Return to Moderate Drinking is Still a Lie

Every few years, someone discovers that problem drinkers can return to moderate drinking—and they're always wrong. So when I saw an op-ed in the New York Times entitled "Cold Turkey Isn't the Only Route," I was disappointed, but not surprised. The op-ed, written by Gabrielle Glaser in support of her new book, has a simple message: for those who struggle to control their drinking, moderation is an alternative to abstinence. This claim is not new, and it's been disproven time and time again, often at the cost of human lives.

The first excitement over moderate drinking came after a 1962 case study by D.L. Davies. Of 93 patients treated for alcohol addiction, Davies found 7 who self-reported (with corroboration from family) drinking at most 3 pints (4 12 oz. drinks) of beer per day for at least 7 years after their treatment[1]. Although this sparked the first wave of claims that alcoholics could achieve moderate drinking, Davies' actual conclusion was that "the generally accepted view that no alcohol addict can ever again drink normally should be modified, although all patients should be advised to aim at total abstinence." Unfortunately, even that modest claim turned out to be based on bad data. A 1994 followup concluded that (surprise!) his patients had understated the severity of their drinking[2].

In the 1970s Mark and Linda Sobell picked up the torch. They devised an experimental technique to train alcoholics to drink moderately and tested it on 20 patients, concluding "some 'alcoholics' can acquire and maintain controlled drinking behavior over at least a 1-yr follow-up interval[3]." Based on those 20 patients, they wrote a book to teach their method to the general public[4]. In 1982, a team of scientists from UCLA did an independent review and follow-up with the Sobells' patients, finding very different outcomes:

Only one, who apparently had not experienced physical withdrawal symptoms, maintained a pattern of controlled drinking; eight continued to drink excessively—regularly or intermittently—despite repeated damaging consequences; six abandoned their efforts to engage in controlled drinking and became abstinent; four died from alcohol-related causes; and one, certified about a year after discharge from the research project as gravely disabled because of drinking, was missing[5].

In 1984, a Federal panel investigated the Sobell's for fraud. The panel found ambiguous language, errors, incorrect statements, and that the Sobells had "overstated their success," but attributed these discrepancies to carelessness rather than deliberate fraud[6].

The 1970s also saw an oft-cited study from the RAND Corporation, reporting that moderate drinking didn't predict relapse in patients previously treated for alcohol problems[7]. But that study only followed patients for six months. A four-year follow-up by the same researchers found that many of the original study's "moderate drinkers" had relapsed[8][9].

In Wednesday's op-ed, Glaser mentions a program called Moderation Management (MM) and reports meeting many women who have used it to change their drinking habits, but she doesn't go into MM's history. In 1994, on the heels of the Sobells' study and the first RAND report, a woman named Audrey Kishline came across the research on moderate drinking. She believed she was a problem-drinker, but not a chronic drinker, and embraced moderate drinking as her goal. Then, under the guidance of the Sobells, and contemporary moderate-drinking proponents Jeffrey Schaler, Stanton Peele, and Herbert Fingarette, she founded Moderation Management. She wrote a book, analogous to AA's "big book," to help other problem-drinkers like herself find an alternative to abstinence[10]. MM continued to grow and gain members over the next 6 years.

Then, on March 25, 2000, Kishline crashed her truck into oncoming traffic on Interstate-90, killing a 38-year-old man and his 12-year-old daughter. At the time, Kishline had been on a two-day vodka bender. She later admitted to NBC that while running Moderation Management, she'd been breaking her own rules, drinking at least 3 or 4 drinks a day, every single day, and sometimes binging on 7 or 8[10]. In her interview, she said she still believes problem-drinkers can achieve moderation as long as they're not truly alcoholic, but when asked where that line is, she replied "Nobody knows."

Kishline's experiment failed, and the small-scale, short-term, self-reporting studies claiming to show a return to moderate drinking have all fallen apart under scrutiny. The longest, largest study of the behavior of problem-drinkers has been by Harvard's George Vaillant, who studied over 600 subjects from the 1930s to present day. His conclusion: "Training alcohol-dependent individuals to achieve stable return to controlled drinking is a mirage.[9]"

In Glaser's defense, she does qualify her claims, saying "This approach isn’t for severely dependent drinkers, for whom abstinence might be best." But (almost) no one suggests abstinence unless a drinker is already having problems. If you want to drink less, try drinking less. If that works, you don't need a book, if it doesn't, there's probably no book that can help you. Glaser's book follows the path laid out by the Sobells, Kishline, Schaler, Fingarette, and Peele: helping no one, and exploiting the hopes and denial of the chronically mentally ill.

If you'd like a credible source of information on alcoholism, I highly recommend Alcoholism: The Facts by Ann M. Manzardo et al. and The Natural History of Alcoholism Revisited by George E. Vaillant. For a more personal account, Drinking: A Love Story by the late Caroline Knapp is honest and brilliant. Let's finally put the myth of return to moderate drinking to rest.

[1] D.L. Davies. "Normal Drinking in Recovered Alcohol Addicts." Quarterly Journal of Studies on Alcohol 23 (1962): 94-104.

[2] G. Edwards. "D.L. Davies and 'Normal drinking in recovered alcohol addicts': the genesis of a paper" Drug and Alcohol Dependence 35.3 (1994): 249-259.

[3] M. Sobell, and L. Sobell. "Alcoholics Treated by Individualized Behavior Therapy: One Year Treatment Outcome." Behavior Research and Therapy 11 (1973):599-618.

[4] M. Sobel, and L. Sobell. Behavioral Treatment of Alcohol Problems: individualized therapy and controlled drinking. Springer, 1978.

[5] M.L. Pendery, I.M. Maltzman, and L.J. West. "Controlled Drinking by Alcoholics? New Findings and a Reevaluation of a Major Affirmative Study" Science 217(1982):169-175.

[6] P.M. Boffey. "Panel Finds No Fraud by Alcohol Researchers." New York Times. September 11, 1984.

[7] D.J. Armor, H.B. Braiker, and J.M. Polich. Alcoholism and treatment. Rand, 1976.

[8] J.M. Polich, D.J. Armor, and H.B. Braiker. The Course of Alcoholism: Four Years After Treatment. Rand, 1980.

[9] G.E. Vaillant. The Natural History of Alcoholism Revisited. Harvard University Press, 1995.

[10] A. Kishline. Moderate Drinking: The Moderation Management Guide for People Who Want to Reduce Their Drinking. Crown Publishing Group, 1994.

[11] D. Murphy. "Road to Recovery." Dateline. NBC. Sept. 1, 2006.

Something About Dopamine - Ignite Detroit 1

This is a quick talk I gave at the first Ignite Detroit. "Research into the brain is uncovering how we make decisions. The limbic system, an ancient and primal part of the brain, and the neurotransmitter dopamine turn out to play a very important role. The emerging understanding of dopamine in the limbic system is shedding a new light on addiction, compulsive behaviors, and some of the quirkier parts of human nature."