This is a topic that produces a lot of controversies: should an addictions expert be advocating moderation of drinking? Or, should I be giving the message that drugs are harmful and should be avoided at all costs; that abstinence is the right way and only path?
Wow. When I put it that way doesn’t it sound nutty?
We’ve been insistent on abstinence-based treatment for so long. The scenario we have established in addictions treatment would be like if you went to your physician because your glucose is too high and the physician said, “You’re an absolute failure if your glucose isn’t completely normal.” Except that isn’t what happens. They talk to you about reducing your blood sugar over time, improving your diet, and if you are not at your ideal weight, the doctor doesn’t say, “Come back when you are ready. I won’t treat you unless you’re absolutely committed to eating no sugar.”
The only reasonable approach is to take people where they are at and encourage them to take steps towards safer lives and improved health. We have this idea in addictions treatment that we need to be delivering the person to a higher state of consciousness, a more moral fortitude. I’d love to do that but I’m also going to accept improved health outcomes, life and survival, and improved goals–improving people’s movement towards their goals. These goals will do for me as a treater.
The Overdependence on Abstinence-Based Treatment
Reduction in blood pressure, obesity, sleep disorders, improved depression, and anxiety, decreased incidents of car crashes, improved relationship are all terrific outcomes in reducing the amount that people are drinking from very heavy to moderate, towards light. But, there’s been a tyranny of abstinence in system treatment. Most people do not come to treatment saying, “I want to stop my drinking problem.” They come saying, “My partner is telling me I have to come in” or “I’ve got some concerns about my drinking and I want to think about it a little bit. But I can’t imagine the rest of my life without drinking.”
Understandably, people start drinking or using any drug because it is fun. Sooner or later, some of them become unlucky and start progressing in their drug and alcohol use. They lose control and they get caught up in a cycle of dependence, but that doesn’t happen to everyone. We are going to focus on those that have a severe dependency. Obviously, many feel better if they can abstain, and for some that are trying to moderate, there can be a lot of anguish as they try to stick to a certain number of drinks or plan their evening obsessively. For many people, it is a lot easier to say, “I’m not going drink” or “I’m not going to use drugs.” And for some people, it can be very painful to reach that stage, but my job is to help motivate people to make positive changes towards improving the quality of their lives and their relationships and to guide people to that decision.
There is plenty of history on the advocation of control drinking, or to return to a low level of drinking, notably work of the Sobells in the 70’s. People with very significant alcohol use can return to a prior low level of drinking if they are coached and supported in those goals. Since then there have been many studies showing that there’s almost no difference in eventual outcome between people whose initial goals were abstinence or moderation. It is about the initial wish and engagement with the client and meeting them where they are. If you force people to be abstinent, then you are turning many of people away at the door. Instead, you need to be asking, “What are your goals? What’s your wish? How can we move towards that and shape the behavior to safer, lower levels of drinking? What if they find along the way that they want to quit drinking? That would be terrific!”
Regardless of what we say as treaters many people will cross over on their own. Many people start off with the goal of quitting, then they move towards control drinking, and many people who are starting off in moderation management will shift towards the decision to abstain. It’s common that people move between these poles along the course of their lives. It is not really about what the treater says they have to do, it is more about helping people along their path.
Determining Whether Moderation or Abstinence is Best
Let’s examine similar factors which might determine whether someone is able to moderate successfully or turn to a moderate state of drinking. Obviously, one factor is the drug itself. So, people might be using the drug very frequently or with great intensity. Those people are going to have a harder time getting back to moderate use. They might have built up a degree of tolerance and so experience withdrawal when they are without the drug and alcohol, which makes it pretty difficult for them to reduce or moderate their use. But that’s where we have to help as clinicians, with guidance and support as they try to bring their tolerance down.
In my experience, certain drugs are easier to moderate. People have a lot of success reducing alcohol, with many shifting out of a diagnosis with alcohol or drug dependence, moving into controlled or low-level use. They don’t necessarily need to identify themselves as “in recovery” and most of them do it without any assistance from the mental health world at all. Some may use peer support, like AA. But most are just making decisions themselves and shifting into control use.
I think it is very hard to moderate nicotine. There’s too much contextual reinforcement and triggers around for people to successfully reduce. You don’t see people going for an established period of nicotine dependence to occasionally having one cigarette. It’s very hard with Benzodiazepine use once people have established a pattern of high benzodiazepine use. I’ve rarely seen people able to return to controlled use. But you do see it occurring with opiates. People obviously go into methadone maintenance or buprenorphine or heroin maintenance programs (in different countries) and being able to control the use and, of course, have much safer patterns of intake of the opiates.
Apart from the drug itself, the other factors are internal, external, and contextual.
The internal issue is the degree of impulsivity and compulsivity that some have. A lot of that is determined by genetics. If you have a strong family history of addictions, it is going to be hard to shift your relationship with the alcohol. It is more compelling and persuasive to you. That kind of compulsivity or susceptibility goes together with certain personality types, whether that is higher novelty seeking or impulsivity. Certain people are more short-term focused and more easily swayed by immediate stimuli rather than being able to focus on the long-term goals and restrain their behavior for those long-term valued goals. You see that kind of personality type in those starting drug use earlier, being more impulsive.
Positive Steps Through Self Care and Therapy
The other internal aspect is affect tolerance. If people are affected by negative mood states and get overwhelmed by anxiety, then they tend to use drugs and alcohol to regulate that affect, to regulate their emotions. You can’t control use if you get overwhelmed by emotion. Controlled use demands a capacity to hold in mind a valued goal, and to stay with the AFFECTIVE SALIENCE of that envisioned goal. They have to feel the good of the valued outcome. If that gets trumped by the immediacy of the moment–by friends whooping it up and goading you on; or by something upsetting or enraging you, that will push automatic behaviors like drug use.
Perhaps in therapy, you can help someone change that internal affective focus and expectation, both by internal changes in working memory and emotional tolerance and faith that a positive outcome is possible. When I see someone with deep negative mood states and low affect tolerance I know they are going to have a hard time moving moderating. Perhaps that’s why their drug or alcohol use has gotten out of hand.
Another reflection of this is the person’s degree of self-care. People are much more emotionally distressed if they are sleeping poorly, if they are not taking care of their food and water intake, if they don’t have relationships with others; AA will talk about HALT, hungry, angry, lonely and tired, as a very good acronym for the kind of self-care questions people need to ask themselves. Without tending to those things the emotional distress tolerance is much lower. People will become more overwhelmed and turn to drugs or alcohol, and in an impulsive fashion to self-medicate, so these are factors for people who have a hard time moderating their drug use. So too, people with poor self-care are derailed by distraction, urgency and emotion from the planning and routine required.
Some external factors are the social and contextual issues contributing. If you’ve got a ton of peers that are drinking heavily, it is going to be way harder for you to manage your own drinking. If someone is attending a Mormon church I’m going to be more encouraged that they could moderate than if they are living in a fraternity and going to the sports bar and everyone is getting hammered all the time. The other external factors are the structure that people have in their life, their degrees of organization, their security of relationships, whether they are getting up at a reasonable time, working through the day, going to bed at a reasonable time, doing exercise: all of the structures they use in their lives.
We’ll talk some more in future blogs about some techniques and approaches to assist people moderating.