Wednesday, October 13, 2010

Abstinence versus Controlled Drinking

Dr. K.F. Mann, Professor and Chair of Addiction Medicine, Heidelberg University, Germany, at the 12th Annual International Society of Addiction Medicine conference, Milan, Italy, 2010, presented on Abstinence versus Controlled Drinking. It was a most informative and enlightened presentation by a brilliant researcher and teacher.
He looked at the types of evidence available to study this question. He reported on the studies of the stability of drinking patterns outcomes in 5, 10 and 16 year follow up studies. These clearly showed that those abstinent after five years were most likely to be abstinent at 10 and 16 years. The other groups were separated into improved and unimproved. The unimproved showed stable unimprovement. At first the 10 year follow up of the 'improved' had shown what appeared to be good results however continued follow up showed that half of these were dead a few years later. This pointed indeed to the benefits associated with abstinence.
PROJECT MATCH study showed that those who sought abstinence were mostly likely to achieve abstinence and if they didn't were most likely to have improvement. In contrast those who thought only to "control" their drinking didn't have as good outcomes.
The UKATT study he quoted was most interesting in that it showed clearly that 1 pound spent on prevention and treatment resulted in 5-6 pounds of financial savings.
PREDICT Study (Mann et al, 2009) showed that people who believed and aimed for abstinence had better outcomes with the use of Naltrexone.
The NESARC study was interesting in that it did show that a large group of people with alcohol problems but not alcohol dependence could get out of their alcohol problems without the need of professional help.
Dr. Mann discussed the Sobell & Sobell study of 1976 that had caused such confusion and misinterpretation. It was a controlled drinking study but what it really showed was that those who were going for abstinence did better.
The Current Standard of Knowledge therefore was that
1. Severely dependent persons show go for abstinence
2. There are those who are low risk drinkers who may be treated differently. This is the conclusion of Sobell in Paris in 2010
The DSMV aims to help such people where the main role is for moderation goals.
Dr. Mann said that one of the major problems surrounded the term "controlled drinking". The WHO has long identified three distinct categories. High Risk, Moderate Risk and Low Risk. It is clear from the research that the High Risk need to be separated from the Low Risk. The Severely addicted are a distinctly different population from the less severely affected. This distinction is significant because each of the different categories can be shown to have distinctly different presentation in regards to risk and influence of drug and alcohol abuse on such diseases as cancer and heart disease.
The European Medicine Agency recognizes that there is a need for Full Abstinence in addiction and that Intermediate harm reduction may be a goal towards that.
Not surprisingly patients preference on first visit separates into 54% wanting abstinence and 46% wanting non abstinence. Those wanting abstinence are mostly female, unemployed and have more alcohol related problems.
Dr. Mann reported that while there was wide exceptance of 'controlled drinking' throughout European care givers it was interesting how this divided. More psychologists than physicians favored 'controlled drinking'. Psychiatrists versus physical doctors had the greatest acceptance of 'controlled' drinking. Acceptance of controlled drinking was greatest in inpatient versus outpatient care givers.
Patient characteristics that influenced the choice of controlled drinking versus abstinence were a) that it was the patient choice b) there was an absence of previous relapses c) the patient had significant social stability d) there was low severity of dependence.
Most importantly, Dr. Mann said that 'controlled drinking' could be seen as a 'stage' towards abstinence. This was most beneficial in Motivational Interviewing where controlled drinking could be a first choice which was great if it worked but if it didn't then the therapist was in a strong position to say, 'well we tried it that way, now what about trying it this way."
Dr. Mann reported that he had changed his own opinions over his years of practice based on reflecting on the evidence of research, seeing that there was a need as with other disease categories to offers options to patients, and consider at what stage a person's disease was by careful assessment.

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