Alcohol Harm Reduction: A World of Growing Possibilities

August 17, 2020

In her early professional life, Louise liked to unwind with wine. She loved the way it looked in a glass; its pleasant flavors; the way it helped complete meals. But she also loved what it did: the way it seemed to coat the inside of her veins with wintergreen; how quickly it shut off anxious thoughts; the way it drew laughter to the surface.

In her early 30s, Louise’s wine consumption accelerated. Drinking, as a young woman in New York, was part of the normal dating scene. Sometimes she secretly worried about the increasing frequency of the days she woke up with a pounding headache and a foggy brain. She could always explain it away—everybody around her seemed to be drinking the same way.

One Monday, though, she opened her eyes and felt sheer panic as she tried to piece together the events of the day and night before. She recalled the Sunday bridal bunch, the copious amounts of rosé she and her friends had downed. But Louise hadn’t stopped at that. She’d come home—and kept on drinking. She looked around her bedroom, trying to remember. How much? she wondered. And: Why?

She dialed her therapist for an emergency appointment, and was grateful that she could fit her in. Sitting across from her a few hours later, that relief evaporated.

Her shrink was unequivocal. Louise needed to quit drinking, and the only way to do it was with the help of Alcoholics Anonymous.

Louise went to a few meetings—and hated every minute of them. In her work as an executive at international nonprofit organizations, she’d spent years poring over research data about effective public health programs. She was incredulous. Her educated therapist had steered her toward an 85-year-old support group espousing a single faith-and-abstinence prescription for everyone—and it utterly lacked scientific rigor. Louise was appalled. She couldn’t tolerate the tenor of “the rooms”—the dramatic confessionals; the black-and-white thinking; the aphorisms; and, especially as a woman, the insistence that she was “powerless.”

“The 12-step world,” Louise said, “did not work for me. I kept asking myself, ‘What is this?’ None of it made sense.”

A growing body of evidence suggests that recovery can include reducing drinking—and that myriad therapy methods and drugs can help.

Despite AA’s roots in an evangelical temperance movement, many therapists, hospitals and rehab centers continue to use the 12 Steps as the blueprint for their treatment plans. But there is a growing acceptance that the program’s yardstick—abstinence as the only measure of success—suits only a small fraction of the people who try it.

Indeed, a growing body of evidence suggests that recovery can include reducing drinking—and that myriad therapy methods and drugs, proven by research, can help people learn to modify their drinking behaviors.

An estimated 14.5 million Americans have alcohol use disorder, and about one in four is a binge drinker. Louise didn’t like that she was among them, but didn’t believe in the lifelong “addict” label ascribed by AA. There had to be another way, she thought—something rooted in evidence.

So she Googled evidence-based recovery alternatives, and found a group of therapists at New York’s Center for Optimal Living whose treatment methods centered on harm reduction. Harm reduction approaches help people make lifestyle changes that reduce the negative consequences of their consumption of drugs, without necessarily quitting.

And for the last couple of years, that’s exactly what Louise has done with her therapist there, psychologist Jenifer Talley, paying attention to the factors that make her want to overdrink.

Like many therapists who specialize in harm reduction, Talley employs a suite of techniques, including motivational enhancement, an evidence-based, goal-oriented form of counseling that recognizes, and incorporates, a drinker’s ambivalence about their use. It has been found in many studies to help to reduce consumption. She also uses cognitive behavioral therapy as well as mindfulness techniques.

“With each person we serve, we let them be in the driver’s seat of their own change process,” said Talley. “We help our clients ask what function these substances serve, and how do we want to reframe their function as we go forward with strategies to help them slow down and think about their urges.” She suggests a technique she calls “urge surfing”—one Louise, now 40, has found helpful.

When the desire to drink arises, Talley urges her clients to understand its origin. “Take a breath, ask, ‘What is this urge telling me? What information does it contain? Am I anxious? Lonely? Bored?” That pause helps the client ride out the intensity of the craving. With practice, the pause can help reduce the urge—or at least the desire to act on it right away.

Over time, Louise has learned to be mindful about her drinking. She meditates daily, builds in time to run every day, and has switched from drinking wine to beer. It’s more filling, has less alcohol, and is easier to count, she says—a technique she uses to hold herself accountable. There are times when she still overdoes it—during the pandemic, she suffered two major losses—a miscarriage and a layoff. But the skills she’s learned helped her regroup back to control.

Mo, who like Louise asked that his middle name be used to maintain his privacy, also rejected the 12-step approach—one he tried, unsuccessfully, for 10 years. A gay immigrant of Indian origin, he suffered anxiety and depression after coming out in his conservative community when he was in his late 20s. For years, he tried to mask those feelings with frequent binges, so heavily that he wound up at a Michigan rehab that was centered around AA.

In rehab, everybody got the same message, no matter what circumstances had led them there. Regardless of whether someone had been ruined financially, was traumatized by sexual violence or, like Mo, was struggling with their identity, the message was the same for everybody. Don’t ever drink. Because if you do, you’ll end up in jail, on the street, or dead.

“Deep down, I never believed it, never felt a part of that subculture,” said Mo, who is 40 and now lives in a Pacific Northwest city. “Their message was, ‘You’re powerless, and you’re headed in one direction: straight to the bottom.'”

The logic didn’t add up. If Mo was completely powerless, he reasoned, he’d never bounce back from his binges. And he always did—enough to succeed at work as a manufacturing entrepreneur; enough to have fulfilling friendships; enough to run 11 marathons in three years.

“I was amazed,” he said. “I drank. But I stopped. And nothing happened.”

In 2018, Mo began employing evidence-based online peer support he found with the online group HAMS (Harm Reduction, Abstinence, and Moderation Support). He read their guidelines and began abstaining, with frequent online check-ins with other members. He also began filling his time with activities—activities he couldn’t possibly do while drunk.

For the past two years, he’s felt great. He writes regularly in a journal and works on a novel; reads a great deal; cooks; trains for marathons; and attends a church that mixes science with spirituality.

A few months ago, though, he was alone on a business trip, and felt the urge to drink.

He walked into a bar and downed a couple of alcohol-free beers. Then, with dinner, he ordered some beer with alcohol. He sat back, registering the pleasant sensations he felt, the levity that followed the bitter taste he enjoyed. He had a nice time with some fellow bar mates, did a couple of shots—and then went back to his hotel in an Uber.

When he woke up, Mo looked around the hotel room, astonished. He washed his face, brushed his teeth, recalling all the events from the night before. After years of being told that one drink would lead to a life-ending binge, he had no urge to drink more. He just wanted to get on with his day, and finish the work he set out to do on his trip. “I was amazed,” he said. “I drank. But I stopped. And nothing happened.”


Naltrexone and Baclofen

Like Louise and Mo, most people who want to change their drinking behaviors don’t want to abstain.

“When people come through the door, nobody wants to quit,” said Mark Willenbring, an addiction psychiatrist in St. Paul who runs a clinic named Alltyr. “Their main goal is to get rid of the negative social, physical and emotional consequences from drinking. But that’s not going to be possible for everybody.”

Like many addiction professionals conducting evidence-based work, Willenbring collaborates with his clients on their goals. But he cautions that those with severe alcohol use disorder might not be the best candidates to attempt moderation. In the Diagnostic and Statistical Manual-5, the most recent edition of the American Psychiatric Association’s handbook, the language regarding alcohol use shifted to include a spectrum of drinking problems, from mild to moderate to severe. People who answer yes to six or more of 11 questions about their consumption have a severe form of the disorder, and probably should consider abstaining, Willenbring said.

Willenbring treats many patients with the opioid antagonist naltrexone, which for decades has been shown to help many people decrease their drinking. The drug works by blocking pleasurable neurochemicals, including endorphins, from reaching the brain’s opioid receptors. Many people who take naltrexone an hour before drinking, find that it reduces their enjoyment of alcohol and, therefore, their cravings for more.

Among Willenbring’s clients, roughly half find success in dialing back once they take naltrexone—or a handful of other anti-craving medications, including topirimate, an anti-convulsant, or baclofen, a muscle relaxer and anti-anxiety drug.

The smaller dose did little to lower his cravings, and he was determined to follow the French protocol.

S., a former journalist who lives in Oregon and wished to be identified only by his middle initial, is among those who have reduced their consumption with medication. In 2018, as a daily drinker of 30 years, S. was tired of how tethered he’d become to his six-pack-a-night habit; how isolated it made him feel as he watched television alone; and how he woke up in a semi-depressed funk each morning.

Searching online for ways to cut back, he read a news article about the promise of high-dose baclofen for heavy drinkers in France. S. found an addiction clinician who did not take his insurance and who agreed to prescribe only 40 milligrams—the recommended US dose for muscle spasms, but a fraction of the 300 mg commonly prescribed for alcohol use disorder in France.

The smaller dose did little to lower S.’s cravings. He describes himself as “lucky” to have had the research skills—and extra cash—to find a physician who would prescribe the drug at all. But it hadn’t put a dent in his drinking, and he was determined to follow the French protocol.

Finally, he mustered the courage to talk to his primary care physician, who familiarized herself with the medical literature and agreed to triple the common US dose to 120 mg. S. felt that at that dose, the drug was beginning to take effect—but he was still drinking more than he wanted to every day.

Embarrassed to seek more baclofen from his internist, he turned to internet groups, which directed him to online pharmacies. They felt somewhat shady. “It’s a little scary—I was worried they were either going to steal my money, or that the DEA was going to come knocking at my door,” S. said.

But the drug—he paid $162 for 400 25 mg pills—arrived without incident. S. began tinkering with higher and higher doses, sometimes reaching 270 mg, according to his detailed diary. At first, he experienced both fatigue and insomnia, but within weeks realized that his compulsion to open his first beer each evening had diminished.

“Different people need different things at different times in their change process. We need to be open to all the tools available.”

In the 20 months since he’s been taking baclofen, S. has cut his beer consumption from 42 a week to nine. (In December 2019, he also asked his doctor to prescribe a week’s worth of naltrexone so that he could try Dry January. The brief combination of pills allowed him to abstain the entire month—something he’d never imagined he could accomplish.)

Today, S. is taking 150 mg of the drug, and finds it easy to stick within his limits. He doesn’t miss the past hazy evenings—and equally murky mornings—at all. “I wake up in the morning after I haven’t had anything to drink in a state of near-euphoria,” he said. “I feel so good, it just reinforces it. I think, ‘Oh boy, I want to wake up like this again tomorrow.'”

To Carrie Wilkens, a psychologist at Manhattan’s Center for Motivation and Change, S.’s triumphant story holds great promise for so many who want to alter their drinking habits. “Even five years ago, it was heresy to say you got sober in any other way besides the 12 Steps,” she said. “Now, people are opening up about all the ways they’re finding to get better. If one method doesn’t work, we can’t just revert to the old story line about someone being ‘in denial’ or ‘just an addict.’ We need to listen to the fact that maybe that person kept getting a tool put in front of them that wasn’t helpful.”

“Different people need different things at different times in their change process,” Wilkens said. “We need to be open to all the tools available.”


Photograph via Pexels/Public Domain

R Street Institute supported the production of this piece through a restricted grant to The Influence Foundation. Filter’s editorial independence policy applies.

Gabrielle Glaser

Gabrielle is a journalist and author of the forthcoming book American Baby: A Mother, A Child, and the Shadow History of Adoption. Her 2013 book examining women's drinking and the American rehab industry, Her Best-Kept Secret: Why Women Drink—and How They Can Regain Control, was a New York Times bestseller. Her work on the intersection of health, medicine and culture has appeared in many publications, including the New York Times, the Atlantic, the Daily Beast, Scientific AmericanStat, the Washington Post and Propublica. 

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