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Can alcoholics just say 'stop'?
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I have a dear friend who’s an alcoholic. When he came out of treatment, I told him I couldn’t see why he wasn’t able to condition himself to have, say, a single glass of beer and stop at that. He said it didn’t work that way, but never got specific. Why can’t an alcoholic learn to drink in moderation?

—Name withheld

Because alcoholics, by definition, are incapable of drinking in moderation. Sorry if that seems like a kiss-off answer, but research and experience tell us that’s how it is.

Alcoholism is no trivial problem. The estimated 75 million or more alcoholics worldwide cost society from 1 to 5 percent of its gross domestic product. In Russia, where the problem is especially acute, male life expectancy is only 60 years, 15 years less than for U.S. men, largely due to alcohol abuse.

The question of how to control heavy drinking — abstinence or moderation — has been surprisingly controversial for something like 60 years. I say surprising because the basic facts have never been in dispute.

The dominant school of thought favors abstinence, arguing that alcoholics are too fragile ever to resist temptation and that a single drink can trigger a binge. Alcoholics Anonymous, founded in 1935 and at something like 2.1 million members the largest alcoholism support and treatment organization in the world, is a strong proponent of abstinence.

Abstinence has an impressive success rate, researchers have found. But some say it’s not the only way.

Investigation into alternative approaches was kicked off by a study of 97 English heavy drinkers in the 1950s, who were tracked for several years and generally found to be able to control their alcohol consumption without abstinence. In 1978 a Rand Corporation followup of U.S. heavy drinkers who’d received abstinence treatment found that 18 months later 22 percent could drink in moderation without problems, and after four years 18 percent were still doing so. Other work in the 1970s found that some with seemingly severe alcohol issues could be successfully trained to drink moderately.

An approach that became a lightning rod in the 1990s was Moderation Management, a nine-step self-help program. “Prominent figures in the treatment and research communities denounced MM as a ‘dangerous temptation to alcoholics’ that was ‘built on the illusion’ that alcoholics could return to controlled drinking,” writes Stanford addiction researcher Keith Humphreys in a 2003 review of the program’s effectiveness.

But he points out the MM and AA crowds don’t fundamentally disagree. MM participants are told initially to abstain from drinking for 30 days, then switch to moderate consumption. If moderation fails, then a return to abstinence is recommended.

The implication is that some heavy drinkers can control their habit and some can’t.

AA, he notes, says the same thing.

Research supports a two-pronged approach, finding that the most out-of-control drinkers generally get better results with abstinence, while those with less severe drinking issues often do OK with moderation.

So what’s the dispute about? A key element in AA theory is alcoholics’ capacity for denial, and its advocates see only the potential for tragedy in a system that lets drinkers decide they’re capable of drinking on occasion.

About 15 percent of MM members, Humphreys reports, had major alcohol problems—“shaking when not intoxicated, delirium tremens, blackouts, convulsions or fits after drinking, and cravings for alcohol upon waking,” plus alcohol-related job issues. These people, he says, fit the profile for alcoholism—they just don’t admit it.

Thus your friend’s response. You don’t say whether he was in AA, but the first of the 12 steps is to acknowledge you’re powerless over alcohol. The research suggests no one arrives at this stark conclusion unless it’s true.