Definition:
Abstinence is the total avoidance of an activity. It is the dominant approach
in the United States to resolving alcoholism and drug abuse (e.g., "Just
Say No"). Abstinence was at the base of Prohibition (legalized in 1919
with the Eighteenth Amendment) and is closely related to prohibitionism — the
legal proscription of substances and their use. Although
temperance originally meant moderation, the nineteenth-century TEMPERANCE
MOVEMENT'S emphasis on complete abstinence from alcohol and the mid-twentieth
century's experience of the ALCOHOLICS ANONYMOUS movement have strongly
influenced alcohol- and drug-abuse treatment goals in the United States. Moral
and clinical issues have been irrevocably mixed.
The
disease model of alcoholism and drug addiction, which insists on abstinence,
has incorporated new areas of compulsive behavior—such as overeating and sexual
involvements. In these cases, redefinition of abstinence to mean
"the avoidance of excess" (what we would otherwise term moderation)
is required.
Abstinence
can also be used as a treatment-outcome measure, as an indicator of its
effectiveness. In this case, abstinence is defined as the number of drug-free
days or weeks during the treatment regimen—and measures of drug in urine are
often used as objective indicators.
(SEE
ALSO: Disease Concept of Alcoholism and Drug Addiction)
Bibliography
HEATH,
D.B. (1992). Prohibition or liberalization of alcohol and drugs? In M. Galanter
(Ed.), Recent developments in alcoholism Alcohol and cocaine. New York:
Plenum.
LENDER,
M. E., & MARTIN, J. K. (1982). Drinking in America. New York: Free
Press.
PEELE,
S., BRODSKY, A., & ARNOLD, M. (1991). The truth about addiction and
recovery. New York: Simon & Schuster.
Controlled Drinking versus
Abstinence
The
position of ALCOHOLICS ANONYMOUS (AA) and the dominant view among therapists
who treat alcoholism in the United States is that the goal of treatment for
those who have been dependent on alcohol is total, complete, and permanent
abstinence from alcohol (and, often, other intoxicating substances). By
extension, for all those treated for alcohol abuse, including those with no
dependence symptoms, moderation of drinking (termed controlled drinking
or CD) as a goal of treatment is rejected (Peele, 1992). Instead, providers
claim, holding out such a goal to an alcoholic is detrimental, fostering a
continuation of denial and delaying the alcoholic's need to accept the reality
that he or she can never drink in moderation.
In
Britain and other European and Commonwealth countries, controlled-drinking
therapy is widely available (Rosenberg et al., 1992). The following six
questions explore the value, prevalence, and clinical impact of controlled
drinking versus abstinence outcomes in alcoholism treatment; they are intended
to argue the case for controlled drinking as a reasonable and realistic goal.
1. What proportion of treated alcoholics abstain completely
following treatment?
At
one extreme, Vaillant (1983) found a 95 percent relapse rate among a group of
alcoholics followed for 8 years after treatment at a public hospital; and over
a 4-year follow-up period, the Rand Corporation found that only 7 percent of a
treated alcoholic population abstained completely (Polich, Armor, &
Braiker, 1981). At the other extreme, Wallace et al. (1988) reported a 57
percent continuous abstinence rate for private clinic patients who were stably
married and had successfully completed detoxification and treatment—but results
in this study covered only a 6-month period.
In
other studies of private treatment, Walsh et al. (1991) found that only 23
percent of alcohol-abusing workers reported abstaining throughout a 2-year
follow-up, although the figure was 37 percent for those assigned to a hospital
program. According to Finney and Moos (1991), 37 percent of patients reported
they were abstinent at all follow-up years 4 through 10 after treatment.
Clearly, most research agrees that most alcoholism patients drink at some point
following treatment.
2. What proportion of alcoholics eventually achieve
abstinence following alcoholism treatment?
Many
patients ultimately achieve abstinence only over time. Finney and Moos (1991)
found that 49 percent of patients reported they were abstinent at 4 years and
54 percent at 10 years after treatment. Vaillant (1983) found that 39 percent
of his surviving patients were abstaining at 8 years. In the Rand study, 28
percent of assessed patients were abstaining after 4 years. Helzer et al.
(1985), however, reported that only 15 percent of all surviving alcoholics seen
in hospitals were abstinent at 5 to 7 years. (Only a portion of these patients
were specifically treated in an alcoholism unit. Abstinence rates were not
reported separately for this group, but only 7 percent survived and were in
remission at follow-up.)
3. What is the relationship of abstinence to
controlled-drinking outcomes over time?
Edwards
et al. (1983) reported that controlled drinking is more unstable than
abstinence for alcoholics over time, but recent studies have found that
controlled drinking increases over longer follow-up periods. Finney and Moos
(1991) reported a 17 percent "social or moderate drinking" rate at 6
years and a 24 percent rate at 10 years. In studies by McCabe (1986) and Nordström
and Berglund (1987), CD outcomes exceeded abstinence during follow-up of
patients 15 and more years after treatment. Hyman (1976)
earlier found a similar emergence of controlled drinking over 15 years.
4. What are legitimate nonabstinent outcomes for alcoholism?
The
range of nonabstinence outcomes between unabated alcoholism and total
abstinence includes (I) "improved drinking" despite continuing
alcohol abuse, (2) "largely controlled drinking" with occasional
relapses, and (3) "completely controlled drinking." Yet some studies
count both groups (1) and (2) as continuing alcoholics and those in group (3)
who engage in only occasional drinking as abstinent. Vaillant (1983) labeled
abstinence as drinking less than once a month and including a binge lasting
less than a week each year.
The
importance of definitional criteria is evident in a highly publicized study
(Helzer et al., 1985) that identified only 1.6 percent Of treated alcoholism
patients as "moderate drinkers." Not included in this category were
an additional 4.6 percent of patients who drank without problems but who drank
in fewer than 30 of the previous 36 months. In addition, Helzer et al.
identified a sizable group (12%) of former alcoholics who drank a threshold of
7 drinks 4 times in a single month over the previous 3 years but who reported
no adverse consequences or symptoms of alcohol dependence and for whom no such
problems were uncovered from collateral records. Nonetheless, Helzer et al.
rejected the value of CD outcomes in alcoholism treatment.
While
the Helzer et al. study was welcomed by the American treatment industry, the
Rand results (Polich, Armor, & Braiker, 1981) were publicly denounced by
alcoholism treatment advocates. Yet the studies differed primarily in that Rand
reported a higher abstinence rate, using a 6-month window at assessment
(compared with 3 years for Helzer et al.). The studies found remarkably similar
nonabstinence outcomes, but Polich, Armor, and Braiker (1981) classified both
occasional and continuous moderate drinkers (8%) and sometimes heavy drinkers
(10%) who had no negative drinking consequences or dependence symptoms in a
nonabstinent remission category. (Rand subjects had been highly alcoholic and
at intake were consuming a median of 17 drinks daily.)
The
harm-reduction approach seeks to minimize the damage from continued drinking
and recognizes a wide range of improved categories (Heather, 1992). Minimizing
nonabstinent remission or improvement categories by labeling reduced but
occasionally excessive drinking as "alcoholism" fails to address the
morbidity associated with continued untrammeled drinking.
5. How do untreated and treated alcoholics compare in their
controlled-drinking and abstinent-remission ratios?
Alcoholic
remission many years after treatment may depend less on treatment than on
posttreatment experiences, and in some long-term studies, CD outcomes become
more prominent the longer subjects are out of the treatment milieu, because
patients unlearn the abstinence prescription that prevails there (Peele, 1987).
By the same token, controlled drinking may be the more common outcome for
untreated remission, since many alcohol abusers may reject treatment because
they are unwilling to abstain.
Goodwin,
Crane, & Guze (1971) found that controlled-drinking remission was four
times as frequent as abstinence after eight years for untreated alcoholic
felons who had "unequivocal histories of alcoholism".
Results from the 1989 Canadian National Alcohol and Drug Survey confirmed that
those who resolve a drinking problem without treatment are more likely to
become controlled drinkers. Only 18 percent of 500 recovered alcohol abusers in
the survey achieved remission through treatment. About half (49%) of those in
remission still drank. Of those in remission through treatment, 92 percent were
abstinent. But 61 percent of those who achieved remission without treatment
continued drinking.
6. For which alcohol abusers is controlled-drinking therapy
or abstinence therapy superior?
Severity
of alcoholism is the most generally accepted clinical indicator of the
appropriateness of CD therapy (Rosenberg, 1993). Untreated alcohol abusers
probably have less severe drinking problems than clinical populations of
alcoholics, which may explain their higher levels of controlled drinking. But
the less severe problem drinkers uncovered in nonclinical studies are more
typical, outnumbering those who "show major symptoms of alcohol
dependence" by about four to one (Skinner, 1990).
Despite
the reported relationship between severity and CD outcomes, many diagnosed
alcoholics do control their drinking, as Table 1 reveals. The
Rand study quantified the relationship between severity of alcohol dependence
and controlled-drinking outcomes, although, overall, the Rand population was a
severely alcoholic one in which "virtually all subjects reported symptoms
of alcohol dependence" (Polich, Armor, and Braiker, 1981).
Polich,
Armor, and Braiker found that the most severely dependent alcoholics (11 or
more dependence symptoms on admission) were the least likely to achieve
nonproblem drinking at 4 years. However, a quarter or this group who achieved
remission did so through nonproblem drinking. Furthermore, younger (under 40),
single alcoholics were far more likely to relapse if they were abstinent at 18
months than if they were drinking without problems, even if they were highly
alcohol-dependent (Table 3). Thus the Rand study found a
strong link between severity and outcome, but a far from ironclad one.
Some
studies have failed to confirm the link between controlled-drinking versus
abstinence outcomes and alcoholic severity. In a clinical trial that included
CD and abstinence training for a highly dependent alcoholic population,
Rychtarik et al. (1987) reported 18 percent controlled drinkers and 20 percent
abstinent (from 59 initial patients) at 5 to 6 year follow-up. Outcome type was
not related to severity of dependence. Nor was it for Nordström and Berglund
(1987), perhaps because they excluded "subjects who were never alcohol dependent."
Nordström
and Berglund, like Wallace et al. (1988), selected high-prognosis patients who
were socially stable. The Wallace et al. patients had a high level of
abstinence; patients in Nordström and Berglund had a high level of controlled
drinking. Social stability at intake was negatively related in Rychtarik et al.
to consumption as a result either of abstinence or of limited intake.
Apparently, social stability predicts that alcoholics will succeed better
whether they choose abstinence or reduced drinking. But other research
indicates that the pool of those who achieve remission can be expanded by
having broader treatment goals.
Rychtarik
et al. found that treatment aimed at abstinence or controlled drinking was not
related to patients' ultimate remission type. Booth, Dale, and Ansari (1984),
on the other hand, found that patients did achieve their selected goal of
abstinence or controlled drinking more often. Three British groups
(Elal-Lawrence, Slade, & Dewey, 1986; Heather, Rollnick, & Winton,
1983; Orford & Keddie, 1986) have found that treated alcoholics' beliefs
about whether they could control their drinking and their commitment to a CD or
an abstinence-treatment goal were more important in determining CD versus
abstinence outcomes than were subjects' levels of alcohol dependence. Miller et
al. (in press) found that more dependent drinkers were less likely to achieve
CD outcomes but that desired treatment goal and whether one labeled oneself an
alcoholic or not independently predicted outcome type.
Summary
Controlled
drinking has an important role to play in alcoholism treatment. Controlled
drinking as well as abstinence is an appropriate goal for the majority of
problem drinkers who are not alcohol-dependent. In addition, while controlled
drinking becomes less likely the more severe the degree of alcoholism, other
factors—such as age, values, and beliefs about oneself, one's drinking, and the
possibility of controlled drinking—also play a role, sometimes the dominant
role, in determining successful outcome type. Finally, reduced drinking is
often the focus of a harm-reduction approach, where the likely alternative is
not abstinence but continued alcoholism.
(SEE
ALSO: Alcohol; Disease Concept of Alcoholism and Drug Abuse; Relapse
Prevention; Treatment)
|
Study
|
Years of
Follow-up |
No. of
Assessed Subjects |
Percent
Abstinent |
Percent
Controlled Drinking |
Percent
Remission Survivors (a) |
|
Untreated
|
|||||
|
Goodwin,
Crane, & Guze (1971)
|
8
|
93
|
8
|
33 (b)
|
41
|
|
1989 Canadian
National Survey
|
>=1
|
497
|
49
|
51
|
100 (c)
|
|
|
|
|
|
|
|
|
Treated
|
|||||
|
Rand
(Polich, Armor, & Braiker 1981)
|
4
|
548
|
28
|
18 (d)
|
46
|
|
Vaillant
(1983)
|
8
|
100
|
39
|
6
|
45
|
|
Helzer
et al. (1985) (e)
|
5-7
|
387
|
15 (f)
|
18 (g)
|
33
|
|
McCabe
(1986)
|
16
|
31
|
26
|
35
|
61
|
|
Nordström
& Berglund (1987)
|
18-24
|
55
|
20
|
38
|
58
|
|
Rychtarik
et al. (1987)
|
5-6
|
43
|
23
|
21
|
44
|
|
Wallace
et al. (1988)
|
0.5
|
169
|
68 (h)
|
-(h)
|
68 (h)
|
|
Finney
and Moos (1991)
|
10
|
83
|
54
|
24
|
78
|
|
Walsh et
al. (1991)
|
2
|
200
|
23 (37) (i)
|
10 (7) (i)
|
33 (44) (i)
|
|
a
Since only survivors are included, successful remission rates are overstated.
b
Nonabstinence remission included 18 percent "moderate drinkers," 9
percent getting "drunk about once a week," 6 percent "switched
from whiskey to beer, . . . drank almost daily and sometimes excessively,
[but] had experienced no problems from drinking since making the
change."
c
The Canadian National Survey data concern only recovered alcohol abusers.
d
Defined as nonproblem drinking, with either low quantities of consumption
(8%) or some heavy drinking (10%).
e
Although all subjects in this study were hospital patients, only one group
was treated in an alcohol unit. This group had the worst outcomes of any
group, but these outcomes were not reported separately.
f
Reported data were weighted by Helzer et al.
g
Controlled drinking outcomes include occasional drinkers (4.6%), moderate
drinkers (1.6%), and heavy, nonproblem drinkers (12%).
h
Wallace et al. reported 57 percent continuous abstinence over 6 months and an
additional 11 percent currently abstinent. Although Wallace et al. reported
no controlled drinking, a small group (4%) had "one brief contained
return to drinking or drug use" in the 180-day period.
i
Figures are for all treated groups, with assigned hospital patients in
parentheses. No controlled-drinking category was included, but this column
comprises those in the study who drank without ever becoming intoxicated
during the 2-year follow-up (the latter data are not fully reported in the
published article).
|
|||||
|
|
Treated Remission (n = 89)
|
Untreated Remission (n = 408)
|
|
Abstinent (51%)
|
92
|
39
|
|
Nonabstinent (49%)
|
8
|
61
|
|
Data
presented by L. C. Sobell & M. B. Sobell (November 1991).
Cognitive mediators of natural recoveries from alcohol problems: Implications for treatment. Paper presented as part of a symposium, "Therapies for Substance Abuse: A View towards the Future," 25th Annual Meeting of the Association for the Advancement of Behavior Therapy, New York. |
||
|
|
Age <
40 at Admission
|
Age >
40 at Admission
|
||
|
|
Abstaining
18 Months |
Nonproblem
Drinking 18 Months |
Abstaining
18 Months |
Nonproblem
Drinking 18 Months |
|
High
Dependence Symptoms
Married |
12
|
17
|
14
|
50
|
|
Single
|
21
|
7
|
24
|
28
|
|
Low
Dependence Symptoms
Married |
16
|
7
|
19
|
28
|
|
Single
|
29
|
3
|
32
|
13
|
|
J.
M. Polich, D. J.. Armor, & H. B. Braiker (1981). The course of
alcoholism: Four years after treatment. New York: Wiley.
|
||||
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