s team at the University of New Mexico shows that people without alcohol dependence can indeed return to more moderate drinking. In these studies, about two-thirds of heavy drinkers managed to reduce their drinking substantially and to maintain their success for two years. When followed for up to eight years,  the figures change - 15 percent had maintained moderate, problem-free drinking, 25 percent had abstained completely for at least a year, 23 percent had cut back but still had some drinking-related problems and 37 percent were no better than when the study started. Other studies in 1980, 1984, 1988 and 1992 showed similar results.

• In a pivotal study of true alcoholics - published 15 years ago in the New England Journal of Medicine but still considered noteworthy by other researchers - Dr. John Helzer, a psychiatrist at the University of  Vermont Medical School showed that only about 2 percent were able to have an occasional drink without becoming dependent again. Curiously, noted Helzer in a telephone interview, a successful return to more moderate drinking was four times more likely in women. Other studies in 1979, 1989 and 1996 also suggest that women may be more successful at cutting back than men.

• Cognitive-behavioral techniques, in which people are taught to recognize and change the thinking patterns that underlie their drinking,  clearly help people cut back on alcohol intake. In fact, they are among the most successful approaches for people with less severe drinking problems,  according to a 1999 review of the data in Alcohol Research & Health, the journal of the alcohol abuse and alcoholism institute. Cognitive-behavior also works for true alcoholics - not to help them cut down but to help them remain abstinent -  according to project MATCH, a large federal study in 1996.

• Brief interventions, in which a doctor or nurse schedules several short appointments to teach a patient about ways to reduce intake, also reduce consumption in people who are not alcohol-dependent, according to the same 1999 review. In fact, in Seattle, a 1999 study of people who wound up in the emergency room after alcohol-related accidents showed that 30 minutes of alcohol counseling from a psychologist before discharge reduced the likelihood of readmission for other alcohol-related trauma. But nationwide, many doctors and nurses have yet to incorporate this technique into their practices.

• On the more discouraging side, research in 1996 by  Dr. George Vaillant, director of research in psychiatry at Brigham and Women’s Hospital ,  tracked more than 700 college-educated and less-educated male alcohol abusers for more than 50 years. Vaillant found that men who tried to control their drinking usually relapsed while those who managed to stay sober for five years rarely did.

 “Nothing is more appealing to a lot of alcoholics than the idea that if they could just figure out how to control their drinking, that would do it,” says Dr. Roger Weiss, clinical director of the alcohol and drug abuse treatment program at McLean Hospital in Belmont.

Dr. Richard K. Fuller, director of clinical and prevention research at the National Institute on Alcohol Abuse and Alcoholism, agrees. With true alcoholics, he says, “it’s very unusual for them to return to moderate drinking. The reason this is so sensitive, why some alcoholics become livid about this, is because they feel their own recovery was delayed for many years because they struggled, kept chasing this will of the wisp…Most people can have a drink or two and stop. The alcohol-dependent person can’t.”

Vaillant of Brigham and Women’s agrees.  “People cling to” the possibility of controlled drinking “because they like it and they don’t like what I’m saying,” which is that over the long run, most people with serious drinking problems can’t return to moderate intake.

That point was illustrated dramatically not long ago with the tragic story of Audrey Kishline, who founded a program called Moderation Management in 1993 on the premise that heavy drinkers who are not yet alcoholics can cut back without abstaining altogether.

In March, Kishline went on a drinking binge and killed two people in a car crash. Afterwards, she reportedly called her own program an example of “denial in action.”

Even so, Stanton Peele, a Morristown, N.J. psychologist, lawyer and former board member of Moderation Management, points out that  it’s “ironic” that Kishline’s accident happened after she joined AA and was trying to be abstinent. It wasn’t just moderation that failed her, he says, “everything failed her.”

Advocates of  moderated drinking like Anthony Martignetti, an addiction specialist who runs the Alcarrest program at Charles River Hospital, insist that, for selected people, reduced drinking programs work.

In fact, says Martignetti (whose family, ironically enough, owns the Martignetti companies, the New England liquor distributor),  it’s the fear of abstinence-only programs that keeps many people from seeking traditional treatment.  So far, about 200 problem drinkers have completed Martignetti’s program, called Alcarrest and by one year after treatment, 70 percent say they’ve reduced their drinking by 70 percent.

The bottom line?

For Paul Robert at least, things look good. He’s optimistic he can continue to drink moderately.

For others, well, let’s put it this way: If you find yourself saying “Bottoms up!” too often, see a doctor or alcohol counselor to evaluate your drinking. Trying to diagnose yourself is likely to be fraught with denial.

Then, if you and your counselor agree your problem is not severe, try a program aimed at cutting back. If your problem is severe, total abstinence is the best answer.

SIDEBAR

There are a number of medications that can help people control or cut down on their drinking, says Dr. Shelly Greenfield,  medical director of the alcohol and drug abuse ambulatory treatment program at McLean Hospital in Belmont, Ma.

Antabuse (disulfiram) is a so-called “aversive” drug that causes nausea and other unpleasant symptoms if alcohol is also consumed. At high doses, the combination of Anatabuse and alcohol can be dangerous. The idea is to make the drinking experience so unpleasant that a person doesn’t drink  but this only works if people take the drug.

Naltrexone (ReVia) is an opiate-blocking drug long used to combat addiction to drugs such as heroin. In 1994, it was approved by the US Food and Drug Administration to curb craving and prevents relapse in people with alcohol problems.

Acamprosate is a drug that has shown promise in European studies to curb craving for alcohol and help maintain abstinence. It is not yet approved in the US, but studies are underway.