A SOBER LOOK AT PROBLEM DRINKING

WASHINGTON -- Can people who drink too much be taught to control their
alcohol consumption?

Unthinkable, say mainstream treatment organizations like the Betty Ford
Center and Hazelden, which have long insisted on total abstinence.

Now criticism of an approach that allows for some controlled drinking has
flared again. In Washington state last week, a leading proponent of this
option, Audrey Kishline, pled guilty to killing two people while driving
drunk. She is the founder of Moderation Management, set up in 1993 as an
alternative to the abstinence-only Alcoholics Anonymous. Then Alex DeLuca,
the director of the respected Smithers Addiction Treatment and Research
Center in New York City, resigned after failing to persuade his clinic to
offer some alternative to total abstinence.

But DeLuca is right. Some problem drinkers might be trained to control
their intake. The difficulty is in figuring out which ones.

The working definition of heavy drinker, according the government's
National Household Survey, is consuming five or more drinks on a single
occasion, five or more times within a month. This kind of consumption,
heavy as it is, doesn't make someone an alcoholic. A heavy drinker could be
a college student who drinks to the point of getting sick on Saturday
nights, but keeps up with his grades and football practice. Or an employee
who drinks a bottle of wine alone at night, but never misses a deadline.

Call these people "problem drinkers" -- but not alcoholics. It is possible,
but far from guaranteed, that they will become full-blown alcoholics,
drinking compulsively despite serious consequences like deteriorating job
performance and withdrawal symptoms.

The distinction between the problem drinker and the alcoholic, while not
razor sharp, exists -- but hard-core opponents of the drinking in
moderation policy don't want to acknowledge it. To them, you are either an
alcoholic or not. Virtually no treatment program will accept a patient who
rejects abstinence as a goal. And counsellors tend to engage in
double-think: if the patient says he's an alcoholic, he is; if he refuses
to admit he has a problem, he's an alcoholic "in denial" and headed toward
the gutter.

But there are data that contradict this view. The Handbook of Alcoholism
Treatment Approaches, a textbook for clinicians, provides evidence that
some problem drinkers can successfully control their consumption.
Admittedly, this approach only works when the risks are relatively low. If
an individual has crossed the line, admittedly fuzzy, into alcoholism, then
the risks of of allowing someone to have an occasional drink or two become
too high.

The warning signs that the line has been crossed are a history of domestic
violence, suicide attempts, missed work, neglected children -- an
"unmanageable" life in the words of Alcoholics Anonymous. Kishline must
have known that the risks for her were too high because she had quit
Moderation Management and joined Alcoholics Anonymous earlier this year,
several months before the fatal accident.

Opponents of controlled drinking are afraid that some people will use
Moderation Management as an excuse to drink. But the majority of problem
drinkers, let alone alcoholics, have already rejected abstinence. Surveys
from Alcoholics Anonymous indicate that its annual dropout rates average
somewhere around 75 per cent.

True, some doctors worry that sober recovering alcoholics will come to
think that moderate drinking is OK and try it again. The task for the
therapist is to have the patient think hard about why he wants to sabotage
so much. Some drinkers will always hope that they can one day enjoy alcohol
minus the devastation, but the chances for relapse are reduced if we are
adamant that controlled drinking is not an option for everybody.

Moreover, intolerance of moderate drinking also has a price.

"If some problem drinkers are told by treatment professionals that their
choice is abstinence or no treatment, they will take nothing and the
opportunity to help is lost," says Jon Morgenstern, director of alcohol
treatment research at the Mount Sinai School of Medicine in New York City.

So, the choice is rather stark. Admit that some problem drinkers aren't
alcoholics, and help them learn how to drink moderately. Or insist on
abstinence for those with even mild drinking problems -- and drive millions
of people who need help away from treatment.

Note: Sally L. Satel is a psychiatrist with Yale who works in a methadone
clinic in Washington. She is the author of the forthcoming PC M.D.