Why and by Whom the American Alcoholism Treatment Industry is Under Siege - Changing Criteria for Controlled-Drinking Outcome—The Helzer Study

Written by Stanton Peele

Changing Criteria for Controlled-Drinking Outcome—The Helzer Study

The main purpose of my 1987 article on controlled drinking was not to discount reported differences in controlled drinking versus abstinence outcomes, but to understand these differences across time, across countries, and across investigators. I concluded that definitions of alcoholic remission and relapse change according to cultural and political climates. Wallace (1989) called me to task for not mentioning in my article Edwards' (1985) critique of Davies' (1962) study reporting significant numbers of controlled drinkers in a hospital treatment population (although I didn't mention the Davies article either). In my 1987 article on controlled-drinking outcomes, I discussed Edwards' and Davies' findings along with almost 100 other conflicting reports of controlled-drinking outcomes in terms of how the criteria for what comprises moderate drinking vary by era and by country.

Both Wallace and I made a great deal of the study by Helzer and colleagues (1985). Wallace (1987b: 24) originally characterized the results of this study as follows: "Only 1.6 percent [of alcoholic patients] appeared able to meet criteria for 'moderate drinking.' More than 98% of the males in the Helzer study were unable to sustain moderate drinking patterns when moderate was defined most liberally as up to six drinks per day" (actually, this result applied to males and females combined in the study). Wallace implied here that alcoholics in the study were attempting to moderate their drinking, but they were not. When asked by the researchers, most claimed that it was impossible for alcoholics to resume moderate drinking and the hospital regimen assuredly discouraged them from believing they could do so.

As I pointed out, the 1.6% moderate drinking figure needs to be augmented by considering the 4.6% of alcoholics who drank moderately, but did so for only up to 30 of 36 of the previous months, while abstaining the rest of the time. In his response, Wallace (1989: 264) first declared, "Peele was apparently distressed that I did not mention that an additional 4.6 percent were mostly abstinent (with occasional drinking)," as though I were oversensitive in thinking that such a provocative outcome group should be "mentioned" in a discussion of this study. On the next page, however, Wallace conceded that "with regard to the . . . group of 4.6 percent occasional but moderate drinkers . . . Peele could have a point." The point is that slightly over 6% of a very severely alcoholic group became moderate or light drinkers. The larger group in this study in which I was interested, however, was the 12% who drank more than "six drinks per day," but who had that many drinks no more than four times in any one month during the previous three years. In his response, Wallace (1989: 264) labeled this a group who "were drinking heavily but denying alcohol-related medical, legal, and social problems." But Helzer and colleagues (1985) found no indication of any such problems for this 12% despite having checked hospital and police records and questioning collaterals, and their interpretation that this group is "denying" problems is an a priori one that reflects the political climate of the times.

Wallace (1989: 264-265) described his fundamental objection to this group: ". . . alcoholics who are drinking in excess of seven or more drinks [this should read "drank seven or more drinks" or" in excess of six drinks"] per day on four or more days in any one month are engaging in at risk drinking whether or not they are denying present medical, legal or social problems .... Peele, however, is obviously distressed that Helzer and colleagues would 'disqualify from remission' any alcoholic who 'got drunk four times in any one month in a three year period.' Personally, I do not believe it is acceptable for anybody, let alone an alcoholic, to get drunk four times in any one month." In his article, Wallace (1989: 267) repeated two insinuating questions from his earlier articles: "Is it possible that Dr. Peele would not mind a moderately 'stoned' American population at all? Furthermore, is it possible that Dr. Peele finds something inherently wrong and unappealing about sober consciousness?"

Here Wallace accused me of being too permissive because I recognize that most alcoholics will continue to drink and many people seek experiences of intoxication. At the same time, disease theorists consider me hopelessly moralistic because I maintain the best antidote to addiction is for a society to refuse to accept addictive misbehavior as an excuse for itself (Peele 1989). Indeed, in a response to my article "Ain't Misbehavin': Addiction Has Become An All-Purpose Excuse" in The Sciences, Wallace (1990) wrote a letter to the editor accusing me of being a "law and order" zealot who wants to punish addicts. What confuses Wallace is my acceptance that people will drink but my intolerance for crime, violence, and other misbehaviors associated with substance abuse that are now frequently excused as being an uncontrollable result of addiction (as when drunk drivers use an alcoholism defense after killing or maiming another driver).

Value issues aside, the question in the Helzer study (1985) is whether or not people who drink more than six drinks at a time a few times a month are actively alcoholic. In particular, if they were formerly alcoholics, could this amount of drinking, however heavy one considers it to be by one's personal standards, represent an improvement in their drinking behavior? In the Rand study (Polich, Armor & Braiker 1980: v), for example, the median level of drinking at intake was 17 drinks per day. Is it important to note whether a person who once drank 17 drinks per day later drank seven drinks or more only as many as four times during any one month in the previous three years? If one believes that "once an alcoholic always an alcoholic," the only question to ask is whether the person has stopped drinking entirely or, in an almost unachievable standard of moderate drinking, if they drink without ever getting drunk.

Improvement Versus Perfection in Treatment Outcomes

In progressively restricting what is called controlled drinking, important clinical details have been increasingly missed, such as the substantial reduction in drinking levels and drinking problems that some people undergo over the course of their lives even though they do not abstain. I used the Tennant (1986: 1489) editorial in the Journal of the American Medical Association to make this point: 'There are now ample epidemiological outcome data to call for other goals in treatment of alcoholism in addition to continuous abstinence." I also reported on Gottheil and colleagues' (1982: 564) study of hospitalized alcoholics that found between a third and over half "engaged in some degree of moderate drinking" and that those who were classified as moderate drinkers "did significantly and consistently better than nonremitters at subsequent follow-up assessments." Furthermore, the Gottheil group declared that "if the definition of successful remission is restricted to abstinence, the treatment centers cannot be considered especially effective and would be difficult to justify from cost-benefit analyses."

It would seem to be worthwhile to know that nonabstaining alcoholics can still do "significantly and consistently better" on various outcome measures than active alcoholics, rather than to rush to lump them—based on their occasional drunkenness—with the most abandoned, out-of-control alcoholics. I want to illustrate this difference in perspective with what I consider to be one of the most intriguing outcome studies ever conducted in the alcoholism field. Goodwin, Crane and Guze (1971) classified 93 ex-felons as "unequivocal alcoholics" and followed their course for eight years after prison, during which time only two were-treated for alcoholism. These researchers classified 38 of the ex-felons as being in remission, although only seven of them were abstinent, indicating a nonabstinence remission rate of a third.

Among the continuing drinkers in remission, l7 were categorized as moderate drinkers (drinking regularly while "rarely getting intoxicated"). But more fascinating were the remaining men that these researchers placed in the remission group—eight continued to get drunk regularly on weekends, while another six switched from spirits to beer and still "drank almost daily and sometimes excessively." Clearly, Wallace would not consider these men to be in remission. Yet Goodwin, Crane and Guze categorized them thus because these men, who had previously been imprisoned, now no longer got drunk publicly, did not commit crimes or other antisocial acts when intoxicated, and stayed out of jail. In other words, Goodwin and colleagues saw a significant overall improvement in the drinkers' lives as sufficient grounds for declaring that they were no longer alcoholics.