There’s a controversial program in Ottawa (and now Vancouver) that pours homeless alcohol dependents a glass of wine every hour. The results of this managed alcohol program (MAP) have been surprisingly good for both the participants and their community. Government spending on legal, medical, and social services has gone down. Participants’ consumption of alcohol has gone down. And their health, functioning, and quality of life have gone up.

This MAP is a form of harm reduction. Harm reduction does exactly what its name indicates: reduces harm to heavy drug users and to their communities. It’s a realistic, practical philosophy that sees drug problems, including alcohol problems, in shades of grey, rather than black and white. Recognizing that not everyone can or will stop drinking or using—or stop all at once—it encourages incremental change. Most people support harm reduction programs such as needle exchange, despite protests from critics who say that making drug use safer encourages addiction, a claim repeatedly undercut by real-world data.

When it comes to alcohol, however, harm reduction remains much more controversial. Critics of Ottawa’s MAP, for example, have issued death threats against the program’s founder. Many AA meetings shut down discussion of harm reduction techniques and refuse to acknowledge the progress of anyone who employs them, which matters because AA (and the 90 percent of US treatment programs that rely on it) is many alcohol addicts’ first—or only—source of recovery information. As a result, many people who might benefit from harm reduction don’t hear about it.

So what kind of harm reduction is available for those struggling with an alcohol use disorder (AUD)? As with heroin and other opioids, the overlapping categories include medication, substitution, and the category that MAP falls into: controlled drinking. Medication I cover in this post on five drugs and one herb used to reduce problem drinking. The obvious substitute is cannabis, which needs no introduction, but there’s another substitute that many people don’t know about: the herb kratom, which may also have pharmacological properties that reduce drinking. Controlled drinking I discuss below.

One essential point when reviewing this and all information about dealing with an AUD: there is no “magic bullet,” no drug or herb or behavioral approach that helps everyone. Neuroscientists are just beginning to understand why a drug that targets the brain works well for some people and poorly for others; what they do know for certain is that dramatic variations exist. And psychologists find the same variation in therapeutic methods. If you are suffering from an AUD or trying to help someone who is suffering, you may have to try more than one approach (or combination of approaches) before you find something that works.

Controlled drinking

Controlled drinking is exactly what it sounds like: continuing to drink but finding some way to moderate intake. In MAP, the hourly pour is a form of control—or, rather, of helping alcohol dependents exercise individual control. Knowing they can count on having enough alcohol to avoid withdrawal, they become less likely to binge because they fear running out of booze or because, when even one drink is considered “blowing it,” you might as well have twenty.

Proponents of controlled drinking reject the idea that addiction is a life-long disease. They cite data showing that some risky drinkers reduce their intake by deciding to cut down and, where possible, changing the things in their lives that support excessive alcohol use. If they work in hard-drinking professions such as the hospitality industry, for example, they might change jobs. If their drinking is an attempt to medicate trauma, as is often the case, they might seek therapy or learn alternative coping strategies such as meditation.

There’s intriguing evidence that mitigating stress and loneliness helps reduce alcohol consumption, starting with the famous Rat Park experiment of psychologist Bruce K. Alexander. If you don’t know about Rat Park, I urge you to visit Professor Alexander’s web site and read his account. Or check out Stuart McMillen’s cartoon version. Here’s the gist: when their lab rats compulsively self-administered drugs such as heroin, cocaine, and meth, researchers concluded that these drugs were inherently addicting. In their focus on the drug, they ignored the conditions in which the rats were kept: isolated from other rats and deprived of both movement and stimulation. Professor Alexander and his colleagues wondered what would happen if the rats were kept together, given ample room to move around, and provided with rat toys, so they built Rat Park. The results were dramatic: much, much less drug use.

The Rat Park experiment reminds us that addiction happens in context and may be a desperate response to intolerable social and environmental conditions. If rats don’t seem relevant, Professor Alexander advises us to look at history, especially at widespread alcohol abuse among indigenous people forced from their lands, separated from their families, and stripped of their culture. At an individual level, we know that crises such as job loss and eviction, as well as chronic pressure of downward mobility, do increase alcohol consumption. And researchers such as Jalie Tucker have shown that supportive factors such as stable employment help people to give up risky drinking without treatment.

Plenty of help is available for people interested in controlled drinking, rather than abstinence. Some turn to researchers such as Stanton Peele, who have devised programs to help dependent drinkers modify their behavior of which Peele’s Life Process Program is perhaps the best known. Those who’d prefer a peer-led program have a couple of options. One is HAMS, which stands for Harm reduction, Abstinence, and Moderation Support. As its name indicates, HAMS is a big tent, welcoming people who want to quit or learn to drink more safely, as well as people who want to cut down. Another is Moderation Management, which uses cognitive-behavioral techniques to curb alcohol consumption. All of these programs were founded to help people let down or turned off by AA. They believe that AA’s “disease model” is scientifically unsound and that it disempowers people by insisting that they are in thrall to physiological processes beyond their control, rather than making choices and capable of making different choices.

Why is this idea so controversial?[1] The main reason is AA’s continued dominance in the treatment industry, the western media, and public perception of alcohol abuse. Since its inception in 1935, AA has maintained that that “alcoholism” involves a complete loss of control with abstinence the only remedy. If you cut down from a handle of vodka a day to wine with dinner on weekends, says AA, you’re in denial of your disease and will resume necking that vodka bottle any minute. Sooner or later, probably sooner, your drinking will land you in jail, in the hospital, or in the morgue, and, if, somehow, you manage to maintain your new modest intake, then there’s only one possible explanation: you were never alcoholic in the first place.

Yes, folks, that is a classic example of the “no true Scotsman” fallacy.

The National Institute for Alcohol Abuse and Alcoholism (NIAAA), once bristling with hostility toward controlled drinking and its proponents, has lately staked out a pretty sensible middle ground between the harm-reduction position and the abstinence-only position. They even made a film with HBO to celebrate this compromise; it’s called “Risky Drinking,” and you can read a not-entirely-respectful review of it here. The NIAAA-HBO film argues that most “risky drinkers” can successfully cut down, but some are just too far gone and have to quit. Pretty reasonable, right? I’m actually kind of proud of the NIAAA right now!

Unfortunately, a lot of disinformation is still out there. When I went to inpatient treatment four years ago, one of the counselors said in a formal lecture that harm reduction meant reducing harm to communities but increasing harm to drug and alcohol users. Given the turnover at that rehab and the repetitiveness of the lectures (the counselors even put the same misspellings on the white board time after time), I calculate that nearly five thousand people heard that lie in 2015, heard it from the mouth of a recovery professional during a formal lecture. If you sometimes wonder why this blog is a little . . . insistent, that’s why.

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[1] For an excellent summary of the controversy through 2001, see Dr. Brooke Hersey’s excellent article, “The Controlled Drinking Debates: a Review of Four Decades of Acrimony.”

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