Why Moderation?

Rationale for Moderation Strategies

Most people with alcohol problems are not alcoholics The more severe a person’s alcohol/drug problem, the

better it conforms to the disease model Most people with alcohol problems are not in treatment There are FOUR times as many problem drinkers as

alcoholics in the U.S. (NIAAA & IOM studies) For every alcoholic, there are 3 problem drinkers at risk for

developing more serious problems

Rationale for Moderation Strategies

Majority of problem drinkers are not in treatment One size does not fit all, no approach is best for everyone Population of problem drinkers is highly diverse:

Severity of alcohol use & its consequences Nature and severity of co-occurring disorders Motivation and stage of readiness for change Desired treatment goals

Rationale for Moderation Strategies

Research shows that moderation is a realistic and achievable goal for many drinkers, especially non-dependent drinkers with less severe problems

Progression to more severe drinking problems is NOT inevitable for all problem drinkers

Traditional treatment providers often fail differentiate alcohol ABUSE from alcohol DEPENDENCE (Clients reporting less severe drinking problems are typically viewed as either alcoholics in denial and/or alcoholics in the making)

Rationale for Moderation Strategies

There are FOUR TIMES as many problem drinkers as alcoholics in the U.S.; i.e, for every alcoholic there are at least three problem drinkers at risk for developing more serious alcohol-related health problems (NIAAA & IOM studies of primary care patients)

Moderation is a realistic and achievable goal for many drinkers, especially nondependent drinkers with less severe problems

IOM suggested that treatment should be expanded to offer options better suited to the needs of nondependent problem drinkers

to reduce or eliminate a person’s alcohol consumption and prevent further alcohol-related consequences.

To create programs aimed at people on the less acute, less severe end of the alcohol problem spectrum

Rationale for Moderation Strategies

Unfortunately, appropriate alternatives for nondependent drinkers remain hard to find in the U.S., although more widely available in other developed countries (e.g., Europe, Australia, etc)

At least 95% of treatment programs in U.S. are based on an abstinence-only disease model

Many if not most people who seek professional help for a drinking problem do not want to stop drinking completely or forever and are unwilling to adopt identity of “alcoholic”

Lifelong abstinence is not their goal

Rationale for Moderation Strategies

At least 95% of treatment programs in the U.S. are based exclusively on an abstinence-only disease model

But many if not most people who seek help for a drinking problem do not want to stop drinking completely (or forever) and are unreceptive to seeing their problem as a “disease” or themselves as “alcoholics”

Permanent abstinence and adopting an AA-oriented lifestyle is simply not their goal

Regrettably, countless people with less severe alcohol problems stay away from treatment due to the absence of more attractive and appropriate alternatives

Rationale for Moderation Strategies

Countless people with less severe alcohol problems categorically avoid seeking/entering treatment not seeing themselves as needing or wanting what traditional abstinence-based disease model treatment offers/requires

Lacking attractive treatment alternatives, many drinkers avoid getting help while their alcohol problem and its consequences continue to get worse

Current treatment system geared mainly toward treat people with more severe problems (i.e, dependence rather than abuse)

Clients with less severe and earlier-stage problems are likely to be seen as resistant, unmotivated, and in denial

Rationale for Moderation Strategies

Many drinkers: Do not want to stop drinking completely and/or

permanently Lifelong abstinence is not their goal Do not see their problem as a disease Reject the identity of “addict-alcoholic” Perceive their problem as not severe enough to

warrant what traditional treatment requires

Rationale for Moderation Strategies

IOM has suggested that alcohol treatment should be expanded to offer options better suited to the needs of nondependent problem drinkers

These options should aim to reduce or eliminate an individual’s alcohol consumption so as to prevent further alcohol-related consequences

IOM called for creation of programs at at people on the less acute, less severe end of the alcohol problem spectrum

Unfortunately, appropriate alternatives for problem drinkers remain hard to find in the U.S., although more widely available elsewhere (e.g., Europe, Australia)

Rationale for Moderation Strategies

Providing flexible alternatives to abstinence-only can attract many more people with drinking problems into treatment before they develop more serious problems

Moderation is a realistic and achievable goal for many people with less severe drinking problems who are not alcoholics

Many who start with moderation, end up choosing abstinence, including many who would not have entered treatment at all

Non-Abstinence Goals: Rationale

Although abstinence is the safest course, it is far better to engage people in a process of incremental change than to turn them away until they “hit bottom” or cause more harm to self and others

Clinicians can encourage abstinence without making it a pre-condition of providing treatment

A professionally guided attempt at moderation is often the best way for clients to learn through their own experience whether moderation is a realistic goal.

Those unable to succeed at moderation often become more motivated to abstain

Principles of Integrative Approach

Non-dogmatic, client-centered, atheoretical approach

Avoids adherence to any single treatment orientation or philosophy in favor of doing “what works”

Utilizes a toolbox of different treatment models, approaches, strategies, and interventions some of which may seem incompatible

Do “what works” Above all, do no harm!

Rationale for Moderation Strategies

Empirically-supported treatment approach Research studies conducted in universities and medical schools in 12

different countries from 1970s to present Actively supported and advocated by NIAAA Sensationalized accusations of faulty research methods turned out to

be unfounded, after careful scientific review The fact that the founder of MM (Audrey Kishline) was involved in a

fatal DWI-related car accident says nothing about moderation strategies.

Reportedly, at the time of the accident she was involved in AA attempting to remain abstinent

Alcohol’s Effects

“Standard Drink” Each contains approximately 14g of pure ethyl alcohol

12 ounces BEER

5 ounces WINE

1.5 ounces LIQUOR

= =

Common Drinks

Cocktails (mixed drinks) usually contain 2-3 standard drinks depending on how they are made

Bottle of table wine (750 ml) holds about 5 standard drinks

“Fifth” of liquor (750 ml) contains 17 standard drinks

Champagne intoxicates more quickly!

Carbonation accelerates absorption of alcohol into the bloodstream and brain

BAC Levels & Alcohol Effects for Drinkers Without Significant Tolerance

0.02% Begin to feel some effect

0.04% Begin to feel relaxed

0.06% Judgment somewhat impaired

0.08% Definitive impairment of coordination and driving skills

0.10% Marked deterioration of coordination and reaction time

0.15% Obviously impaired balance and movement; risk of blackouts, passing out, & accidents increase markedly

0.30% Loss of consciousness, profound CNS depression, risk of death

Possible Mechanisms: Women have lower total body water content which

results in higher concentrations of alcohol in the blood Women have decreased levels of alcohol

dehydrogenase in their gastric mucosa which causes 30% more alcohol to be absorbed into the blood

Gonadal hormone levels during the menstrual cycle may affect the rate of alcohol metabolism, increasing vulnerability to physiological consequences of drinking

Women become intoxicated on less alcohol than men

Achieving Legal Intoxication Limits: Women vs. Men

In women, it takes 3-4 standard drinks over 1-2 hours to produce a BAC of 0.08 mg%

In men, it takes 5-6 standard drinks over 1-2 hours to achieve a BAC of 0.08 mg%

APPROXIMATE BLOOD ALCOHOL PERCENTAGE

BODY WEIGHT IN POUNDS (MEN) EFFECT ON PERSON

  DRINKS per Hour

100 120 140 160 180 200 220 240  

0 .00 .00 .00 .00 .00 .00 .00 .00ONLY SAFE

DRIVING LIMIT

1 .04 .03 .03 .02 .02 .02 .02 .02IMPAIRMENT

BEGINS.

2 .08 .06 .05 .05 .04 .04 .03 .03

3 .11 .09 .08 .07 .06 .06 .05 .05DRIVING SKILLS

SIGNIFICANTLY

AFFECTED. POSSIBLE CRIMINAL

PENALTIES

4 .15 .12 .11 .09 .08 .08 .07 .06

5 .19 .16 .13 .12 .11 .09 .09 .08

6 .23 .19 .16 .14 .13 .11 .10 .09

7 .26 .22 .19 .16 .15 .13 .12 .11

LEGALLY INTOXICATE

D. CRIMINAL

PENALTIES IMPOSED.

8 .30 .25 .21 .19 .17 .15 .14 .13

9 .34 .28 .24 .21 .19 .17 .15 .14

10 .38 .31 .27 .23 .21 .19 .17 .16

APPROXIMATE BLOOD ALCOHOL PERCENTAGE

BODY WEIGHT IN POUNDS (WOMEN) EFFECT ON PERSON

 Drinks per Hr

90 100 120 140 160 180 200 220 240  

0 .00 .00 .00 .00 .00 .00 .00 .00 .00ONLY SAFE

DRIVING LIMIT

1 .05 .05 .04 .03 .03 .03 .02 .02 .02 IMPAIRMENT BEGINS.

2 .10 .09 .08 .07 .06 .05 .05 .04 .04DRIVING SKILLS

SIGNIFICANTLY

AFFECTED. POSSIBLE CRIMINAL

PENALTIES

3 .15 .14 .11 .10 .09 .08 .07 .06 .06

4 .20 .18 .15 .13 .11 .10 .09 .08 .08

5 .25 .23 .19 .16 .14 .13 .11 .10 .09

6 .30 .27 .23 .19 .17 .15 .14 .12 .11

LEGALLY INTOXICAT

ED. CRIMINAL

PENALTIES IMPOSED.

7 .35 .32 .27 .23 .20 .18 .16 .14 .13

8 .40 .36 .30 .26 .23 .20 .18 .17 .15

9 .45 .41 .34 .29 .26 .23 .20 .19 .17

10 .51 .45 .38 .32 .28 .25 .23 .21 .19

Blood Alcohol Concentration (BAC)