Mike Ashton of the Drug and Alcohol Findings Effectiveness Bank serialises the project’s essay on arguably the most controversial issue in addiction treatment: whether dependent drinkers should always aim for abstinence. First instalment asks – why such heat over a seemingly innocuous decision?
Your cholesterol is high and your doctor says, “No butter, no cheese, no cholesterol-raising foods – full stop.” You plead, “Can’t I just cut down and take some tablets?” The doctor is unmoved: “If you want me to help, do as I say, otherwise you are clearly not serious about protecting your health. Come back after you have a heart attack – then maybe you’ll see it my way.”
“…‘treatment’ actually consists of convincing the patient they are atypical and different from normal drinkers, that they are an ‘alcoholic’ to the core”
Not so long ago that was effectively the stance dependent drinkers could expect to face. At issue was not just what patients should be advised, but whether they should be denied treatment until revelation or deterioration impressed on them the need to stop drinking altogether and forever. Moderation tempted, but was seen as merely a steep and slippery slope to excess; abstinence was the only safe ground.
Challenges to this orthodoxy generated the most bitter and prolonged controversy ever seen in substance use treatment. Decades behind us now and with the doors closed on some of the fiercest debates, still the impacts and underlying drivers remain. Far from receding into a box labelled ‘pointless debates’, prioritising abstinence as a treatment objective returned to policy prominence in the UK from 2008 as a component of influential visions of ‘recovery’.
In academia the heat died down somewhat as controlled-drinking objectives accumulated research support, but was stoked again when in 2020 the prestigious vehicle of a Cochrane review was interpreted by its authors as vindicating what in the USA and perhaps too internationally are the main structured routes to abstinence – approaches based on Alcoholics Anonymous’s 12 steps. “Let’s not turn back the clock,” warned a commentary on this interpretation from the lead author of the book Controlled Drinking first published in 1981. Professor Nick Heather was concerned that “an exclusive focus on abstinence in treatment and the use of [Alcoholics Anonymous/12-step facilitation treatment] as the sole means to achieve it, which the Cochrane review … is likely to encourage, ignores decades of progress in broadening and articulating the treatment response to [alcohol use disorder], together with the findings of recent rigorous research, and is therefore retrogressive.”
Why such heat over a seemingly innocuous decision between patient and clinician on which form of remission to go for? And why does it persist, despite evidence that the health benefits of reducing drinking from very high to high levels can be greater than reductions from lesser levels to zero? In part heat was generated by concerns that allowing controlled drinking would let ‘alcoholics’ (presumed unable to stop drinking once they start) off the hook of non-drinking and set them up to fail, perhaps fatally. On the other side was the concern that while insisting on abstinence did nothing to improve outcomes, it did limit treatment to the minority whose problems were so severe they were prepared to countenance a life without drink. Underlying these views were incompatible visions of dependence as a distinct disorder characterised by inevitable loss of control, or one end of a continuum of behaviour which even at its most extreme can be replaced by moderation if the circumstances are sufficiently supportive.
Responding (free source at the time of writing) to a pivotal US report, in 1977 a long-time student of the history and sociology of problem drinking in the USA took us deeper into why its findings on the feasibility of post-treatment controlled drinking were seen as so “dangerous”. Ron Roizen drew a distinction between the truth of a theory and its utility, stressing that mistaken theories may still be thought useful. As promulgated then and now, the “classical” disease theory of alcoholism is a special case of this duality, since “acceptance of that theory is itself the essence of alcoholism treatment” – ‘treatment’ actually consists of convincing the patient they are atypical and different from normal drinkers, that they are an ‘alcoholic’ to the core and for ever, constitutionally unable to touch a drop without descending into a destructive bender. From this perspective, “ ‘abstinence’ is not solely a measure of the patient’s improvement, but a sacred and essential element in the ‘treatment’ process … a sign that the model of alcoholism has been accepted by the patient”.
Recognising that enables us to understand visceral reactions to challenges to an abstinence-based understanding of recovery. The perceived utility of the theory as a treatment tool capable of rescuing the otherwise un-rescuable holds only insofar as “therapists can present the theory honestly and openly without fear of contradiction … Without the ability … to create a genuine conviction in the classical disease concept of alcoholism, the theory, its treatment implications, and its authority and legitimacy dissolve.” From this point of view, “an attack on the abstinence criterion is an attack on the classical disease concept of alcoholism … And undercutting that truth is only done at great peril because the embracing of that truth proves to be the most successful treatment known for the condition.”
But ‘undercut’ it was; how, and what the reaction was, is the story told in this series. It began in earnest in the early 1960s in south London with the first research-driven crack in the abstinence consensus, later to become a gaping wound in the USA. We will re-examine the major milestones along this journey, distinguished by the bitterest conflicts ever to mar scientific discourse on addiction treatment. So many commentaries and studies have been devoted to the issue that this contribution cannot claim to be comprehensive: see the documents recommended in the “Further reading” panel to fill in the gaps.
Contact Mike Ashton here.
Further reading
For more information see this detailed and freely available US account from Ron Roizen. It dealt more than adequately with the history of the controversy, but was unable to fully take on board later developments arising from early British findings. A much cited book offers a British perspective on the debate (turn to chapter four) and the evidence. On the evidence, see also this Effectiveness Bank analysis of a recent UK study (the background notes are particularly informative) and this review.
Next episode: “A gentlemanly start.” The first telling crack in the abstinence-only consensus opens in 1960s London. Full essay available on the Effectiveness Bank
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