Out of Control Alcohol: Is Abstinence Required, or Will Moderation Work? Part I of II
Suzanne knew something was wrong when she woke up with a hangover on a Monday morning.
She never drank on Sunday night, but her friends had come over to provide some company since her husband was out of town. Suzanne had gotten out a bottle of wine to go with some crackers and cheese. At first, it was just regular girl talk, but then they’d all got to giggling, and Suzanne found that she couldn’t stop refilling her glass.
The next morning, her head was pounding and she was dragging herself through a shower in an attempt to wake up her face and get her mind on her day. Staring in the mirror at her puffy eyes and sallow skin, she shook her head.
Why hadn’t she just put the bottle down?
The situation bothered her enough that she made an appointment that morning to see a counselor. The counselor then referred her to an alcohol recovery center, but when Suzanne went she was disappointed to find that the program insisted on total abstinence.
She had not been court ordered to attend the program. She had not had any trouble with drinking and driving, or with drinking and her work or family. She just felt like sometimes, when she wanted to stop, she had a hard time doing so.
She wondered: Wasn’t there a middle ground somewhere for someone like her?
Abstinence Works Best at Solving Serious Addiction
Indeed, many alcohol recovery programs require total abstinence. Alcoholics Anonymous (AA), for example, states very plainly that it is a “program of total abstinence.” In the so-called “Big Book” entitled, Alcoholics Anonymous: 12 Steps and 12 Traditions, it states: “The only relief we have to suggest is entire abstinence.”
Why would this be? Because much of the research we have so far on addiction shows that abstinence works best. In a recent 2016 study, for instance, researchers observed about 200 participants who were considered “alcohol-dependent” in two different treatment programs:
- one had an abstinence-oriented goal,
- the other had a low-risk drinking goal.
The researchers followed the participants’ progress for 2.5 years, and found that the abstinence-oriented treatment was significantly more effective, no matter what the participant’s goal was to begin with (moderation or abstinence). By the end of the study period, 90 percent of those in the abstinence program had successfully stopped drinking, while only 50 percent in the low-risk program had successfully limited their alcohol intake. Fewer people in the abstinence-only group relapsed, as well.
There may be many reasons for this, but one is that abstinence provides a very clear goal for people. If you know you’re not supposed to be drinking, there’s no gray area there. You know exactly what you need to do—avoid alcohol entirely.
Those who are trying to “control” their intake, on the other hand, may have more difficulty knowing exactly what the goal is. Does that mean only one drink per day? But then what if you don’t drink every day—you only drink socially? Then where is the limit? Is it three drinks per event? The goal is less clear, which can make it easier to relapse, and make it more difficult to reach some nebulous “more controlled” state.
There’s another reason why abstinence is often recommended as the best approach: it causes immediate and positive changes in the brain.
Abstinence Has an Immediate Positive Effect on the Brain
According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), alcohol affects the brain no matter who you are. That’s why we experience effects like slurred speech and slower reaction times. Those who drink more often, however, or more heavily, are more at risk for more severe and lasting damage, including memory loss, blackouts, and even brain shrinkage.
Studies show that women may be even more vulnerable to these effects than men. We already have evidence that women are more at risk for side effects like liver damage, cardiomyopathy (heart muscle damage), and nerve damage than men, after fewer years of heavy drinking. Some other studies have also indicated that woman show memory and learning problems as well as brain shrinkage after shorter periods of heavy drinking than men.
Researchers from the University of North Carolina at Chapel Hill reported in 2004 that when used in excess, alcohol damages brain structure and function to the point that people have more trouble reasoning or planning things out. They also show difficulties in understanding the negative effects of their behavior.
Those same researchers tested alcohol dependency and subsequent abstinence on animals. They found that during dependency, brain cell development decreased, but that within one week of abstinence, there was a two-fold burst in brain cell proliferation.
This may partially explain why abstinence works better in many cases—a person who completely restricts alcohol has a brain that is no longer being damaged by the drink, which may, in turn, help them improve their decision-making process and help them better associate what they’re doing with the possible negative consequences.
Studies in humans have shown similar results. In one case, researchers matched alcohol-dependent patients with healthy controls, and tested cognitive abilities both before and after treatment. They found that in the beginning, the alcohol-dependent group showed impairments in short-term memory, verbal knowledge, spatial imagination, and non-verbal reasoning, compared with healthy controls. After five weeks of abstinence-focused treatment, the formerly alcohol-dependent patients improved significantly.
“Our results provide evidence for the well-established fact that chronic alcoholism has detrimental effects on cognitive performance,” the researchers wrote, “but that performance improves with neuropsychological recovery which occurs rapidly within weeks when abstinence is maintained.”
Another study showed similar results—researchers found that the cognitive abilities of middle-aged alcoholics who had been abstinent for six months to 13 years were “indistinguishable from those of age and gender comparable non-alcoholics,” with the exception of spatial processing abilities.
Abstinence May Help Reduce Depression
Depression is a large factor for women when it comes to overusing alcohol. According to one study, women with a history of depression had a 2.6 times greater risk of abusing alcohol than those who didn’t. The connection was so strong that researchers warned that women suffering from depression should be considered at risk for heavy alcohol use.
These findings go together with recent research that indicates more women are drinking heavily today. A recent report from the Journal of the American Medical Association (JAMA) indicated that alcohol use, high-risk drinking, and alcohol-use disorder all increased from 2001-2002 to 2012-2013—with increases in all of these outcomes greatest in women. The researchers acknowledged that stress could be a factor in the increase.
Other studies have found that depression and alcohol abuse often go together, including one that showed that heavy drinking could actually encourage episodes of depression. The National Comorbidity Survey (NCS) also found that compared with non-depressed respondents, the lifetime odds of alcohol dependence were significantly higher for women with major depression.
Abstinence in cases of depression- or stress-related drinking may again be the best approach, as getting the alcohol out of the brain tends to reduce depressive symptoms. Researchers discovered in one study, for example, that 42 percent of about 200 alcoholics in treatment for alcoholism were depressed when they first started treatment.
After four weeks of abstinence-related therapy, however, only 6 percent remained depressed. Treatment was so effective that the researchers advised doctors not to use antidepressants in the first few weeks of an alcohol program, because just getting off the alcohol improved mood so significantly.
Another 2015 study of recovery programs like AA found that overall, depression decreased over a 24-month follow-up period, and lower levels of depression were related to greater abstinence and less intensive drinking. Researchers went on to explain that the effects on depression were connected directly to abstinence.
Is Abstinence the Only Way?
With all of this evidence in front of us, we can see why many recovery programs insist on abstinence when it comes to recovering from alcohol abuse, no matter how severe. Abstinence has many health benefits, including improved decision-making and mood, both of which often result in healthier life choices, overall.
But what if you, like Suzanne, don’t believe that abstinence is the answer? What if you have experienced some issues with controlling your intake, but you’re not a full-blown alcoholic? You’ve had no legal problems, you’ve had no problems at work, and you’re a fully functioning adult, but you’d just like to increase your ability to control your intake, perhaps before it gets to the point where you can’t?
Turns out there are many people who fit into this category, who feel shut out or ignored by traditional recovery programs. Surely there must be some help out there for them?
Recent research has indicated that indeed, abstinence isn’t required for everyone. People are different, and have different needs when it comes to their relationship with alcohol. For some, a more moderate approach called “controlled drinking” can be effective.
“AA At a Glance,” Alcoholics Anonymous, https://www.aa.org/assets/en_US/f-1_AAataGlance.pdf.
“164 and More,” http://www.164andmore.com/words/abstinence.htm.
Kristina J. Berglund, et al., “Is There a Need for Congruent Treatment Goals Between Alcohol-Dependent Patients and Caregivers?” Alcoholism, April 2016; 40(4):874-879, http://onlinelibrary.wiley.com/doi/10.1111/acer.13003/abstract.
“Alcohol’s Damaging Effects on the Brain,” NIAAA, October 2004, https://pubs.niaaa.nih.gov/publications/aa63/aa63.htm.
University Of North Carolina School Of Medicine. “New Brain Cells Develop During Alcohol Abstinence, UNC Study Shows.” ScienceDaily, 12 November 2004. <www.sciencedaily.com/releases/2004/11/041108015734.htm>.
Karl Mann, “Rapid Recovery from Cognitive Deficits in Abstinent Alcoholics: A Controlled Test-Retest Study,” Alcohol and Alcoholism, July 1999; 34(4):567-574, https://academic.oup.com/alcalc/article/34/4/567/188047/RAPID-RECOVERY-FROM-COGNITIVE-DEFICITS-IN.
“Long-term abstinence may resolve many of the neurocognitive deficits associated with alcoholism,” Alcoholism: Clinical & Experimental Research (ACER), [Press Release], August 27, 2006; https://www.eurekalert.org/pub_releases/2006-08/ace-lam082106.php.
Dixit AR, Crum RM, “Prospective study of depression and the risk of heavy alcohol use in women,” Am J Psychiatry, May 2000; 157(5):751-8, https://www.ncbi.nlm.nih.gov/pubmed/10784468.
Bridget F. Grant, et al., “Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013: Results From the National Epidemiologic Survey on Alcohol and Related Conditions,” JAMA Psychiatry, 2017;74(9):911-923, https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2647079.
S. A. Brown, M. A. Schuckit, “Changes in depression among abstinent alcoholics,” Journal of Studies on Alcohol., 1988; 49(5):412-417, http://www.jsad.com/doi/abs/10.15288/jsa.1988.49.412.
Marc A. Schuckit, et al., “Relationships Among Independent Major Depressions, Alcohol Use, and Other Substance Use and Related Problems Over 30 Years in 397 Families,” Journal of Studies on Alcohol and Drugs, 2013; http://www.jsad.com/page/legacy.
L. Sher, “Depression and Alcoholism,” QJM: An International Journal of Medicine, April 1, 2004; 97(4): Pages 237–240; https://academic.oup.com/qjmed/article/97/4/237/1525431/Depression-and-alcoholism.
Wilcox CE, et al., “Effects of long-term AA attendance and spirituality on the course of depressive symptoms in individuals with alcohol use disorder,” Psychol Addict Behav., June 2015; 29(2):382-91, https://www.ncbi.nlm.nih.gov/pubmed/26076099.