A better way to kick the habit

'One drink is too many, and a thousand not enough." This is the philosophy behind Alcoholics Anonymous and other alcohol recovery groups that believe total abstinence from drinking is the only way to recovery and permanent -- i.e. drink-free -- rehabilitation for alcoholism. It is the same philosophy that helped make alcoholism officially recognized by the American Medical Association in 1956. Today's diagnosis of alcoholism requires, above all, demonstration of a profound "loss of control" over one's drinking, leading to significant impairment of social and/or occupational functioning and the inability to pursue a self-directed life.

In parallel with the transformation of alcoholism from a moral to a medical condition, mounting scientific evidence has further solidified the alcoholism-as-disease model. Though a single "alcoholism gene" will likely never be identified, researchers have discovered a number of genetic factors that contribute to the risk of alcohol abuse. A useful analogy is diabetes, in which the interactions of certain genes with the environment determine the development and course of the disease, thereby affecting individuals in different ways depending on the choices they make (their diet) and their particular biological makeup (their genes).

However, current thinking about alcoholism, particularly within self-directed "therapeutic communities" like AA, conflates the disease and its treatment. Though AA undoubtedly deserves praise for its ongoing efforts to emphasize the former, its decades-long promotion of abstinence as the only solution has institutionalized zero-tolerance therapies leading to the popular notion of an "addict for life." AA's opinion of the world is hopelessly bimodal -- either you are an alcoholic or not -- with recovery from alcoholism being forever incomplete.

Unfortunately, recent empirical studies have shown that abstinence-only approaches simply do not work. For example, more than 50 percent to 75 percent of AA participants relapse to clinically significant levels of alcohol consumption within a year. Similarly, combining AA counseling with pharmacotherapy also performs poorly at achieving long-term abstinence rates among alcoholics, albeit better than counseling or medications alone. Indeed, it is becoming increasingly clear that lifelong abstinence may be a feasible option for only a small percentage of alcoholics, with the rest facing inevitable failure.

Moving beyond the AA mindset requires us to admit once and for all that "no drinking" may be an impossibility for the majority of alcoholics. We should instead focus our efforts on harm reduction. In this treatment model, controlled drinking is prioritized over abstinence, with the immediate goal of minimizing heavy alcohol consumption in favor of more moderate levels of use that permit a return to normal living. As in any harm-reduction paradigm, the focus is on minimizing the consequences of the illness rather than the illness itself and is the first-line approach toward handling other substance-abuse disorders.

Findings reported earlier this month by the Cochrane Collaboration, an international organization that evaluates medical research, lends support to harm reduction-based alcoholism treatment. Reviewing 29 studies conducted across four continents, authors Dr. Manit Srisurapanont and Dr. Ngamwong Jarusuraisin assert that naltrexone, a drug that blocks the effects of endogenous opioids in the brain, reduces the risk of heavy-drinking relapses in 36 percent of alcoholics, breaking the cycle where one drink leads to one more. Almost all the participants were also enrolled in some sort of counseling or self-help therapy, indicating a more fruitful role of AA-like activities in the context of harm reduction that should not be overlooked.

Commenting on the results in the Medical News Study, the U.S. Substance Abuse and Mental Health Services Administration noted that "abstinence should be a desired goal for the patient; however, reductions in drinking may be an acceptable intermediate outcome because there are many other areas of a patient's life that can improve, such as job performance, social relationships and general physical health."

Such remarks are encouraging, hinting that attitudes toward alcoholism treatment are gradually aligning with the more reasonable standards of harm reduction. This should also come as welcome news to the 18 million Americans who suffer from alcoholism but who are not, for whatever reason, actively seeking help. Casting alcoholism as a problem that can be handled without going cold-turkey will surely attract more to treatment clinics, where they can begin to slowly -- and less painfully -- regain control of their lives.

Ultimately, we should be willing to accept that one drink may not be too many and that a few more may be just enough, at least for now.

Jason Lott is a first-year student in the School of Medicine from Anniston, Ala. Whole Lotta Love appears on Mondays.

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