Abstinence and moderation

[Hari_Seldon]

This quote from today’s column

These findings aroused bitter argument, for an obvious reason: if 18 percent of heavy drinkers can learn to drink in moderation, 82 percent presumably can’t. Nonetheless, over the years strategies were developed to teach heavy drinkers to control but not necessarily halt their consumption.

is utterly useless. Shame Cecil! The relevant statistic is: of those who underwent abstinence (through AA or otherwise), what percentage were able to resume drinking normally? The 82% includes both those who went off the wagon and those who remained abstinent.

I know two former alcoholics quite well. One has remained abstinent for over 50 years and will not touch a drop. He is around 85 now. The other dried out at a facility about 30 years ago (not at AA; he is thorough atheist and could not hack their God-centered approach). After four years of abstinence, he began drinking a glass of wine with dinner. Every winter, we spend 2 weeks in Barbados with him and his wife, sharing quarters, and I can observe him closely. He might drink a beer (occasionally wine) with dinner, although mostly not, and every night he makes a batch of frozen daiquiris and we drink them. In two weeks we don’t quite finish a 1.5 liter bottle of rum. That’s moderate drinking by any standard. He is 77.

[bup]

Link to Column.

I don’t think **Cecil **implied otherwise. He’s just raising the question, “if only 18% can become moderate drinkers, is it worth it to even have moderation therapy, over complete abstinence?”

[Thudlow_Boink]

I was disappointed in the column, because it doesn’t even try to answer the question asked in the title. What is it about alcoholics that compels them to keep on drinking; what’s going on, physiologically or psychologically, that prevents them from stopping after one or two drinks? Something like “In an alcoholic individual, alcohol, once consumed, knocks out the brain’s impulse control center.” I have no idea whether this is true or not, but it’s the kind of thing that, if true, would contribute toward actually answering the question that was asked.

[oceansong]

There is now a scientific cure for alcoholism that is 75-80% effective.
The Sinclair Method is very well known in Europe and Asia. It has been slower to be known in the US because of the prevalence of AA and 12 step groups.

Most people are aware that alcohol is more addictive to some people than to others. It doesn’t have to do with who is in the most emotional pain, who is trying to self-medicate to avoid overwhelming feelings, etc.
It has to do with how alcohol releases endorphins (compounds similar to opiates) that reinforce the drinking – increasing obsessive thoughts, cravings and focus on alcohol.

Until recently, the only way to deal with this genetic inclination was to white-knuckle abstain from alcohol – often using AA and 12-step groups to focus on recovery. This approach works great for some people, but is a total failure for others. (Who often feel like even more of a failure when this doesn’t work for them.)

David Sinclair has more than 20 years of research in Finland on using an opiate/endorphin blocker that helps an alcoholic’s brain un-learn their addiction to alcohol.

To quote from an article at Can a Pill Cure Alcoholism?
“In the simplest terms, Dr. Sinclair found that every time a person engages in a behavior such as drinking that releases endorphins—…… it strengthens or reinforces the neural pathways in the brain associated with that behavior. Over time, these super-strengthened pathways lead to habitual behavior—or what scientists know as addiction.

Dr. Sinclair hypothesized that if he could find a way to block the endorphin receptors in the brain—thus removing the reinforcement—the super-strong neural pathways in the brain associated with the addictive behavior would gradually weaken over time, and cravings would cease. He discovered naltrexone does just that.

Unlike previous drugs for treating alcoholism that require the patient to abstain, naltrexone is only effective if taken in combination with ongoing drinking. When the alcoholic takes a pill one hour before imbibing, naltrexone blocks the endorphin receptors in the brain, eliminating the effect that reinforces the addictive behavior. Over several weeks, the brain “unlearns” the craving, and most people, even the most serious alcoholics, find they have no desire to drink, can abstain completely, or can drink occasionally or socially—so long as they always take naltrexone before drinking. ………… Dr. Sinclair developed a de-addiction program that has become the mainstream method of treatment for alcoholism in Finland, where it has been used by more than 100,000 patients. The Sinclair Method enjoys the highest success rate of any treatment for alcoholism—including rehab programs, Alcoholics Anonymous, and medications that enforce abstinence, such as Antabuse. Naltrexone is used in Europe and Asia, and is becoming better known in the US. “

If you would like to know more: http://www.28weekrecovery.com/index_files/Page389.htm
http://www.thecureforalcoholism.com/
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=11132
There is also a forum for people using the Sinclair Method at: V68 Máy Chủ Ở Đâu - Cổng game bài quốc tế, quay là phê

[Canuckistan_Bob]

The basic problem is that there is not a clear, scientific, objective tool to diagnose alcoholism. How can you measure a success rate when you have no objective yardstick to measure what you are treating? (And self reporting is pretty dubious; these are mentally ill people according to the DSM after all.)

This is probably in part attributable to the fact that addiction seems to not be a single issue-- there is “physical” addiction (used heavily in all the scare you straight type anti drug/alcohol programming but basically ignored in real treatment) which involves low level neurological issues, and involves all the usual physical symptoms-- interestingly, alcohol is actually one of the single most addictive drugs on this level; a “hangover” is indistinguishable from “physical withdrawal” except for severity/duration.

Then there is the “craving” which seems to be a mid level pre-cognitive neurological issue, where consumption of any alcohol triggers an overwhelming drive for more, and so far, can only be treated by abstinence, and finally the “obsession,” which seems to be a purely cognitive issue. It is quite possible that if the only problem is obsession, without craving, it might be treatable with one kind of cognitive therapy or another.

“Early onset” type alcoholics have immediate issues with craving; pretty much from the first time they consume alcohol, the craving sets in-- your classic binge drinker, who may not drink all the time, but when they do, they do so prodigiously and uncontrollably. There is pretty good looking evidence for genetic tracing for this. But it can be learnt as well; a good chunk of alcoholics develop it later in their drinking careers. Myself, I could walk away from a drink after having had a drink for many years (with increasing difficulty), but eventually, it became impossible.

Craving shouldn’t be a problem; if you can’t stop, don’t start; and perhaps a pharmaceutic intervention might help (though I am skeptical about that). But that is where the obsession kicks in; not starting isn’t an option for the obsessed. At that point, I don’t think that there is much choice but AA or something very much like it; essentially a full brain-washing/personality reconstruction. That, or death, really.

If it were possible to say pharmacologically treat the craving ***and ***psychotherapy the obsession away, you might be able to turn an alcoholic into a normal person. I am very skeptical that this could be done. And of course the obsessed is going to lie like the very dickens to achieve the object of his/her obsession, so the testimony of addicts is worthless.

[si_blakely]

@Canuckistan_Bob

This is probably in part attributable to the fact that addiction seems to not be a single issue-- there is “physical” addiction (used heavily in all the scare you straight type anti drug/alcohol programming but basically ignored in real treatment) which involves low level neurological issues, and involves all the usual physical symptoms-- interestingly, alcohol is actually one of the single most addictive drugs on this level; a “hangover” is indistinguishable from “physical withdrawal” except for severity/duration.

This is not true - a hangover is the consequence of alcohol metabolism and dehydration. It involves a headache, nausea and a dry mouth, and passes in a few hours with fluids and rest. Alcohol withdrawal is a potentially life threatening condition that may require medical supervision and is nothing like a hangover at all.

@Canuckistan_Bob

Then there is the “craving” which seems to be a mid level pre-cognitive neurological issue, where consumption of any alcohol triggers an overwhelming drive for more, and so far, can only be treated by abstinence, and finally the “obsession,” which seems to be a purely cognitive issue. It is quite possible that if the only problem is obsession, without craving, it might be treatable with one kind of cognitive therapy or another.

As noted by oceansong, there is a positive reward response to alcohol in the form of endorphins - some people are more sensitive to endorphins than others - this can make them susceptible to reward systems (gambling, sexual addictions, drugs as well as alcohol). This is the basis on which the Sinclair method mentioned above works, by blocking the endorphin response, and thus desensitising the response to the stimulation.

[Canuckistan_Bob]

From the Wikipedia article you cite: “Six to 12 hours after the ingestion of the last drink, withdrawal symptoms such as shaking, headache, sweating, anxiety, nausea or vomiting occur.” ie, a hangover. Its the 12 to 48 hour period, where you might, in a minority of cases, get DTs and seizures-- a majority do not. I have been there and done that, more than once sadly. And seen others going through it, often. If dehydration were all there were to it, hangovers would be very swiftly cured (and rehydration is indeed a big part of detox). The best cure for a hangover in fact is hair of the dog, which in detox is known as ‘tapering.’

[si_blakely]

First - hangovers don’t generally involve the shakes. While some of the symptoms are similar, the root causes are quite different. Cite.

In the first, hangovers are described as the first stage of alcohol withdrawal, which is then alleviated by further alcohol intake. Although “…Low [ethanol] doses may effectively prevent alcohol withdrawal syndrome in surgical patients”, this idea is questionable as the signs and symptoms of hangover and alcohol withdrawal are very different.

Second, medical studies don’t support the concept of “the hair of the dog” as a hangover cure - however, it’s use by a drinker can point to development of dangerous patterns of drinking.

Social drinkers and alcoholics claim that drinking more alcohol gives relief from hangover symptoms, but research shows that the use of alcohol as a hangover cure seems to predict current or future problem drinking and alcohol use disorder, through negative reinforcement and the development of physical dependence. While the practice is affirmed by tradition and by many hospitality providers, medical opinion holds that the practice merely postpones the symptoms, and courts addiction

[Tethered_Kite]

@si_blakely

First - hangovers don’t generally involve the shakes. While some of the symptoms are similar, the root causes are quite different.

Alcoholism progresses in stages. Early stage hangovers don’t generally involve the shakes. But indulging to the point of hangover is one of several criteria used for the a diagnosis of alcoholism.

And mid- to late-stage hangovers do involved shaking which is a symptom of alcohol withdrawal.

A hangover however mild is, unfortunately, a signal of alcohol withdrawal. But doesn’t necessarily indicate alcoholism.

Naltrexone has been used in the US for about ten years now. While it has been helpful to many people it’s scarcely the miracle drug it is sometimes touted to be. In fact there have been reports associating its use with overdose.

I imagine that’s because the user continues to chase the high. This, and the development of other dependencies, have been the common problem with drug therapy to combat drug addiction.

Then there is that liver damage issue. . .

[si_blakely]

@Tethered_Kite

Alcoholism progresses in stages. Early stage hangovers don’t generally involve the shakes. But indulging to the point of hangover is one of several criteria used for the a diagnosis of alcoholism.

Indulging in any behaviour despite suffering known negative consequences is a red flag for a number of addictions. It says nothing of the nature or cause of that consequence.

@Tethered_Kite

And mid- to late-stage hangovers do involved shaking which is a symptom of alcohol withdrawal.

At which point the hangover may well be co-symptomatic with alcohol dependance/withdrawal - that does not make the two the same thing.

@Tethered_Kite

A hangover however mild is, unfortunately, a signal of alcohol withdrawal. But doesn’t necessarily indicate alcoholism.

I’m going to pull the cite card - I have provided cites that indicate that medical professionals do not consider this to be the case. Many people have suffered hangover symptoms after drinking without any continual or repeated pattern, and sometimes after very low intake - I personally do not drink very much at all (i.e. months between drinking) and drink extremely moderately (no more than 2-3 units in an evening) and can still suffer a hangover: I have not developed a tolerance to alcohol and withdrawal symptoms in a single evening of drinking two pints of cider. What I have suffered from is a consequence of alcohol metabolism - a bunch of alcohol metabolites and congeners causing problems for my system and making me feel uncomfortable until they clear out my system. If you want to make any other case, you need to provide medically justified proof of your assertion.

[Tethered_Kite]

You have no need for a cite from me. They are numerous and easy to find. Start with Wiki. I will accept the fact that there is overlap. But you stated that hangovers are not withdrawal which isn’t exactly correct.

And I can agree that congeners can cause problems for people who drink alcohol. It does raise the question why anyone would repeat the experience.

As far as cites from MDs regarding addiction, it is well know that they receive little education regarding the subject and are a population that has its own addiction problems. Pain and addiction are two areas where we need renewal in the training of medical staff.

[Ambivalid]

A couple questions; if the naltrexone therapy depends on the alcoholic taking a pill prior to every time he/she drinks, isn’t there going to be a very high likelihood of non-compliance with this sort of therapy as the alcoholic (especially after experiencing the pleasure-less version of drinking with the medication) would choose to not take the pill? Also, if the medication makes the drugs (or alcohol) not effective to the user, couldn’t this potentially lead to the user attempting to use more and more of the drug or alcohol in a desperate attempt to get high? This obviously could lead to overdoses.

[Tethered_Kite]

Naltrexone is given in pill form. I’m unfamiliar if physicians ever monitor it’s administration. In the days of Antibuse use sometimes the detox staff would require a person to show up in person for their daily dose.

I believe sometime in the early 2000s an injectable form of the drug was developed. I don’t know how often it is used.

Yes, not only is there a risk of overdose involved with its use, but it isn’t uncommon for people attempting to remain sober to undergo moderate to severe depression which, if unaddressed, can play havoc with their efforts.

It would be a real benefit to mankind if a pharmaceutical intervention for addiction could be developed. But the disease (alcoholism was declared to be a disease by the American Medical Association in the 1950s) itself involves so many related psychological issues that rare is the person who can quit cold turkey without considerable struggle.

I have a strong reaction to articles that give hope to addicts that they can be reprogrammed to drink in moderation because the percentage who can succeed is so small and the risk so high. In fact I know a number of good people who have died in the hope of learning to be normal drinkers.

[si_blakely]

@Tethered_Kite

You have no need for a cite from me. They are numerous and easy to find. Start with Wiki. I will accept the fact that there is overlap. But you stated that hangovers are not withdrawal which isn’t exactly correct.

I have provided cites in this thread that support my position - if you wish to support your claim, you need to provide counter-cites. That is how debate and discussion works.

Most links refer to the concept of “Hangover as Alcohol Withdrawal” as a theory, commonly used by drinkers (and purveyors of alcohol) to justify imbibing more alcohol the morning after. Research shows that hair-of-the-dog drinking has limited value as a treatment for hangover symptoms but does (in a statistical sense) indicate present or future drinking addiction related problems. I certainly have not found any serious research articles backing the position. I’d like to see some.

I’d also like to know where the idea comes from - I certainly have never heard it before.

[JM_Hanes]

Without opining on the efficacy of naltrexone, I’m afraid this quote from the Sinclair Method website strikes me as neurological hogwash:

The de-addiction process rolls back the addictive mechanism in the brain to its original pre-addicted state—before the first drink was consumed, making this program an actual cure for alcoholism.

All heavy drinkers are not necessarily alcoholics, of course, and it seems worth noting this study (as described at Wikipedia), which certainly seems to speak to a genetic component of alcoholism which is less susceptible naltrexone therapy:

A naltrexone treatment study released by the National Institute of Health in February 2008 and published in the Archives of General Psychiatry has shown that alcoholics having a certain variant of the opioid receptor gene (G polymorphism of SNP Rs1799971 in the gene OPRM1) demonstrated strong response to naltrexone and were far more likely to experience success at cutting back or discontinuing their alcohol intake altogether, while in those lacking the gene variant, naltrexone appeared to be no different from placebo.[40] The G allele of OPRM1 is common in individuals of Asian descent, with 60% to 70% of people of Chinese, Japanese, and Indian ancestry having at least one copy, as opposed to 30% of Europeans and very few Africans.[41] In line with this finding, studies found naltrexone to be more efficacious among white subjects than among black subjects,[42] and a 2009 study of naltrexone as an alcohol dependence treatment among African Americans failed to find any statistically significant differences between naltrexone and placebo.[43] Studies have suggested that carriers of the G allele may be experiencing higher levels of craving and stronger “high” upon alcohol consumption, compared to carriers of the dominant allele, and naltrexone somewhat blunts these responses.[44]

While I remain skeptical of anyone who promises to deliver an actual “cure” (and don’t for one second believe a claimed success rate of 75%-80%) perhaps a naltrexone regime might attract some people who aren’t (yet) willing to call themselves alcoholics, before they end up doing irreversible harm to themselves or others. Hopefully such a program would also include counseling and/or a savvy therapist who could usher the unsuccessful into an abstinence program.

[oceansong]

I understand the skepticism about the Sinclair Method.
Until a person reads more details about how pharmacological extinction works, it seems counter-intuitive to how we are used to thinking about alcohol and abstinence.

But I have known several alcoholics (very severe alcoholics who were drinking 8-15 units per DAY of alcohol) who successfully used the Sinclair Method. They became moderate drinkers, or naturally abstinent without having to white-knuckle it.

When it is followed correctly, it helps the person gradually wean off the alcohol - it thus avoids the risk of detoxing too fast. As the person takes a 50mg tab every day that they will consume alcohol, they gradually lose their desire for drinking. A significant percentage of people who successfully use this method become totally abstinent and others find it easy to drink in moderation.

I have not observed, as JM Hanes states: “perhaps a naltrexone regime might attract some people who aren’t (yet) willing to call themselves alcoholics…”
In my experience, these drinkers are well aware that they are alcoholics. Denial is not their problem. Many of them have sincerely tried AA, but were not able to hold to the program due to the intensity of the addiction. (And not because they weren’t willing to try.)

Some of the comments about Naltrexone above are based on Naltrexone being used in different ways, dosages and applications than it is used in the Sinclair Method. The Sinclair Method is a very specific way of using Naltrexone.
Again, if you or someone you care about has a severe alcohol problem, and hasn’t found that AA works for them - check it out further. Read the on-line forums of people who are using this method; read the book by Roy Eskapa. Don’t just rely on the opinions of people who have not read the book or taken the time to listen to people who have successfully used the Sinclair Method.

And if you are one of the people who is fortunate to have successfully stopped drinking with the support of the AA community - great! Just don’t assume that AA works for everyone. Check the Sinclair Method out more thoroughly.

[John_W.Kennedy]

Claudia Christian (best known as Susan Ivanova from Babylon 5) has good things to say about the Sinclair Method. I, personally, appear to have whatever the opposite of an addictive personality is, so I can’t honestly address the subject one way or the other.

[Tethered_Kite]

@John_W.Kennedy

Claudia Christian (best known as Susan Ivanova from Babylon 5) has good things to say about the Sinclair Method. I, personally, appear to have whatever the opposite of an addictive personality is, so I can’t honestly address the subject one way or the other.

There is no one particular personality that can be called the alcoholic personality. There are different drinking styles and different kinds of personality changes when people are alcoholic and drinking but no personality type per se.

si_blakely, I have been thinking about an answer which may satisfy you. How about this? In the vernacular people prefer to say they are suffering from a hangover rather than withdrawal. It could be said that medical staff would use the same term to imply that a drinker who wasn’t physically addicted to alcohol was experiencing mild withdrawal. Withdrawal implies addiction.

I’ve bumped into a couple of peer-reviewed papers in a small effort to provide you with a more satisfying answer. As is so common, all but one require registration.

Since hangover (withdrawal) onset coincides with a lessening of blood alcohol level and since it is somewhat ameliorated by the ingestion of more alcohol it is a good clue that the two are often one in the same. We’ve already mentioned metabolites and congeners and other factors.

Apparently more research needs to be done. I’m comfortable with the comparison but can see how it would be offensive to a moderate drinker or an alcoholic who thought he was a moderate drinker.

I studied this at the Masters level and this is the information for diagnosis I was given. It made enough sense that it never occurred to me to challenge the professor. It, along with concurrent diagnostic material, has proved reliable enough.

(Actually all you gotta do is get a good look at the guy’s wife. )

[Tethered_Kite]

You can read the paper I referred to by using Bing:

Alcohol Hangover - Nation Institutes of Health

[si_blakely]

@Tethered_Kite

si_blakely, I have been thinking about an answer which may satisfy you. How about this? In the vernacular people prefer to say they are suffering from a hangover rather than withdrawal. It could be said that medical staff would use the same term to imply that a drinker who wasn’t physically addicted to alcohol was experiencing mild withdrawal. Withdrawal implies addiction.

I’d certainly feel that using the term withdrawal implies ongoing dependance, and (in my experience) hangovers are suffered by the casual/occasional drinker as well as by regular drinkers. It may be that the CNS does overactivate to compensate for alcoholic CNS depression, which contributes to hangover symptoms (oversensitivity, for example), but I question the degree to which this occurs rapidly (as per an isolated drinking event that nevertheless causes a hangover).

@Tethered_Kite

…

Since hangover (withdrawal) onset coincides with a lessening of blood alcohol level and since it is somewhat ameliorated by the ingestion of more alcohol it is a good clue that the two are often one in the same. We’ve already mentioned metabolites and congeners and other factors.

Apparently more research needs to be done. I’m comfortable with the comparison but can see how it would be offensive to a moderate drinker or an alcoholic who thought he was a moderate drinker.

I agree that maybe there does need to be more research - if I drank more I’d volunteer as a research subject, but I hate hangovers
I think the questions I’d like to see answered are:
is there a placebo effect with hair-of-the-dog treatments (i.e does the expectation of having a drink reduce hangover symptoms - can you slip a virgin mary to a hungover drinker to see if they respond as positively cf a bloody mary)
how does hangover recovery track BAC/Acetaldehyde/acetic acid/formaldehyde in the bloodstream (I am aware that many people who have hangovers may still have a significantly raised BAC following heavy drinking)
whether hangover symptoms respond to GABA inhibition (such as benzodiazepines used to suppress alcoholic withdrawal symptoms) as well as to alcohol (and I am aware that the two should not really be mixed).

I’m also wondering if fMRI would show overexcitation of the CNS as a response to alcoholic CNS depression (but I doubt you could get a hungover volunteer to willingly climb into a noisy, confined MRI machine with a hangover.

@Tethered_Kite

I studied this at the Masters level and this is the information for diagnosis I was given. It made enough sense that it never occurred to me to challenge the professor. It, along with concurrent diagnostic material, has proved reliable enough.

As I say, I’ve never seen the concept of the hangover as withdrawal expressed before, so it is pretty new to me. I can see it may have a place when moderate drinking to excess starts to tip that corner into problematic drinking, where I am sure withdrawal effects may start to come into play, and I’d be interested to understand at what sort of point the withdrawal effects start to supplant other hangover like effects.

Anyhow, a worthwhile discussion and I’ll check out your suggested search tomorrow.