Rethinking Alcohol: Can Heavy Drinkers Learn To Cut Back?
The thinking about alcohol dependence used to be black and white. There was a belief that there were two kinds of drinkers: alcoholics and everyone else.
"But that dichotomy — yes or no, you have it or you don't — is inadequate," says Dr. John Mariani, who researches substance abuse at Columbia University. He says that the thinking has evolved, and that the field of psychiatry recognizes there's a spectrum.
Problems with alcohol run the gamut from mild to severe. And there are as many kinds of drinkers along the continuum as there are personality types.
People with severe problems, such as those who keep on drinking even after they lose jobs or get DUIs, need treatment to stop drinking completely.
But there are other drinkers, including some who are in the habit of drinking more than one or two drinks a day, who may be able to cut back or moderate their consumption and reduce their risk.
In fact, a recent study by the Centers for Disease Control and Prevention found that the majority of Americans who drink more than one or two drinks a day are not alcoholics. They don't report symptoms of dependence.
So what would it take for them to cut back? Increasingly there are researchers and therapists evaluating this question. And they're finding a host of strategies that may be helpful.
Another CDC study found that alcohol screening and counseling in doctors' offices — for instance, your primary care doctor asking about drinking during an annual checkup — can reduce drinking by 25 percent per occasion in people who drink too much.
And the National Institute on Alcohol Abuse and Alcoholism has a whole list of tips aimed at cutting down — everything from drinking tracker cards that you can keep in your wallet to help you track your drinking when you go out, to strategies for handling urges.
For people concerned that their drinking may be moving towards dependence, a screening tool called the Drinker's Checkup can evaluate and give feedback.
There are also support groups such as Moderation Management, which aims to help drinkers who are trying to cut back.
Ten years ago, Donna Dierker, who lives in St. Louis, was concerned about her drinking. "When I did drink, I drank a lot," Dierker told us. She never drank during the workweek, but on weekends were different. "Fridays would be a six-pack," she says. And Saturdays meant more drinking. "On Sundays I'd feel awful."
Her blood pressure was going up; her weight was creeping up. And so she resolved to cut back.
"I had these good intentions, but then every time Friday rolled around, I'd lose my resolve," Dierker says.
She checked out Alcoholics Anonymous because that was the only alcohol support group she'd ever heard of. But she says it didn't seem like the right fit.
Then she read about Moderation Management. "And I just decided to try it."
When she connected with leaders and other people on the MM listserv, they helped her work through her issues.
The first task was to identify her triggers. Why was she was drinking so much?
She realized that she used alcohol as a reward for a hard week's work. "Getting through a Friday evening without my reward, you know, that was the tough one," Dierker says.
But she also realized that her drinking was more of a habit than a compulsion. And the friends she drank with reinforced that habit. "That was the norm," she says.
So Dierker set out to change her weekend routine. Instead of drinking beer on a Friday night, "I'd drink seltzer water ... and dance in the playroom with my son," she says.
Slowly she developed a new relationship with alcohol. To pull this off, she learned tools and techniques to help her keep it in check. For instance, her old routine was to drink one drink after another, back to back — what's known as chain drinking.
"I had to consciously slow down and learn to sip instead of gulp," Dierker says.
And just as people learn to eat less by counting calories, she learned to count her drinks and set limits. "For me, that really helps."
Dierker says that for the most part it works for her. She has no problem just having a glass of wine with dinner or a couple of drinks with friends.
And every so often she takes a monthlong break from drinking so it doesn't start to creep up.
"I feel I'm in the driver's seat again," Dierker says. She no longer drinks out of habit. "I've gotten to the point where it's a treat again and I look forward to it."
Since Donna first tried moderation, the concept of helping people try to moderate their drinking has gained traction. The Substance Abuse and Mental Health Services Administration (SAMHSA) lists Moderation Management as an evidence-based program.
And the National Institute on Alcohol Abuse and Alcoholism has reviewed one study that found that the moderation approach offered by Moderation Management and ModerateDrinking.com can help some heavy drinkers cut back.
But many experts would like to see more evidence of its effectiveness. "It's only one study," says NIAAA Director George Koob.
Moderation as an alternative to abstinence certainly doesn't work for everyone.
And the tricky part of the moderation path is that there's no way to know which heavy drinkers can learn to control their drinking rather than having to give it up completely.
There isn't enough data to know if a certain person with a certain profile is going to be successful, says Koob. "The science just hasn't been done."
And to some, the concept of moderation is controversial.
Some critics point to the story of the woman who founded Moderation Management. After leaving the organization, she struggled with drinking, caused a fatal drunk-driving crash and then committed suicide.
"For everybody, it's really a process to figure out what's going to work and what's not," says Sarah Vlnka. She's a social worker and therapist in Michigan who has struggled with alcohol.
In her case, after about a year and a half of experimenting with moderation she realized that she wanted to quit drinking entirely.
In part, she realized she was spending too much time thinking about managing the process.
"I got tired of it," she says. "Anything that takes [so much] brain space doesn't feel worth it." So she stopped. In her case, moderation led her to abstinence.
Mariani says there are lots of heavy drinkers who are resistant to help or the idea of abstinence, but are open to the idea of cutting back.
"As a starting place," Mariani says, "moderation is often a goal that everyone can agree on."
And it also addresses what many experts see as a treatment gap. In the past, it was only the people with the most severe cases of alcohol dependence who got treatment or help.
With the moderation approach, "it's a way of reaching people earlier," says Dr. William Miller, professor emeritus of psychology and psychiatry at the University of New Mexico and author of Controlling Your Drinking. It's a way of meeting people where they are.
And if moderation doesn't work? It may be a step on the path to abstinence.
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Transcript
RENEE MONTAGNE, HOST:
A few months ago, we did a story about Americans' drinking habits that got a lot of people thinking. The bad news was that many Americans are drinking more than one or two drinks a day, which is the upper limit of what experts think is safe. And this means that many who think of themselves as social drinkers actually fall into the category of excessive drinking. Today in Your Health, NPR's Allison Aubrey follows up on this story asking a new question - if you're drinking too much and want to cut back, where can you go for help?
ALLISON AUBREY, BYLINE: The thinking about alcohol dependence used to be very black and white. There was a belief that there were basically two kinds of drinkers - alcoholics, who needed treatment, and everyone else whose drinking was OK.
JOHN MARIANI: But that dichotomous yes-no, you have it or don't, is inadequate.
AUBREY: That's John Mariani, an addiction expert at Columbia University. He says the thinking among researchers has evolved.
MARIANI: The field recognizes that there's a spectrum.
AUBREY: Alcohol problems run the gamut from mild to severe. And to some, people do need treatment to stop drinking completely because alcohol is ruining their lives. They keep on drinking even after they lose jobs or get a DUI.
MARIANI: For them, the only solution is to abstain.
AUBREY: But do all excessive drinkers need to go this far? A recent CDC study found that the vast majority of Americans who drink more than one or two drinks a day are not alcoholics. They don't report symptoms of dependence. But many do want to cut back because they know it's not good for their health or they're concerned about their drinking progressing.
MARIANI: It's very common for people to want to moderate, to drink less, and see if that will work. And some people will be able to do that.
AUBREY: Take the story of Donna Dierker. She's the mom of two kids and she works as a scientist in St. Louis. About 10 years ago, she began to think she had a problem.
DONNA DIERKER: When I did drink, I drank a lot.
AUBREY: Not ever during the work week, but come the weekend, she and her husband would go out or drink with friends.
DIERKER: Like, Fridays would be, like, a six-pack and Saturdays probably split a pitcher of margaritas and then have a few beers after that. And then Sunday morning I would feel awful
AUBREY: Her blood pressure was going up. Her weight was creeping up, and so she resolved to cut back.
DIERKER: I had these good intentions, but then every time Friday would roll around, I would, you know, lose my resolve.
AUBREY: She checked out AA because that's the only group she'd ever heard of, but she says that that didn't seem right. Then she read about a group called Moderation Management. The organization has a national presence and is often the first alternative people find out about if they search online for help. It's basically an online support group to help people cut back.
DIERKER: And so I just decided to try it.
AUBREY: Now, through the group she connected with leaders and other people on the listserv who helped her work through her issues. The first thing she had to do was to identify why was she drinking so much? And what she realized is that she used alcohol as a reward for a hard week's work.
DIERKER: Getting through a Friday evening without my reward, you know (laughter) that was the tough one.
AUBREY: But she also realized that for her, drinking was more of a habit than a compulsion, and her friends, whom she drank with every weekend, reinforced that habit.
DIERKER: It was almost like not having ever grown out of college, you know (laughter)? That was the norm.
AUBREY: So she changed her weekend routine. On a Friday night instead of drinking beer...
DIERKER: I would drink seltzer water and dance in the playroom with my son.
AUBREY: And when she did drink, she learned tools and techniques to help her keep it in check. Her old routine was this...
DIERKER: As soon as one drink's gone getting the next drink - it's like habit; it really is. And I had to consciously slow down and drink-sip instead of gulp.
AUBREY: And just like people learn to eat less by counting calories, Donna learned to count her drinks and to stop when she reached her limit.
DIERKER: For me, that really helps.
AUBREY: Now, it's been 10 years, and Donna says for the most part it works. She has no problem just having a glass of wine with dinner or a couple of drinks with friends. And every so often she takes a month-long break from drinking so it doesn't start to creep up again.
DIERKER: I feel like I'm in the driver's seat. I don't feel like it's habit anymore. I think, you know, I've gotten it to where it's a treat again.
AUBREY: Now since Donna got started, the concept of helping people try to moderate their drinking has gained traction. Researchers have evaluated everything from cognitive behavioral therapy to motivational counseling to the self-help group like the one Donna uses, Moderation Management. So the question is how typical is Donna's success?
GEORGE KOOB: There's only been really one study that we know of that's evaluated Moderation Management, and they did find significant reductions in alcohol consumption and alcohol-related problems, but it's only one study.
AUBREY: That's George Koob. He's the director of the National Institute on Alcohol Abuse and Alcoholism. Now, other studies have also shown that moderation techniques can help some people, but Koob says what's important to remember is that there are as many kinds of drinkers as there are people. Everyone is different. And the tricky part of the moderation path is that there's no way to know which heavy drinkers can learn to control their drinking rather than giving it up completely.
KOOB: We don't have enough data to suggest that a certain person with a certain profile is going to go back to being a moderate drinker. The science has not been done.
AUBREY: It certainly does not work for everyone. It's controversial. Some critics point to the story of the woman who founded Moderation Management. After leaving the organization, she struggled with drinking, caused a fatal drunk driving crash and then committed suicide.
SARAH VLINKA: For everybody, it's really a process of trying to figure out what's going to work for you and what's not going to work.
AUBREY: That's Sarah Vlinka, a social worker in Michigan who has struggled with alcohol herself. In her case, about a year-and-a-half after experimenting with moderation, she realized that she needed to quit drinking entirely. In part because she was spending so much time thinking about and trying to manage the process.
VLINKA: I got tired of it. I said anything that is going to take this amount of my brain space doesn't really feel worth it to me right now.
AUBREY: So she stopped.
VLINKA: Yeah, I just said I think I'm done.
AUBREY: In her case, moderation helped lead her to abstinence, and some experts see this as an advantage of the moderation approach. Columbia University's John Mariani says there are lots of heavy drinkers who are resistant to help or the idea of abstinence, but are open to the idea of cutting back.
MARIANI: I think as a starting point, moderation is often a goal that everybody can agree on.
AUBREY: And if it doesn't work, it may be a step on the path to abstinence. Allison Aubrey, NPR News. Transcript provided by NPR, Copyright NPR.
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