By Peter Provet, Ph.D.
Published in Alcoholism & Drug Abuse Weekly, July 31, 2000

A fundamental question has recently resurfaced within the field of addiction: Can alcoholics learn to drink moderately? Audrey Kishline, founder of a group called Moderation Management and one of the earliest and strongest proponents of moderate drinking, recently pledged guilty to vehicular homicide after a binge drinking episode in which she drove the wrong way down a highway and smashed into a car, killing a father and his young daughter.

Her lawyer said that the remorseful Kishline has changed her position on moderate drinking and now plans to write a book that will stress that moderation is not an option for people with serious alcohol problems.

Earlier this month, controversy surrounding the use of moderation management at the Smithers Addiction Treatment and Training Center in New York City resulted in the resignation of center director Alex DeLuca, M.D. DeLuca had stated in a New York magazine article that the center would abandon its abstinence-only approach to treatment in favor of a more flexible model under which some clients would be allowed to drink moderately.

The same day that DeLuca's resignation was announced, the center issued a statement that its officials were reviewing its programs to ensure that they were consistent with the abstinence-based approach, adding that no change from the abstinence approach had ever been approved.

The strongest argument in support of moderate drinking is that for some people, abstinence may be a deterrent to treatment. While motivation to enter treatment is an important variable within the addiction field, the desire to attract substance abusers to treatment must not determine the essential model used in addressing addiction. The abstinence model is the most proven and effective approach in the field today.

This is largely due to the essence of addictive disease. Moderation is simply not in the behavioral vocabulary of the addict. In fact, the principle of moderation represents the antithesis of addiction. The most common feature of all addictions (drugs, alcohol, food, gambling, etc.) is an excessive drive toward the addictive object. The addict can never get enough. Addiction and recovery are all-or-none phenomena.

The following points strengthen the argument that moderate drinking for alcohol abusers is inappropriate:

1. As the biological and genetic underpinnings of addiction are identified, addictive behavior is increasingly understood as a biologically based event where the reinforcement of pleasure for some can be an insatiable drive.
2. Addiction is now widely recognized to have biological, psychological and social causality. Addiction should not simply be regarded as the need for the addictive substance but rather as a complex process fulfilling, however temporarily, an individual's need for pleasure and avoidance of pain. The theory of cross-tolerance posits that if an addict's object of addiction were to disappear, a replacement soon would be found. Thus, the abstinence model calls for abstinence to all mood-altering substances. For example, too many cocaine addicts without histories of alcohol abuse have successfully quit cocaine and become alcoholics after thinking they could drink socially.
3. The argument supporting moderate drinking is based on the premise that it is possible to accurately and consistently diagnose the degree and severity of alcohol abuse. Moderate drinking is then seen as an option for individuals with milder cases of abuse. The problem with this premise is that substance abuse diagnosis is still at a relatively primitive level, complicated by the fact that abusers often have heightened if not sociopathic abilities to convince others of their perspectives and beliefs.
4. Because of the ambivalence, confusion and denial that most addicts bring into early treatment, consistency, certainty and clarity must underlie all treatment approaches. The moderate use of a substance that has been immoderately abused contradicts this fundamental position.
   

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