Magazine article Clinical Psychiatry News

Is Total Sobriety Necessary?

Magazine article Clinical Psychiatry News

Is Total Sobriety Necessary?

Article excerpt

The thinking among some addiction specialists that perhaps patients can be treated effectively in the absence of total abstinence is not only controversial but also questionable ("New Paradigm Embraced for Alcohol Treatment," CLINICAL PSYCHIATRY NEWS, January 2006, p. 1). What is your philosophy when it comes to working with patients addicted to alcohol? In your work with these patients, do you insist that they give up drinking entirely?

Definition Is Key

Much of the controversy over controlled drinking is attributable to confusion about what the term "alcoholism" means. If by alcoholism one is referring to alcohol dependence, including significant physical dependence, studies indicate that few with this problem can adopt controlled drinking. If, instead, one is referring to alcohol abuse without dependence, studies show some can adopt controlled drinking. Another important consideration is the urgency of the alcohol problem. If someone is physically abusing his spouse, repeatedly driving while intoxicated, etc., initial abstinence is especially important.

John Hughes, M.D.

Burlington, Vt.

It Depends on Patient

For low-risk social drinkers, the question of sobriety never comes up. Why should it? Alcohol is not a problem. For heavier drinkers, it generally does not come up unless, or until, a problem with alcohol becomes evident. This could be social (DUI, an angry spouse, a lost job) or health-related (hypertension, gout, elevated liver function tests, or an injury).

Research has shown that in "heavy drinkers" who do not, or barely, meet criteria for alcohol dependence, a goal of reduction can be considered. In general, these people have not lost control over drinking and maintain the cognitive ability to resist urges, change behavior, and respond to consequences.

Yet, there are those who are truly alcohol dependent and who generally are seeking treatment secondary to problems. For these folks, the general wisdom--backed by scientific evidence and clinical lore--is that abstinence is the best policy. But it depends. It might depend on whether they are receiving continued treatment or whether there is a bolus of treatment that will stop at some point.

One might liken it to diabetes. Many type 2 diabetics can control blood sugar by losing weight, dieting, and exercise. Others need oral hypoglycemics, or even insulin, since they cannot completely control what they eat or can't change their lifestyle. Medications help "control" their blood sugar despite dietary indiscretion.

The same holds for alcoholics. If they can achieve significant abstinence (say 90 days, as Alcoholics Anonymous recommends) their success over the next year is much greater than if they don't. However, with the advent of relapse prevention medications, such as naltrexone, people might do well even if they drink once in a while. The conundrum is that many people may not want to take a medication for a prolonged period, or it might simply stop working. The concern, backed by data, is that once treatment ends, there might be a higher risk of heavy relapse drinking if total abstinence is not achieved during treatment.

Total sobriety is likely the safest but not the only option for many alcoholics. However, the alternative model of no abstinence is still in evolution and, if used, will likely need more intense medical monitoring, intervention, and step-care approaches.

Raymond Anton, M.D.

Charleston, S.C.

Dr. Fink replies:

I've treated patients with alcohol addiction problems over many years and have found it to be extremely disruptive to psychotherapy if the patient continues to drink while in treatment. The key words in the nonmedical approach to treatment, most notably Alcoholics Anonymous, as well as the medical approach, are "abstinence" and "sobriety." These terms represent goals to be met under both approaches. …

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