‘Dangerous data’: drinking after dependence part 6. Evidence accumulates and expert opinion converges
The heat dies down as it becomes clearer that neither controlled drinking nor abstinence has a definitive advantage as a treatment goal, and as evidence emerges about what types of patients do better with either strategy.
Where have the historical milestones in controlled-drinking research described in previous episodes led us? Though controversy is far from extinguished, in 2005 a commentator felt “the professional debate [about controlled drinking] in the field does not … elicit as much passion as it once did”. Among the reasons was “increased consensus that abstinence remains the preferred, safer outcome for individuals with alcohol dependency,” allied with a realistic acceptance of “a harm-reduction strategy emphasizing the outcome of reduced harm and improved psychosocial function as an alternative to a sole focus on abstinence”.1
The Sobells’ later writings exemplified these trends. In 1995 their editorial for the Addiction journal revisited the debate sparked over two decades earlier by their findings. Eight responses in the same edition signified its continuing vitality. The Sobells accepted that “Recoveries of individuals who have been severely dependent on alcohol predominantly involve abstinence,” but queried whether this is because the need for abstinence is inherent to recovery from severe dependence. Instead they argued that adverse life circumstances such as poor social support and employment prospects tend to accompany more severe dependence, and these may be what obstruct reduction-based recovery. Beyond this minority for whom abstinence is best suited, they rehearsed the long-standing contention that reducing alcohol-related harm across an entire population demands acceptance of use-reduction goals because many prospective patients (especially those less or non-dependent) who want to tackle their drinking simply will not accept interventions predicated on abstinence.
In 2011 the Sobells returned to controlled drinking in another Addiction editorial. They noted that in the interim evidence had accumulated (see this example) that across the full spectrum of alcohol use disorders, including people who have never been in treatment, “low-risk drinking outcomes occur and are common”. Due they felt to staffing by formerly dependent drinkers steeped in the philosophy of Alcoholics Anonymous, US treatment services had largely ignored this evidence, deterring patients who might have sought treatment if controlled drinking had been on the table.
In support of its arguments the first editorial had cited a 1984 report (free source at the time of writing) on a Canadian trial which had randomly allocated problem drinkers to treatment expressly aiming either for abstinence or for moderation. As part of their treatment moderation-oriented patients were offered training in controlled drinking, the sole difference between the regimens. Most patients seemed to be drinking heavily enough to meet criteria for dependence but as yet were not (severely affected by their drinking.
Told their allocation during the first session of counselling, 23 of the 35 allocated to an abstinence goal either found it unacceptable or expressed reservations, but were not allowed by the study to switch to moderation. In contrast, just five of the 35 allocated to moderation rejected that endeavour; on ethical grounds, they were allowed to switch to an abstinence goal. During and at the end of treatment, goal allocation had generally not significantly affected drinking reductions. In the six months after treatment had ended, whatever goal had been impressed on them, most patients in the end had chosen to drink moderately, usually without reporting serious consequences;2 just 7% allocated to abstinence had actually achieved this goal.
Reviews explore who does best with what goal
So far the cited research has pitted abstinence as a treatment goal against moderation/controlled drinking, and shown that even for severely dependent patients, neither universally sweeps up the outcome prizes. Several reviews have confirmed that conclusion, but also helped answer the more nuanced and practice-relevant questions of what types of patients do best with either goal, and under what circumstances. Answers are important because without strong evidence about whether the kind of patient facing them can sustain controlled drinking, treatment staff may be unwilling to advocate non-abstinence goals, preferring the less professionally risky ground of an abstinence-based approach, but also running the countervailing risk of drinkers who could benefit from help being deterred from seeking or accepting it. The closer we get to answers about who does best with what goal in what circumstances, the less reason there will be to universally insist on abstinence, helping to douse the passion in the debate and open up treatment to a more diverse caseload.
The most comprehensive and recent of the reviews was completed in 2020. Its overall verdict was honours even: results from the studies did not unequivocally favour either abstinence-based or reduced-drinking goals/approaches. Neither was a controlled-drinking goal more effective among women than men. More surprisingly, the evidence also failed to support accepted wisdom that abstinence would become increasingly suitable as drinking disorder diagnoses became more severe. However, other kinds of analyses might reverse this conclusion, and other dimensions of severity might prove more relevant (1 2). The reviewers did find evidence that outcomes from controlled-drinking goals benefited from treatment geared to those goals.
Earlier reviews concurred on overall results, but sometimes differed on who does best with which goal (1 2 3). Moderation goals have been judged most appropriate for patients whose dependence is less embedded or severe, who face more severe medical and psychological risks from continuing to drink, believe these goals are feasible generally or for them in particular and are adamant about their choice, are employed, psychologically and socially stable, younger, and female. However, neither alone nor in combination are such indicators sufficiently closely associated with successfully achieving controlled drinking to be able to securely identify whether a particular individual should be channelled down this route. The findings of these reviews are expanded on in unfoldable supplementary text included in full essay available on the Effectiveness Bank.
Additional to reviews (and sometimes unable to be included in them or not within their remit), results from three of the largest and most sophisticated alcohol trials ever seen have recently been explored for their relevance to the controlled-drinking issue, especially the feasibility of controlled drinking as an outcome after treatment, analyses with implications for the advisability of choosing this goal at the start. Findings from UKATT (along with other UK studies) and from the US Project MATCH and COMBINE trials are explored below. Among their many thousands of patients, collectively they reinforce the feasibility of remission in the form of moderation or controlled drinking.
UK studies offer little reason to insist on abstinence
In the seminal Sobells’ study and the Canadian trial described above, patients had been allocated by the researchers to aim for abstinence versus non-abstinence. Outside a research context too, sometimes goals are imposed by the treatment service or by the clinician, but in the UK the more usual situation is that together with their clinicians, patients choose their goals – the route whose consequences were documented in the early accounts of D.L. Davies and the Rand corporation. Since the first of these appeared in the early 1960s, what have we learnt about how patients fare if they themselves opt for moderation versus abstinence as an initial treatment goal?
For the UK the most nationally representative answer emerged from the UKATT trial of psychosocial therapy for 742 patients seeking treatment for alcohol problems at specialist services in England and Wales. Implemented in the late ’90s, it remains Britain’s largest alcohol treatment trial. Its main and rather disappointing findings were that eight sessions of an intensive and comprehensive therapy based on enlisting the patient’s social network were not shown to have been more effective overall than just three sessions of a more basic motivational approach. Dashed too were expectations that that each of the two approaches would differentially benefit certain types of patients (1 2).
But along the way UKATT did illuminate the controlled-drinking issue by way of secondary analyses of which patients preferred which goal and how they fared after expressing this initial preference. An initial report documented differences at study entry between those who (according to the judgement of treatment staff screening patients for the study) were probably aiming versus not aiming for abstinence. The caseload was fairly evenly split, 54% aiming for abstinence, 46% not. Before treatment, abstinence-aiming clients were generally drinking more intensely, experiencing greater drink-related and other problems, and were more socially isolated. Based on what was known about them before treatment, once overlapping influences were taken into account, around 70% of the sample could correctly be classified as aiming versus not aiming for abstinence, with abstinence the more likely choice among those who: were women; drinking more heavily but on fewer days; had detoxified immediately before entering the study (a signal of severe physical dependence); had a social network less encouraging or accepting of drinking3, meaning that abstinence would be a less socially isolating choice than among the kinds of patients who preferred to continue to drink; lacked social support4 in general; and had recently experienced relatively severe alcohol-related problems. Strongest of these predictors were sex, drinking pattern, pre-treatment detoxification, and lack of social support for drinking. While these were the predictors that survived the elimination of overlapping variables, compared to the remainder, clients opting for abstinence were also relatively motivated and confident in their attempts to resist drinking, more likely to be out of employment, had more positive expectations about the effects of drinking, and suffered greater mental and physical health problems. As opposed to alcohol-related problems, a measure specifically of dependence bore no significant relationship to choice of drinking goal.
Having made their initial choice, how well did these patients overcome their drinking problems? A further analysis revealed that regardless of this choice, by 12 months after the UKATT therapies had ended patients were doing about equally well in terms of reducing drinking and its unwelcome consequences. Even among those who at first wanted to stop drinking altogether, more later substantially ameliorated their drink-related problems while continuing to drink than did so by abstaining; see chart.
Before UKATT there seem to have been four relevant British studies, all conducted at NHS inpatient alcohol treatment units, and all but one in Liverpool, including two at the same unit. Like UKATT, the four studies found that goal choice was meaningful, in the sense that successful outcomes generally took a corresponding form. The three Liverpool studies also agreed that overall success rates in eliminating risky drinking were similar whether or not abstinence was chosen. The remaining study found that opting for abstinence was more likely to be followed by non-problem drinking, but did not report whether lesser degrees of improvement were also more likely than among the remaining patients.
Large-scale US studies validate non-abstinent recovery
UKATT was inspired by another very large alcohol treatment trial, the US Project MATCH trial. Its primary aim was to compare the effectiveness of 12 weeks of different forms of psychosocial therapy for different types of patients, but led by Dr Katie Witkiewitz of the University of New Mexico, analysts plumbed its extensive databank for evidence on the controlled drinking issue (1 2 3). Her team focused on patients who had not just emerged from intensive inpatient or day programmes, known as the ‘outpatient’ arm of the trial. For these patients, MATCH’s therapies were effectively standalone treatments. The question asked was not so much whether low-risk drinking (interpreted in some analyses as allowing occasional heavy drinking) was a viable treatment goal, but whether it had proved a viable treatment destination, prefigured by a similar drinking pattern during treatment.
The same research stable reached similar conclusions after conducting a the same kind of analysis of data from COMBINE, another large-scale US alcohol treatment trial. The implications were that while in the US context, abstinence (or near abstinence) is the most common basis for broad-based recovery from alcohol dependence, nevertheless a substantial minority who continue to drink – and sometimes even to drink in excess of national guidelines – do about as well in terms of their psychological health, social functioning, and quality of life. Conversely, some who are virtually abstinent do poorly on the same measures. It led the analysts to argue that abstinence should be demoted from its status as the gold standard of recovery or at least an essential ingredient, to be seen instead as one of several bases for recovery, and sometimes a basis for non-recovery. More on these studies individually in the panel below, or skip to a pooled analysis of the three largest studies from the UK and the USA.
Pooled analysis from US and UK trials probes who does best with which objective
In 2017 Dr Witkiewitz and colleagues published two analyses based on pooled data from the three large-scale trials described above: from Britain, UKATT, and from the USA, Project MATCH and COMBINE. Together they offered unrivalled detail on a pooled sample of 3,851 patients treated for drinking problems at 27 clinical centres, with sufficient commonalities across the studies to make pooling feasible.
The first analysis (free source at time of writing) found the sample divided most neatly into seven categories based on their patterns of drinking during the (first) 12 weeks of treatment. Some 41% of patients were best classified as virtual abstainers throughout treatment and 17% as low-risk10 drinkers. The remaining five classes to some degree featured heavy drinking.
Based on their drinking and wider welfare nine months after the trials’ treatments had ended, the analysts said “providers could inform patients that one heavy drinking episode itself is not predictive of long-term failure and that returning to abstinence or low-risk drinking following heavy drinking is predictive of better long-term outcomes”. However, they could not say which types of patients might best be encouraged to opt for abstinence versus low-risk drinking as a treatment objective. That question was addressed by another analysis (alternative source at time of writing) of the same pooled sample, which linked characteristics of the patients at the start of the trials to which of the seven drinking patterns they were most closely aligned to during treatment. The implications of the findings were that low-risk drinking was best managed by patients who leading up to treatment were relatively less severely dependent and/or drinking less, whose social networks were less packed with heavy drinkers, and who suffered less from negative moods and feelings akin to depression. Surprisingly out of the frame were the patient’s drinking goals. More on this key study in the panel below.
Don’t throw out the abstinence baby
Concern to rebalance the dominant emphasis on abstinence with recognition of the viability of alternatives should not blind us to the fact that selecting abstinence as a goal is often prognostic of the best treatment outcomes. In the studies included in the previous section, total or near abstinence was the most common basis for broad-based recovery, perhaps partly reflecting US treatment culture. This does not necessarily mean that pressuring the unwilling to accept an abstinence objective will improve their outcomes. Especially in societies such as the USA where abstinence is seen as the gold standard, selecting this objective may not be an active ingredient in itself, but simply a sign of commitment to overcoming your problems with drink which in other cultures or circumstances might take the form of a commitment to controlling one’s drinking. That said, abstinence clearly remains a viable and often (for patient and service) preferable ambition, sometimes in studies favoured by most patients.
Already the reviews cited above have shown the continuing salience of abstinence. This section describes a few sample studies to offer a taste of the kind of research incorporated in the reviews, showing that abstinence remains a goal associated with desired drinking outcomes, sometimes more closely than other goals. An important caution is that ‘association’ does not necessarily mean ‘causation’. When (as was usually the case) patients perhaps together with services chose their goals, other factors associated with this choice which the studies could not take into account may have been the active ingredients in differential outcomes, not the actual choice itself.
Among the studies the reviews uncovered was an analysis of relevant findings from the large US COMBINE alcohol treatment trial of medical care allied with pharmacotherapy. In a previous section we looked at the prevalence and stability of non-abstinent recoveries three years after patients had been allocated to their treatments. Published in 2013, a second analysis examined the fate of patients with different drinking goals as they entered COMBINE’s treatments.
At the start 25% of participants were aiming for controlled drinking and 37% complete abstinence; most of the rest were also broadly aiming for abstinence, but perhaps not for ever, completely, or in every circumstance. The more dependent a patient was at the start of treatment, the more likely they were to opt for an abstinence goal, but this and other such differences were statistically ‘evened out’ in subsequent analyses to profile the relation of goal choice to drinking during treatment. During the 16 weeks of treatment patients aiming for total abstinence did actually spend more days not drinking, but when they did drink, drank more heavily. Non-problem drinking/abstinence was more likely among patients aiming for total abstinence than those aiming for moderation, but especially when medical care had been supplemented by psychosocial therapy, the gap was minor – about 76% v. 72%.14 Though overall around two-thirds of patients aiming for moderation achieved remission, somewhat more did so when abstinence was firmly on the patient’s agenda. However, these results emerged after abstinence-oriented treatments; the gap favouring an abstinence goal would probably have been narrower and perhaps non-existent had non-abstinence aiming patients been offered a treatment adapted to their objectives.
Other recent studies to find abstinence the preferable aim include one from 2018 on alcohol treatment in Switzerland. Patients who as far was known15 persisted throughout with a controlled-drinking as opposed to an abstinence objective were more likely to have scored as less severely problematic drinkers at entry to treatment. After these initial indicators of problem severity and other factors had been taken into account, both in terms of drinking reductions and attainment of non-hazardous drinking or abstinence, 12 months after leaving treatment drinking outcomes were significantly better among patients who throughout treatment had focused on attaining abstinence as opposed to controlled drinking. However, three-quarters of those aiming for controlled drinking had actually reduced their drinking – possibly, the authors admitted, to degrees which achieved their own ambitions, even if not those set by the study or by national guidelines. Nearly 4 in 10 patients changed their drinking goal between the start and end of treatment, mainly from abstinence to controlled drinking (31%) rather than the reverse (12%).
Another recent study to find abstinence-aiming patients do better was a US trial of acamprosate prescribing for alcohol dependence in family doctor practices. In 2016 it reported that over the 12 weeks of treatment, patients who endorsed an abstinence goal on average reduced their heavy-drinking days by far more than those who did not. This study also exemplified another frequent finding: that reduced but continued drinking was a very common goal. Had non-commitment to abstinence barred them from treatment, most of the study’s participants would have lost the chance to engage in programmes during which on average they roughly halved their heavy-drinking days.
In 2020 abstinence emerged – but not convincingly – as probably the objective most closely associated with low-risk drinking in a US study of patients treated for conjoint substance use disorders and post-traumatic stress by the nation’s service for ex-military personnel. They were asked at the start of treatment whether they preferred not to use their primary substance (which for almost all was alcohol) at all or to reduce use. The main analysis took into account intensity of substance use, age, gender, alcohol dependence severity, and whether drinkers were also dependent on other drugs, and used all the available data to estimate missing outcomes at the end of treatment. It revealed that the 20 patients who chose abstinence were four times more likely than the 19 who chose use-reduction to be abstinent or drinking within the USA’s low-risk drinking guidelines. However, this difference was far from statistically significant, so could have been due to chance sampling variation. Statistically significant differences emerged only when other factors were not taken into account, meaning that what seemed like a big advantage due to choosing abstinence could instead have been due to this choice being associated with what really were the influential factors, such as intensity of use or dependence before treatment. Unplanned analyses of this kind are also considered unreliable because they can capitalise on different ways of analysing the data until one comes up with the desired results. In this case too, the analysis abandoned the recommended method for estimating missing data in favour of one which did not use all the information to hand. All this means that the most secure conclusion is that there was no reliable evidence that aiming for abstinence produced the safest drinking patterns, but that was the way the data was tending given the limited set of influences the study was able to adjust for. Again, this study revealed how many – nearly half – the patients might have refused treatment if an attempt had been made to insist on abstinence. In that light the researchers felt their results were not sufficiently in favour of an abstinence goal to limit or delay treatment of patients adamantly opposed to that goal, provided that low-risk substance-use goals are explicitly targeted and there are no medical contraindications to continued drinking.
A broader perspective
Treatment trials tend to miss or exclude deeply marginalised populations, and in societies where only a minority of people experiencing drinking problems enter treatment, their participants are unrepresentative of the totality of recovery. Dipping into research on the marginalised niche and on the broader population offers some context for what has so far been an account based on treatment and treatment-trial populations.
Generally controlled drinking is itself controlled by the patient, but in some programmes for marginalised populations the service does the controlling by administering set doses of alcoholic beverages at set times. Sometimes offered to inpatients as a way of ameliorating withdrawal, of greater interest in the current context are programmes which administer alcohol to people in the community as a therapeutic or harm reduction strategy.
A 2018 review of both types of programmes found that those based in the community integrate social support with patient care, including referrals or access to counselling and addiction treatment, primary health care, meals, shelter-style supportive or permanent harm-reduction housing, and entertainment or group activities. The services are geared to the needs of their typically indigent participants, who tend to be chronically homeless or lacking stable housing, with severe alcohol use disorders, and unable or unwilling to participate in abstinence-based housing or treatment – the kind of people who would often have been excluded from alcohol treatment trials. Positive outcomes included fewer encounters with the police, improved personal hygiene, and uptake of other health and social support. Even among these populations, a more conventional harm-reduction approach not involving the supply of alcohol – but also not predicated on abstinence – can generate benefits, including reduced drinking, drunkenness and alcohol-related harm.
Focusing on treatment populations risks giving a distorted impression of the bigger picture of how people normally emerge from problem drinking, especially in countries where abstinence is the favoured treatment goal. Published in 2000 (free source at the time of writing), Mark and Linda Sobell teamed up with a colleague to review studies which shed light on “natural recovery” from substance use problems, meaning people whose recoveries were not attributable to treatment or self-help groups.
Three-quarters of the studies they found had been conducted in North America. In the current context their key finding was that “across all studies two-fifths (40.3%) of alcohol recoveries involved low-risk drinking, suggesting that such drinking is a common route to recovery among naturally recovered alcohol abusers”. Note however that it was still a lower figure than the 60% of recoveries based on abstinence. The review covered substance use problems in general, but since three-quarters of the studies were of problem drinking, the overall finding that typical and average recovery durations were over six years suggests that in most cases recovery from problem drinking was stable and enduring, aided (according to the problem users themslves) most commonly by social support or transition to new (and presumably more recovery-friendly) social circles.
1. Nick Heather has drawn (https://doi.org/10.1080/16066350500489170) a distinction between harm reduction (“emphasis on decreasing problems resulting from consumption rather than on decreasing consumption itself”) and use-reduction or moderation. Reduction may reach the point (eg, within safe drinking guidelines and in safe situations among adults with no health contra-indications) where alcohol-related problems and risks to health are eliminated, for which the term ‘controlled drinking’ has sometimes been reserved. This term may be used to distinguish continued drinking within safe levels from abstinence, or include not drinking at all.
2. To be classified as not having experienced serious consequences they could report up to six episodes of intoxication during the six-month period, but none of the following consequences of heavy drinking: blackouts; shakes; morning drinking; or missed meals or work.
for the questionnaire used to assess this and also to assess general social support.
4. Expressed as numbers of contacts seen at least weekly, excluding heavy drinkers.
5. Defined as one or more days of drinking during a given week but no heavy drinking days.
6. At least one day of consuming 4/5 or more US standard drinks (14 g alcohol) during a given week.
7. Meaning a high probability that all the individuals could be correctly allocated to one of the categories.
8. Some measures required to duplicate the classification were unavailable.
9. Reflected in a “purpose in life” measure including life satisfaction, suicidal ideation and how worthwhile you feel your life is.
10. Drinking in that week but no more than 4/5 US standard drinks (14 g alcohol) on any one day.
11. Drinking in that week but no more than 4/5 US standard drinks (14 g alcohol) on any one day.
12. Revealed not in the main article but in supplementary information.
13. Revealed not in the main article but in supplementary information.
14. Estimated from figure 4.
15. Some patients in these comparisons had missing data at discharge.
Next episode: “Who takes the decision and how?” With both objectives on the care-planning table, shared decision-making between client and patient has become the recommended way to decide between abstinence and controlled drinking.
Full essay available on the Effectiveness Bank.
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