July 21, 2000 -- Must heavy drinkers "admit powerlessness over alcohol" -- the first of Alcoholics Anonymous' 12 steps -- and strive for abstinence, or can they, through force of will and pharmaceuticals, learn to "moderate" their drinking? Although moderation is an accepted treatment goal in Europe, the approach is generally viewed with a skepticism approaching rancor by much of the U.S. medical establishment.
The long-standing debate returned to the fore this month, when two heavy-hitters from the world of addiction treatment made headlines.
First, Audrey Kishline, founder of alcohol treatment organization Moderation Management (MM), pleaded guilty to vehicular homicide after killing a man and his 12-year-old daughter while driving drunk. The accident occurred shortly after Kishline renounced MM's controlled-drinking approach and began attending AA.
Also, Alex DeLuca, MD, former director of New York's renowned Smithers Addiction Treatment and Research Center, which has treated such celebrities as Truman Capote, resigned his post after the St. Luke's-Roosevelt Hospital governing body rejected his appeal to adopt MM as a "kinder, gentler" alternative to the center's abstinence-based approach.
Though unrelated, the incidents underscore the seriousness of the controversy, "at the crux of which is ignorance of or refusal to accept that problem drinkers differ from alcoholics," says National Institute on Alcohol Abuse and Alcoholism (NIAAA) spokeswoman Ann Bradley. "The press has lumped them together," fueling the controversy, she says.
To clarify, "alcohol abuse is a constellation of problems related to alcohol use that stop short of ... addiction, [whereas] alcoholism entails dependence [or addiction]," Bradley says. "In this country, most doctors believe that abstinence is the appropriate treatment for alcohol dependence," while extensive data indicate that "for alcohol abusers, cutting back is a reasonable goal," she says.
"We in Moderation Management agree fully with that statement," says Marc Kern, PhD, member of MM's board of directors, and founder and director of Addiction Alternatives in Los Angeles. "I don't know if it's the Puritan ethic or what," he says, "but there is a fundamentalist view of alcohol treatment in this country." Those who are "up in arms about this have preconceived notions that we're prescribing [moderation] for everyone, which is not the case," he tells WebMD.
Kern says that his approach suggests moderation as the initial goal for all drinkers, but for some, it simply will not work. When, after repeated failures, they realize that moderation is not possible for them, the idea of becoming abstinent becomes a bit easier to take than it might have been were it offered as the first, and only, option, he says. "Every single person in AA has tried moderation management," he says. "They just did it on their own, without the [World Health Organization] guidelines, techniques, and tools we provide to support them."
Among the available tools are medical alcohol deterrents -- from the old-standby Antabuse, to gentler, safer drugs like naltrexone (ReVia) and acamprosate. Already available by prescription in the U.S., naltrexone, which some believe can be used indefinitely as needed, can help curb the urge to drink and reduce alcohol intake. Acamprosate, which is expected to gain FDA approval within the year, can help weaned drinkers maintain abstinence. Unlike Antabuse, neither of these new drugs causes physical illness if taken with alcohol.
When moderation attempts fail, says Max A. Schneider, MD, clinical professor of addiction medicine at the University of California-Irvine College of Medicine, it's likely the person is among the one in 10 drinkers who are especially sensitive to alcohol's brain-altering effects.
"They may not even feel the buzz," he tells WebMD, but the brain alterations that lead to compulsive drinking "are there nonetheless." Each drink brings these individuals a step closer to addiction, he says. Schneider also is immediate past chairman of the board of directors of the National Council on Alcohol and Drug Dependence, and a past president of the American Society of Addiction Medicine.
According to Schneider, the evidence that alcoholism is a disease with genetic elements is overwhelming and undeniable. "Docs who still think [otherwise] are living in the 1950s and don't know what they're talking about," he tells WebMD. "It has nothing to do with willpower, it has to do with brain cells, and what we end up with is a disorder, a brain disease." And for these people, moderation is no more realistic a goal than trying to will oneself taller.
To help doctors and patients identify problem drinking, Schneider suggests asking the following questions, referred to as "C.A.G.E." questions, developed by John Ewing at the University of North Carolina in 1971:
- Have you ever felt that you should Cut down?
- Have you ever felt Angry because people asked about your drinking?
- Have you ever felt Guilty about your drinking?
- Have you ever needed an Eye-opener (another drink or lots of coffee to get you going) in the morning?
If you answer yes to any of these questions, "you should take that as a warning," Schneider says. "If you answer yes to two, you have a problem." The tell-tale signs of alcohol dependence or addiction include:
- a compulsion or craving to drink
- a loss of control over how much and how often you drink
- continued drinking in spite of negative life consequences, such as family trouble or physical illness
"If you lose your ability to control your drinking and your behavior associated with it, then you've got a problem," Schneider tells WebMD. "It's not so much the amount you drink -- it's what it does to you."
Bradley suggests doctors provide blood tests to patients. Although they can't be used to find out if a patient is dependent or not, they "can help reveal years of heavy drinking and the beginning of [bodily] damage." These are laboratory tools that the doctor can use to "let a drinker know where they stand," she tells WebMD. And given the dangers of abruptly quitting alcohol, such information could be potentially life saving for alcohol-dependent patients, she says.