Commentary on Henssler <i>et al</i>.: The public health case for promoting and valuing drinking reductions in the treatment of alcohol use disorder

Abstract

Drinking reductions short of abstinence are achievable, sustainable and associated with improvements in how some individuals with alcohol use disorder (AUD) feel and function. The public health burden of AUD could be lessened if drinking reductions were more widely accepted and promoted as a treatment goal in addition to abstinence. Sustained abstinence from alcohol has been the primary target in the treatment of alcohol use disorder (AUD) for the past century. More than 40 years ago, research showing the possibility of controlled drinking outcomes among some individuals with AUD was swiftly condemned and criticized [1]. Despite pushback from the alcohol field during ‘the controlled drinking controversy’ [1], a few research groups continued to examine controlled (i.e. moderate or low-risk) drinking as a potential treatment goal and outcome. This body of work comprises a limited number of randomized clinical trials and a larger number of non-randomized treatment evaluations that compared non-abstinent and abstinence-based treatment strategies, including a subset of studies that allowed patients to choose their drinking goals and provided goal-specific interventions. The recent systematic review and meta-analysis by Henssler and colleagues [2] examined this research using modern review methods and replicated earlier reviews [3] that provided compelling evidence that controlled drinking is possible, even among some individuals with severe AUD. Moreover, for the first time, Henssler and colleagues [2] rigorously showed that treatments focused on abstinence goals did not significantly differ from treatments that allowed controlled drinking with respect to patient psychosocial functioning and successful maintenance of drinking reductions. These meta-analysis and meta-regression [2] findings are aligned with other recent empirical research showing that drinking reductions, short of complete abstinence from alcohol, are achievable, sustainable and associated with improvements in how individuals with AUD feel and function for several years or more after treatment [4-6]. These results provide further support for considering non-abstinent recovery from AUD as a potential treatment target that could expand the scope and reach of AUD treatment in the population with problems [7, 8]. They are also consistent with drinking reductions and positive functional outcomes achieved by the majority of the population with alcohol-related problems who recover on their own outside of the context of formal treatment (‘natural recovery’) [9-11]. Based on this research, we argue that expanding the reach of treatment and research to include non-abstinent drinking reductions as a treatment target could substantially lessen the public health burden of AUD. Expanding treatment targets to include non-abstinent drinking reductions could have a large salutary effect in promoting treatment-seeking among people with AUD and subclinical drinking-related problems [12]. The gap between alcohol treatment need and utilization is large and chronic, with only approximately 14% of affected people seeking care [13]. A large nationally representative survey of the US population showed that the majority of individuals with AUD reported not seeking AUD treatment because they were not ready to stop drinking [14]. Further, the majority of those who sought treatment in recent clinical trials have not expressed an interest in abstinence-based goals [15]. Thus, the common public view that abstinence is required as part of treatment is a significant barrier to treatment-seeking and one that contributes to the shame and stigma associated with AUD treatment [16]. Maintaining an exclusive treatment goal of abstinence in a society that condones and encourages drinking alcohol perpetuates a binary model of AUD that is not conducive to alcohol problem recognition or treatment-seeking [17]. For instance, a binary model (whereby AUD only applies to those perceived as ‘alcoholics’) allows the majority of those with AUD to view their drinking as not sufficiently serious to require treatment in contrast to stereotypes of the ‘alcoholic other’ [17]. Alternative non-binary AUD models that view drinking problems along a continuum ranging from lower to higher risk appear to offer important benefits for increasing problem recognition and help-seeking and reducing stigma [17-19]. Increasing scientific, professional and public perceptions of the possibility of non-abstinent recovery from AUD is relevant to broader population health and promoting and valuing reduced drinking goals is likely to have significant public health benefits. The work of Henssler and colleagues [2] sheds new light on an old controversy [1] and provides additional evidence using rigorous reviewing methods that controlled drinking outcomes can be achieved, and are associated with improvements in functioning among individuals with AUD. Consistent with a public health approach to targeting drinking reductions, future research should continue to develop and evaluate treatments that are geared toward drinking reduction goals and examine whether broadening the scope of recovery and treatment research and practice to include drinking reduction goals may engage more individuals with AUD in treatment. The reality is that this important topic has received minimal empirical attention in the 21st century in the aftermath of the controlled drinking controversy, yet it persists as a central issue in expanding services for AUD and improving population health by reducing drinking-related harms. None. Preparation of this manuscript was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (R01 AA022328). Katie Witkiewitz: Conceptualization. James Morris: Conceptualization. Jalie Tucker: Conceptualization.

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