Are you worried about your patient’s drinking? Do he say he is not an alcoholic and AA is not for him?
Approximately six percent of the Unites States’ population struggles with a severe alcohol use disorder. This group and their loved ones will experience devastating consequences. On the plus side, most traditional treatments and self-help groups are geared for their recovery. However, there is a larger number of the population—over 90 million people— that have a gap in services.
Moderation Management found that they will avoid getting help for fear of being labeled an alcoholic, forced into treatment, made to attend 12-step meetings and have to stop drinking completely. As health care providers, we need find ways to assist this large number of alcohol users who are not experiencing addiction, but may be dealing with a mild or moderate alcohol use disorder.
There is a controversial, emerging treatment option: moderation. Moderation is described as a return from out of control or harmful drinking to consuming within safer drinking guidelines. Moderation has also been called moderate drinking, asymptomatic drinking, controlled drinking or reduced risk drinking.
The Dietary Guidelines for Americans defines moderate alcohol consumption as having up to one drink per day for women and up to two drinks per day for men while the National Institute on Alcohol Abuse & Alcoholism (NIAAA) offers another definition: up to four alcoholic drinks for men and three for women in any single day, according to and a maximum of 14 drinks for men and 7 drinks for women per week.
I have found NIAAA’s guideline to be more risky. Many people start to feel an effect of the alcohol after two drinks and may be intoxicated by four drinks, thus having a harder time sticking within his or her predetermined number of drinks.
A standard drink= 12ounces of beer=5ounces of wine=1.5ounces 80-proof liquor
Based on my 20 years experience of working with people experiencing problems from alcohol use, I developed the “How Do I Know If I Can Keep Drinking Quiz.” The quiz offers predictions for whether someone is a candidate for moderate drinking. It is personalized to the patient’s specific experiences and goals. Certain questions have positive predictions for success while others offer lower chances of success in being able to moderately drink.
The more positive predictors the better, and vice versa. If there are too many negative predictors continuing to drink may be very risky for your client.
Negative predictors for being able to moderate include:
- Daily drinking
- Consuming to deal with emotions
- Drinking alone
- Experiencing mental or physical health problems
- Having legal, probationary or employment conditions
The worst predictor for being able to continue drinking is having withdrawals potentially life threatening withdrawals such as delirium tremens “the shakes,” sweating, increased pulse, hallucinations and seizures. This result almost always means that the body has a physical dependence on alcohol and that the person likely meets Diagnosis and Statistical Manual 5 criteria for a severe alcohol use disorder, placing them into the six percent of the population who is physiologically unable to moderate.
Several predictors that lead to a better chance of being able to drink moderately include:
- Experiencing a period of abstinence to develop and implement coping skills
- Monitoring amount and frequency of drinking and staying within the guidelines listed above
- Consuming when alcohol is part of a celebration and not the main focus
- Delaying first drink until after age 15. One study of over 40,000 adults found that nearly half of the people who began drinking under age 15 met criteria for a severe alcohol use disorder while that percentage dropped to less than 10% if they waited until age 21.
- Having family support. Research shows that the number one predictor for being able to moderately drink is having a support system that can offer perspective, accountability, and motivation.
It is important for clients to have tools to learn how to moderate. They need to understand why they were drinking, why they want to continue and ways to make it safer for them.
We also need to prepare them for how to drink again—something that is very unusual for an addictions specialist to do! Some of my clients have been surprised at how they feel when they begin drinking again. For months, they faithfully tracked their clean days. It was a way to earn back trust from family members and increase their damaged self esteem from the past choices they made in relation to their drinking.
As clients resume alcohol use, clinicians should help watch out for any emerging mental health symptoms, an increase in amount and frequency, the impact of consumption and the intent of drinking. If someone is trying to change their mood, this situation may be a slippery slope back to risky patterns.
Some tools for successful moderation include:
- Learning new ways to relax and have fun without alcohol
- Sipping slowly and enjoy the flavor. If you don’t’ enjoy it- don’t drink it.
- Alternating between an alcoholic and nonalcoholic drinking
- Avoiding “shots”
- Putting money that would have been spent on drinks towards a fun event
A Sample Moderate Drinking Plan is below:
Moderate Drinking Plan
I am choosing to keep drinking because: _____________________________________________________________
I will not drink in these situations: _____________________________________________________________
I will not drink until: ____________________________________________
I will not drink after: ____________________________________________
I will alternate an alcoholic beverage and: _____________________________________________________________
I will have no more than: __________drinks per: _______________________
I will not drink under these conditions: _____________________________________________________________
I will review my plan with: _______________________________________
If I/we notice: _____________________________________________________________
I/we will: ____________________________________________________________
Revise the plan as goals change and lifestyle demands. For example, as someone becomes a parent, his or her consumption patterns are likely to decrease. Parents of pre-teens and adolescents will want to be aware of the messages they are sending regarding alcohol. Obviously if a medical issue arises, the plan will need to be adapted.
A Moderate Drinking Plan is not written in stone. We need to watch out for denial and involve a friend or family member in the moderation process. Once clients have successfully implemented their plan, I often move them into a maintenance phase of therapy. I will see them periodically to monitor progress and watch for relapses in risky patterns.
Moderation Management found that there are four times as many drinkers experiencing problems than people who drink at levels that meet criteria for a severe alcohol use disorder. They also note that nine out of 10 drinkers will not seek help—that’s 90%. There are varying degrees of alcohol use and consequences. Behavioral health care providers need to offer alternatives to the traditional models of alcohol treatment.
While it may seem counterintuitive, by engaging your client in a discussion about moderation as a treatment option, you might actually reduce their risk of becoming an alcoholic.
Cyndi Turner, LCSW, LSATP is the co-founder and clinical director of Insight Into Action Therapy and has been in the addictions field for more than 20 years. She co-developed and facilitates the Dual Diagnosis Recovery Program©, is an expert witness, a clinical supervisor for licensure and provides therapy for players involved in the National Football League Program for Substances of Abuse. Her book “Can I Keep Drinking? How You Can Decide When Enough is Enough” challenges the traditional belief that all drinkers experiencing problems must be alcoholics who need to quit drinking forever. www.canikeepdrinking.com or www.insightactiontherapy.com