Can reduced drinking be a viable goal for alcohol dependent patients?
Authors: Karl Mann, Henri‐Jean Aubin, Katrin Charlet, Katie Witkiewitz
Journal: World Psychiatry (2017)

Abstinence from any alcohol remains the safest treatment option for individuals with alcohol dependence, and the one associated with the best long-term outcomes. However, many individuals with alcohol use disorders, including severe alcohol dependence, do not wish to seek treatment because they are unwilling or feel unable to engage in abstinence1. Thus, allowing for alternative treatment options that offer drinking reduction goals is an important step to decrease the treatment gap associated with alcohol use disorder. People in treatment are likely to change their drinking goals a number of times. Acceptance of a patient's drinking goal in a client-centered approach usually helps create a stronger therapeutic alliance, and patients who initially select a moderation goal might ultimately transition to abstinence2. Controlled studies testing this alternative approach have shown sustained drinking reductions for many patients following behavioral treatments and pharmacotherapy3, 4. With reduced drinking, long-term improvements have been reported regarding mortality rates, incidence of alcohol-associated injuries and accidents, levels of mood symptoms, quality of life, social functioning, along with significant weight reduction, a normalization of systolic and diastolic blood pressure, slowed progression of alcohol-attributable liver fibrosis, and recovery of ventricular heart function5. Treatment guidelines and the guidance papers of European and US authorities have taken note of these research findings and accept "intermediate harm reduction" (European Medicines Agency, EMA) or "low-risk drinking limits" (US Food and Drug Administration, FDA) as indicators of treatment success. The FDA recommends a low risk drinking outcome of no heavy drinking days (where a heavy drinking day is defined as more than 70 g of alcohol for men and more than 56 g of alcohol for women). The EMA allows several harm reduction goals, including change from baseline in mean daily consumption of alcohol and reduction in number of heavy drinking days (where a heavy drinking day is defined as more than 60 g of alcohol for men and 40 g of alcohol for women). The EMA also provides examples of the levels of reduction that could indicate a positive treatment response, including a 50%, 70% or 90% decrease in mean daily alcohol consumption or a significant categorical shift in World Health Organization (WHO)'s risk levels of drinking. Recently, the clinical value of a shift in WHO risk levels of drinking with respect to improvement in functional outcomes has been validated in a clinical sample6 and a population-based sample7 of drinkers. Specifically, results indicated that even a one level shift in WHO risk levels – e.g., reduction from very high risk (61+/101+ g per day for women/men) to high risk (41 to 60/61 to 100 g of alcohol per day for women/men) – resulted in clinically meaningful decreases in drinking consequences and improvements in mental health. Based on this compelling scientific evidence4-7, there is growing recognition that harm reduction outcomes including reduced alcohol consumption need to be considered in addition to abstinence for defining treatment success, even among alcohol dependent patients. However, at the level of individual patients, potential limitations need to be acknowledged. The harm reduction approach may deter severely affected individuals from the difficult path towards abstinence. Even among those who accept reduced drinking as a viable treatment option, there is consensus that non-abstinence goals are less appropriate for some patients, particularly those at the severe end of the alcohol dependence continuum and pregnant/nursing women. In conclusion, a wider acceptance of reduced alcohol consumption as a goal for dependent patients holds the potential to increase the appeal of seeking help for many of these underdiagnosed and undertreated individuals. Consequently, treatment demands could increase considerably and require additional professional involvement. This calls for a more active role of psychiatrists in counseling, monitoring and treating patients in this sensitive area of mental health care. Karl Mann1, Henri-Jean Aubin2,3, Katrin Charlet4, Katie Witkiewitz5 1Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany; 2Université Paris-Saclay, INSERM, Villejuif, France; 3Hôpitaux Universitaires Paris-Sud, Villejuif, France; 4Department of Psychiatry and Psychotherapy, Charité-Universitätsmedizin, Berlin, Germany; 5University of New Mexico, Albuquerque, NM, USA