Abstinence and moderation

Cecil's Columns/Staff Reports
21

I don’t mean to come across as wholly dismissive of the potential benefits of pharmaceuticals, or the possibility of mitigating chronic excess. Whatever the method, deciding to seek help of some kind is a necessary first step.

From the abstinence-only advocates’ point of view (with decades of collective experience), the single most dangerously seductive idea of all is that an alcoholic can successfully drink in moderation, so their rejection of ostensible alternatives out of hand will be well nigh impossible to overcome. Once more comprehensive, long term, recidivism stats are officially in, however, it is, indeed, possible that naltrexone and/or other medications could revolutionize the treatment of alcohol abuse. It does look like collective or one-on-one support of some kind will always be part of the package.

Per the Director of NIH, and a scan of related trials, it appears that most of the existing research has centered on the effectiveness of naltrexone “as an adjunct to traditional treatment,” (presumably abstinence), while its effectiveness in a program of moderation has yet to be unequivocally confirmed at the clinical level. This doesn’t mean it’s not effective in that regard, but the problem with anecdotal success is that you generally hear very little about the failures.

I suspect that clinical trials like this one will eventually establish, and hopefully allow us to distinguish between those who can be helped to moderate their drinking and those for whom abstinence is the only solution. I have no trouble imagining potentially defining differences between, say, chemically acquired dependence and genetically compelling dependence (albeit in a more complex formulation). That would certainly be a welcome advance, but as the NIH Director’s testimony suggests, alas, remediation of the latter, short of abstinence, will be a long time coming.

I would, as you do, encourage anyone who thinks alcohol is, or even may be, a problem in their lives to seek help, because help is out there if they look – sometimes in unexpected places (like a message board!). You will generally be welcomed with open arms.

22

My non-medical opinion (also verified by talking to several experts):

  1. An alcoholic’s body doesn’t process alcohol the same way as other people, because of two processes: liver damage and tolerance.
  2. An alcoholic wants to reach a certain level of drunkeness, because of this they have to drink more each time because of higher tolerance.
  3. Because their liver cant process alcohol as fast as it used to, alcoholics will “fall off a ledge” and suddenly become extremely drunk within a few minutes.
  4. Therefore, an alcoholic will drink more to get the same feeling, but require less to get very drunk.

So this leads to two conclusions:

  1. Alcoholics cannot moderate their intake based on how drunk they feel.
  2. A moderate amount can make them very drunk.

Cecil’s column did not mention the process of liver deterioration nor tolerance, which paradoxically contribute to an inability to moderate alcohol consumption.

In all the examples mentioned of successful moderation, it seems to me that they imposed absolute limits on themselves, not “moderation.” If an alcoholic forces themselves to stop after say 1 drink, it is possible for them to stick to it through willpower. But, i don’t know many alcoholics who felt much after a single drink.

23

Missed window: as tolerance increases and liver damage gets worse, this creates a situation where moderation can’t occur: the amount needed to feel drunk is too high and the liver’s ability is so low the only possible outcomes are no feeling at all or extreme drunkeness.

24

[Regarding hangover = alcohol withdrawal]

Are you referring to “Mechanisms and Mediators” by Robert Swift, M.D., Ph.D.; and Dena Davidson, Ph.D. ?

That’s not very convincing. The paper gives-- backed up by citations to relevant studies – multiple direct physical effects leading to a hangover (dehydration, gastrointestinal irritation, sleep disruption and low blood sugar, though evidently low blood sugar is mostly an issue for alcoholics on multi-day benders). It then speculates that withdrawal may also be a factor, but doesn’t really give any evidence except “Gee, the symptoms kind of overlap a bit” and “Hair of the dog helps a hangover, right?”. Unlike the citations for the physical causes, they don’t provide any citations to studies that show hair of the dog really does help.

So, until there’s better evidence, I don’t think the withdrawal theory makes much sense – if there’s perfectly good physical explanations, why bother with more complicated ones?

Then there’s the anecdotal evidence. I’m generally a moderate drinker, but have had occasions where I may have consumed just a bit more than, in retrospect, would have been ideal. In one unpleasant incident I woke up with not only a hangover, but also the realization that I was still somewhat drunk.

25

At the end of the day though is there any need for people, especially alcoholics, to drink? It seems like an awful lot of effort is being put into trying to allow a person to consume a toxin and hope really hard that they don’t ruin their lives because of it. You don’t see people trying to get smokers to just smoke a little bit and alcohol will kill you much faster than a cigarette can.

26

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27

I agree with this and it leads me to discount the “moderate drinking” philosophy. If a person has reached a point where his drinking is out of control and causing family and work problems, then why try a position where it could possibly happen again?

Many people do not drink alcohol by choice and from all observations they lead as happy and successful lives as those who drink moderately. Where is the compelling need to be a moderate drinker? I can’t help but feel that the addiction is so ingrained that the very thought of a life without alcohol seems horrific. That thought needs to be addressed.

Alcohol isn’t like food, water, or oxygen in that it is a necessity. If it has caused problems, then don’t take half measures that can still ruin your life. Quit entirely.

28

I am currently reading the recently published book Drink: The Intimate Relationship Between Women and Alcohol, and as a non-drinker, the thing that strikes me most is how the author (an alcoholic) discusses the way that alcohol is such an important part of all aspects of life – family, work, romance, socializing. I was just reading a story she tells about being offered champagne on an airplane flight, and making up some bogus reason to decline, and having the flight attendant rebuff her reason, and tell her that she should go ahead. In the author’s mind, this was one more example of how difficult it is to avoid alcohol. To me, it just sounds bizarre. I have said, “No thanks” to alcohol hundreds of times, and no one cares. To an alcoholic, the whole world looks like a bar. This author also goes on and on about champagne at her wedding (and at the weddings of other women she interviewed). Some felt that there was no way they could give up drinking because they had to have champagne at their wedding, or if they were being abstinent, they had to give it up, because how can you not drink champagne at your wedding? It’s these kinds of people who desperately search for a solution to their problem that doesn’t involve abstinence, because they cannot envision a life without alcohol.

29

Yeah, I’m always saying “no thanks” to alcohol, too. Perhaps one time in ten, the person making the offer presses me on it, to which I reply that I don’t drink. It’s at most one time in a hundred that they press further than that. And if I should happen to decide that a toast is needed at my wedding, my glass will contain sparkling juice.

30

It is true that drinking alcohol is ingrained in our culture as something of an expectation. It’s built around socializing at parties. There’s the after work hanging out at happy hour and the buying somebody a beer. There’s drinking wine with dinner on dates, or going to bars to meet people for romance. And it’s embedded in customs for celebration, with champagne being the biggest one. It’s less of an immediate social faux pas to decline alcohol in these situations than it used to be, but there is still some level of awkwardness with the fact that there are expectations one is violating by not participating fully.

I imagine at least part of that flight attendant’s response was based upon the author’s excuse. If she said something about watching her weight or being a good girl or “I shouldn’t this early” or any kind of excuse that made it look like alcohol was an indulgence for her, then the flight attendant is just trying to suggest it is okay to indulge in that rare circumstance. Same way someone being offered a cookie or brownie might say “I shouldn’t, I’m watching my figure,” and might get a reply, “It’s okay, it’s a small brownie, and they’re really good.” Whereas if the author had dropped pretense and just said, “No thank you, I don’t drink,” then it would probably have been the end of the conversation.

Yes, the answer to “how can you not drink champagne at your wedding?” is simply “because I don’t want to”. Your wedding is a celebration, and champagne is supposed to be a treat as part of that celebration. If it isn’t enjoyable for you, then it shouldn’t be done.

The challenge for the abstaining alcoholic is having champagne freely available for guests without partaking themselves. Because the desire for alcohol is in conflict with their desire to remain in control, and the circumstance puts them with easy access.

31

I agree with you in some ways, but in others I don’t. Many, many millions of people simply go home after work and don’t stop off at happy hour. The same number will drink iced tea at a nice dinner or look for potential mates at other social gatherings instead of in a bar. I’ve also been to many weddings where no alcohol was served.

The alcoholic mind seems to think that life itself is just unlivable without champagne at a wedding or having a few (or twenty) beers with your buds after work. It’s not. I’m not a prohibitionist by any means, and if one can do all of those and not jeopardize his heath, family, or job, then great. But I know far too many people who simply don’t do those things that some alcoholics believe are just a natural part of life.

I don’t think that there are many tee-totalers out there who are wistfully dreaming of a life where they can go pick up women at a bar, or drink wine at dinner. I don’t think that the life without alcohol is inherently worse than one with it in moderation. But the author of the book sees booze everywhere. If you see booze everywhere, you need to look in different places if you want to stay sober.

The thought of “It’s so hard to live life by always having to say ‘no’ to alcohol” is yet another symptom of the disease that needs to be treated, not a sad circumstance facing a recovering alcoholic.

32

Oh certainly, I’m one. My point was that there are social expectations in our culture that are not dead, and even though it is much more acceptable to skip them, they are still there. I don’t regularly go out with the office workers after work. However, occassionally there will be things to celebrate or commisserate and someone will suggest a happy hour. Now I can go along to socialize and then not drink the free beer, or I can skip the bar environment. It’s not a huge social burden, but it is a minor point of social friction.

Agreed, and I think your point is very valid. I was just highlighting that there are some ways that expectations of alcohol show up for even the most uninterested of us. It certainly isn’t a daily occurrence or a minute-by-minute challenge.

True.