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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

For Alcohol Problems: Abstinence or Moderation?

November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School

Is it possible to control problem drinking, or must a drinker give up alcohol completely? This question, which is still important today, has been debated among addiction experts for almost 50 years.

Drinkers who enter alcohol treatment programs for the first time often say that they would like to find ways to cut back on their drinking rather than give up alcohol entirely. They may, for example, be willing to go without the feeling of intoxication, but are reluctant to give up the social pleasures or the taste of alcohol.

An Attractive Option

The number of people wrestling with this dilemma is potentially enormous. At least one-quarter of Americans ages 18 and older either suffer with Alcoholism (also called alcohol dependence) or drink enough to put themselves at risk for developing alcoholism, liver disease or some other medical problem. Many people who have not yet developed the symptoms of alcoholism, such as high tolerance for alcohol or withdrawal symptoms, are in danger of developing a full-blown problem.

But people who have a problem with drinking are likely to tell you that it's not so easy to "just say no." That's why moderation seems like such an attractive option.

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What is Risky Drinking?

The recommended limits for drinking are lower for women than men. Women generally weigh less than men. And pound-for-pound they have less body water than men. This means that the alcohol is less spread out through the body and levels rise more quickly in vital organs.

Remember, there is no set amount at which drinking becomes risky. It depends on the individual. Some people are vulnerable to problems even if they drink a small amount. In general, as drinking amounts increase, the risks also increase.

Experts recommend the following limits:

  • Women – 7 drinks per week, limit of 3 drinks on any one day
  • Men – 14 drinks per week, limit of 4 drinks on any one day

One drink contains 14 grams of alcohol. This is equal to:

  • 12-ounce bottle of beer
  • 5-ounce glass of wine (a standard 750 ml wine bottle contains about 5 glasses)
  • 1.5-ounce shot of vodka

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Severity Predicts Relapse

How do you decide whether moderation or abstinence makes the most sense for you?

Research into moderate or "controlled" drinking has shown that this strategy can be successful for people who have not yet developed a pervasive pattern of alcohol abuse, or who have experienced few negative consequences from drinking. You're also more likely to succeed if you're young, female, employed, have reasonable social support, and are confident about limiting intake. The principle behind moderate drinking is to set goals and limits before crossing the line into dependence.

But the research is clear: Moderation is unlikely to be successful for people whose pattern of drinking fits the definition of alcoholism.

For example, one study followed drinkers' for three to eight years after taking a course of behavioral self-control training. This therapy is designed to teach moderate drinking behavior. The researchers found that as severity of dependence increased, the likelihood that subjects could reduce their drinking to moderate levels, and keep it there, went down dramatically.

Thus, for the most dependent drinkers, abstinence may be the only option. In other words, it may be particularly difficult to return to moderate drinking if you have several of the following symptoms of alcoholism:

  • Needing more alcohol to reach a given level of intoxication
  • Withdrawal symptoms, such as anxiety, sweating, trembling, trouble sleeping and nausea, when stopping
  • Failed attempts to cut down or quit
  • Lack of control over quantity of drinking
  • Spending a lot of time thinking about drinking, making plans to drink, or recovering from alcohol's effects
  • Continuing to drink despite problems it causes (to health, in relationships, at work)

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Moderation as Motivation

Although moderate drinking may not work for someone with significant alcohol dependence, it may be useful for introducing the notion of change.

Many people are ambivalent about giving up alcohol, even though dependence may be straining their relationships or jeopardizing their jobs. The sad reality is that alcohol has become so integral to their lives that they can't imagine what life would be like without it. On the upside, someone who expresses a desire to drink in a more controlled way is indicating a willingness to confront the problem.

Attempts to moderate drinking are certainly worth trying as a first step. First of all, it might work. And if it doesn't work, it can help a person understand how difficult moderation is. By paying close attention to the experience, he or she may come to appreciate exactly how drinking reinforces the impulse to drink. Moderation may also be a way to practice changing drinking behavior.

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Working With a Counselor

Many people prefer to work with a counselor or therapist who lets them set the agenda. Some individuals who are on the brink of change may be turned off by a counselor who demands they stop drinking immediately or prescribes too rigid a formula. Even patients who are ready to try abstinence are likely to appreciate a clinician who does not dictate how things should be. Rather, as partners, the two can discuss the risks and benefits of various approaches and weigh all of the options.

When a person expresses a desire to cut back on drinking, it may be the time when he or she is most open to learning something new about the problem and therefore ready to grapple with the real consequences of drinking. It may be a "teachable moment." Trying to moderate your drinking, and discovering you can't, may be the best way to learn about the reality of alcohol dependence. And, in turn, you may be motivated to abstain.

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Michael Craig Miller, M.D. is editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 25 years.

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