To the editor:

I believe the article by Brown and colleagues¹ implying that patients who meet the criteria for alcohol dependence can spontaneously stop and resume drinking is an incorrect view of alcohol disorders. Although it is quite true that many people with alcohol abuse issues and problems may stop drinking under threat of job loss, incarceration, loss of family, and so forth, those who have true alcohol dependence cannot resume drinking on a controlled basis. Those of us in the field of alcohol treatment, as I have been for the past 30 years, know that persons who meet the true diagnosis of alcohol dependence cannot resume drinking alcohol in any form, because they will indeed relapse, quicker, and the medical, psychological, and legal consequences are devastating. The average alcoholic who meets the criteria for alcohol dependence and continues to drink will shorten his or her life by a minimum of 12 years.

Those individuals who have alcohol dependence and meet the criteria for tolerance (a need for increased amounts of the substance to achieve intoxication) have a markedly diminished effect with continued use of alcohol, or their withdrawal is manifested by severe symptoms including shakes, tremors, sweats, and grand mal seizures. These individuals spend a great deal of time in activities necessary to obtain their alcohol, and their continued use of alcohol interferes with social, occupational, and recreational activities.

Persons who meet substance dependence disorder criteria will continue using alcohol in spite of problems with family, friends, job, health, the law, finances, and spirituality. To imply that individuals who are contacted by a telephone call have “successfully resumed drinking” does a great disservice to millions of people who, through the aid of 12-step programs such as Alcoholics Anonymous, counseling, and medications such as naltrexone, acamprosate, or nalbuphine, are able to remain abstinent.

As one of the cofounders of the Committee for Physician’s Health (Impaired Physician Program) for the Medical Society in the State of New York, I have encountered hundreds of health care professionals who believed erroneously that they could resume and control their drinking, with the consequences of losing their family, their patients, and finally their license, and even their lives.

Ronald J. Dougherty, MD
Tully Hill Alcohol & Drug Treatment Center
New York

REFERENCE

Brown RL, Saunders LA, Bobula JA, Lauster MH. Remission of alcohol disorders in primary care patients: does diagnosis matter? J Fam Pract 2000; 49:522–28.

The preceding letter was referred to Drs Brown and Bobula and Ms Saunders who responded as follows:

Dr Dougherty expresses doubt about our findings. Indeed, our study’s data and our own clinical observations suggest that there are substantial numbers of alcohol-dependent individuals who can only recover through abstinence. However, the data from other studies (which are cited in the article) and our own suggest that more than a few alcohol-dependent individuals can resume drinking at some point with out ill effects.

One reason that views of alcohol dependence from primary care and specially treatment perspectives may differ is that we may see a different spectrum of patients. In general, specialists see the sickest patients. There have been many clinical dictums that have emanated from tertiary care and have not applied well to primary care populations. In primary care settings, we may see patients with milder forms of alcohol dependence; perhaps these are individuals with fewer genes for alcohol dependence; those whose alcohol-related cravings, preoccupations, and compulsions can be overcome without specialized treatment; and those who can have some alcohol without suffering additional negative consequences.

I also wonder whether imprecision in the diagnostic criteria for alcohol dependence results in overdiagnosis. Alcohol dependence is clearly a neurophysiologic phenomenon. Without accurate biologic markers, the field has necessarily established behavioral criteria for alcohol dependence. Such criteria are bound to be imperfect. Two key criteria are “the substance is often taken in larger amounts or over a longer period than intended” and “there is a persistent desire or unsuccessful efforts to cut down or control substance use.” I wonder how many individuals who seem to fulfill these criteria have actually never been fully committed to modifying their drinking. Perhaps individuals with mild biologic predisposition and a strong commitment to functional lives can consume limited amounts of alcohol without losing control.

Dr Dougherty and I would agree that all alcohol dependent individuals should be counseled that abstinence is their safest option. I would suggest further that patients who nevertheless choose to drink should be counseled to keep their drinking under National Institute of Alcohol Abuse and Alcoholism recommended limits (14 standard drinks per week for men, 11 drinks per week for women; 5 drinks in any occasion for men, and 3 to 4 drinks in any occasion for women). Patients who learn that they cannot adhere to such limits should be advised, and may then be more motivated, to accept abstinence and, if necessary, specialized treatment.

Richard L. Brown, MD, MPH
James A. Bohula, PhD
Laura A. Saunders, MSSW
University of Wisconsin Medical School
Madison

Remission of Alcohol Disorders