Moderate Drinking: Beyond the Numbers

What does reasonably healthy, moderate drinking look like? Some of the best answers to that question have little to do with numbers of drinks and plenty to do with quality of life. On this page, we’ll look at some of the subjective descriptions of what it means to sustain reasonable balance in our drinking.

We’ve also looked at moderate drinking by the numbers.

Dr. Ruth Engs also has a pageful of hints taken from her 1987 book, Alcohol and Other Drugs: Self Responsibility, titled Hints for Sensible, Moderate, and Responsible Alcohol Consumption and Party Hosting.

Below: (a) Dictionary; (b) Moderation Management; (c) Rules-free; (d) Personal Responsibility; and, (e) A Way of life.

Moderate: From the dictionary

M-W.com offers this as its first definition for the adjective moderate:

1 a : avoiding extremes of behavior or expression : observing reasonable limits <a moderate drinker> b : CALM, TEMPERATE

WordNet 2.0 expands on that:

verb: 3. control, hold in, hold, contain, check, curb, moderate — (lessen the intensity of; temper; hold in restraint; hold or keep within limits; “moderate your alcohol intake”; “hold your tongue”; “hold your temper”; “control your anger”)

adjective: 1. moderate (vs. immoderate) — (being within reasonable or average limits; not excessive or extreme; “moderate prices”; “a moderate income”; “a moderate fine”; “moderate demands”; “a moderate estimate”; “a moderate eater”; “moderate success”; “a kitchen of moderate size”; “the X-ray showed moderate enlargement of the heart”)

MM’s Concept of Moderation

Moderation Management characterizes moderate drinking this way

A Moderate Drinker:

• considers an occasional drink to be a small, though enjoyable, part of life.
• has hobbies, interests, and other ways to relax and enjoy life that do not involve alcohol.
• usually has friends who are moderate drinkers or nondrinkers.
• generally has something to eat before, during, or soon after drinking.
• usually does not drink for longer than an hour or two on any particular occasion.
• usually does not drink faster than one drink per half-hour.
• usually does not exceed the .055% BAC moderate drinking limit. (see Note 1 below)
• feels comfortable with his or her use of alcohol (never drinks secretly and does not spend a lot of time thinking about drinking or planning to drink).

Moderate Drinking: Rules-free, Permanent

Addiction specialist Debra Jay offered a description of moderate drinking on an episode of the Oprah show titled Moms Who Drink Too Much:

If you don’t have a problem, you never even think about making up a rule [about when and how to drink]… [W]ith somebody who doesn’t have a problem, they don’t even have to think about it. They just really can use [alcohol] responsibly… They’re not going to be thinking at 2 o’clock about what they’re going to be drinking at 5 o’clock if they don’t have a problem.

In expanding on the rules-free concept of moderate drinking, Jay suggested that rule-making itself may not be a problem as much as rules that are repeatedly broken and take on an air of emotional unmanageability. She also identified a set of rules that could shift a person from problematic to moderate drinking:

[If] alcohol [is] creating repeated problems in any area of [your] life, … and you think, “Well, maybe I don’t have a problem,” you know what? Change your drinking behavior, cut way back … [committing that:]

• I’m going to drink when I’m not around my kids,
• I’m going to only drink with other people,
• I’m going to drink once or twice a week,
• I’m going to have one or two glasses of wine,
• And, [that] it’s a permanent change in my life.

If you can do it, you don’t have a problem.

Asserting Personal Responsibility to Drink Moderately

Dr. Stanton Peele offers an alternative to Ms. Jay’s never-make-a-rule guideline in his response to a drinker who says “there have been some occasions where I have drank more than I intended,” and wonders if they are a red flag:

Evaluating feedback about how your drinking is going is critical as you decide on your plans and goals…

A lot of drinkers occasionally drink more than they intend or than they wish they had. The issues are:

1. Is this a regular occurrence,
2. Can they stop, resist, and reverse this overdrinking,
3. Are they showing problems in their life as a result of overdrinking,
4. Do those close to them feel their overdrinking is harmful to the drinker and themselves?

Your answers seem to be “no” to these things…

Moderation as a Way of Life

In an important sense, quantifying moderate drinking is critical. The numbers help us to determine where the drinking risks lie and make well-informed choices.

But instead of being a numbers game, I find the essence of moderate drinking to be more about living than drinking or abstaining. After an extended phase when I wasn’t being very sensible about my drinking, getting healthy took time. There was no magic switch to flip, no mystical word of salvation to take me from being “lost” to being “found.”

What worked for me were Abstinence, Balance, and Consciousness.

I found abstinence helpful in grounding myself. It’s not as useful for everyone as it’s been for me, but once I started making peace with being DAFT — Delightfully Alcohol-Free Today — on a regular basis, I had more clear-headed energy to invest in the rest of the work. Some periods of abstinence have been weeks or months long; many have been embedded in weeks that also included a day or two of drinking.

Balance involved developing a number of skills, and freshening up existing ones. Goal-setting, self-examination, testing out rules, adjusting targets, and focusing on things that I value most were all a part of that. Gathering good information and getting support from my peers made a big difference.

It turns out that healthy balance isn’t always about setting iron-clad rules, at least for me. My life is often a pendulum which can swing into very positive space, or be blown into difficult or crisis-laden space. I can’t always prevent a wild swing from occuring, but I can use harm reduction to keep problems from compounding, and I recover more readily when I accept that the pendulum exists.

Learning to be more conscious is the glue that brings the abstinence and the balance together for me. I’ve grown to appreciate and resolve some of my ambivalence and demystify my relationship with alcohol. Awareness of the stages of change has allowed me to see where I’m at in the process, and keep taking small steps forward.

Bottom line, skill-building is empowering. Becoming a moderate drinker hasn’t been a personal purity campaign for me, trying to conform to a fixed numeric standard. It’s been about taking a lot of simple, pragmatic steps, being alert to various risks and agile about reducing and eliminating harm — all in the name of sustaining balance.

(Companion page: Moderate Drinking: By the Numbers.)

One Drink

How big is a standard drink, as generally cited in the U.S.?

The U.S. Department of Agriculture guidelines, in which moderate drinking is defined, say:

Count as a drink—

• 12 ounces of regular beer (150 calories)
• 5 ounces of wine (100 calories)
• 1.5 ounces of 80-proof distilled spirits (100 calories)

Moderation Management is a bit more specific in its definition of moderate limits:

Standard drink:

• one 12 oz-beer (5% alcohol); or,
• one 5-oz glass wine (12% alcohol); or,
• 1½ oz of 80-proof liquor (40% alcohol)

Each of these contains 0.6 ounces of pure alcohol. The Moderate Drinking book adds this information about drink sizes:

Special Note

To calculate a standard drink for other types of beverages, divide 0.6 [for 0.6 ounces of pure alcohol] by the percentage of alcohol in the beverage. (The alcohol content of most beverages is printed on the label. If it is not, contact the producer and ask for this information.) For example, if you want to know how many ounces of fortified wine there are in a standard drink, you would take 0.6 and divide by 0.2, since there is 20% alcohol in fortified wine. The result is 3 ounces of fortified wine. The amount of light beer (4.2% alcohol) that equals one standard drink is: 0.6 divided by 0.042, which equals 14 ounces. If the concentration of alcohol is listed as “proof,” as in 80-proof liquor, divide the proof by 2 to get the percentage of alcohol — 80 divided by 2 equals 40 percent.

The standard drink unit has been changed in this edition of Moderate Drinking from 0.5 ounces of pure alcohol to 0.6 ounces. This is the standard used in Canada and it translates to more practical portion sizes. Beer is most often sold in 12-ounce bottles, and most regular beers are now 5% alcohol (not 4%). In restaurants, wine is typically poured in 5-ounce portions, and drinks containing hard liquor usually contain 1½ ounces of distilled spirits. The BAC charts … reflect this change.

The International Center For Alcohol Policies notes that the concept of a standard drink varies from country to country:

Though a number of governments have issued “standard drink” specifications based on the amount of pure ethanol, these vary greatly from country to country. For example, the United States government defines a “standard drink” as 14 grams of ethanol: 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits. But this standard does not apply in many other countries. In the United Kingdom, a “standard unit” contains the equivalent of 8 grams of ethanol; in Japan, the equivalent of 19.75 grams of ethanol constitutes a standard drink.

Moderate Drinking: By the Numbers

How much is too much? Two drinks? Five? Ten?

Oprah Winfrey asked that question on her show, but the answers she got seemed muddy to me.

It sounds like a simple question, but to be fair, the most accurate answers aren’t going to be monolithic or apply universally. Even the experts’ answers aren’t all the same. Let’s poke around some of the available answers from U.S. dietary guidelines, a study about harm thresholds, and recommendations in Britain and other countries.

Note that:

• The definition of a drink is on this page.
• Dual thresholds (one per day for women, two for men, for example) are used because of the physiological differences in the ways men and women metabolize and are impacted by alcohol.
• The companion to this page is: Moderate Drinking: Beyond the Numbers.

Below: Frameworks for moderate drinking: (a) One/Two drinks daily; (b) U.K.: Three/Four units daily; (c) Three/Four daily with 9/14 weekly; and, (d) Higher Levels, and then a Summary.

One/Two Drinks Daily

The NIAAA cites the Dietary Guidelines for Americans (233K PDF), also known as the Food Pyramid, as the source for its numeric definition of moderate drinking. The Food Pyramid was developed jointly by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services. From page 40 of the guidelines:

If adults choose to drink alcoholic beverages, they should consume them only in moderation.

WHAT IS MODERATION?

Moderation is defined as no more than one drink per day for women and no more than two drinks per day for men.

Current evidence suggests that moderate drinking is associated with a lower risk for coronary heart disease in some individuals.

The guidelines also list risks of drinking more than the moderate amount, as well as the conditions under which folks are better off abstaining.

The NIAAA’s 1992 Alcohol Alert, "Moderate Drinking" discounts the usefulness of quantifying moderate drinking, and makes the following points:

• Moderate drinking (i.e., that which does not generally cause problems) is often confused with — but is distinct from — social drinking (patterns that are generally accepted in the society in which they occur).
• The accuracy of numeric definitions of moderation is tempered by the wide range of effects a given dose of alcohol may have on people of different sizes, genders, and drinking histories.
• Evidence suggests that moderate drinking may have psychological and cardiovascular benefits.
• Negative effects of moderate drinking may include higher incidence of stroke, vehicle crashes, medication interactions, birth defects, and future alcohol abuse and/or dependence.

U.K.: Three/Four Units Daily

In the U.K., an interdepartmental group of officials was convened in 1994 to review medical and scientific evidence on the long-term effects of drinking alcohol. Its results were published in the December, 1995 report "Sensible Drinking". (If you’re interested in a detailed review of the evidence, follow the link to the PDF version of the report — it is a thorough accounting of global scientific evidence as of 1995.)

Drink units are measured in increments of 8 grams of pure alcohol in the U.K., compared to 14 grams of alcohol per drink in the U.S. The Sensible Drinking report’s recommendations included:

MEN: Regular consumption of between 3 and 4 units a day by men of all ages will not accrue significant health risk.

WOMEN: Regular consumption of between 2 and 3 units a day by women of all ages will not accrue any significant health risk.

The International Center for Alcohol Policies (ICAP) analyzed the distinctions between the U.S. one/two drink and the U.K. three/four unit recommendations in this report (360K PDF):

The alcohol levels deemed safe for women by UK standards are approximately 70% higher than the levels deemed safe in the US. The difference in levels deemed safe for men, on the other hand, is only 17%.

Three/Four Drinks Daily, 9/14 Weekly

Moderation Management names slightly higher daily limits than the NIAAA, while its recommended weekly limits are in sync with the NIAAA definition.

MM Limits:

• Strictly obey local laws regarding drinking and driving.
• Do not drink in situations that would endanger yourself or others.
• Do not drink every day. MM suggests that you abstain from drinking alcohol at least 3 or 4 days per week.
• Women who drink more than 3 drinks on any day, and more than 9 drinks per week, may be drinking at harmful levels.
• Men who drink more than 4 drinks on any day, and more than 14 drinks per week, may be drinking at harmful levels.

Notes: (1) BAC info, BAC charts; (2) Standard drink definition

The MM limits are based on research by Martha Sanchez-Craig, DA Wilkinson and R Davila: Empirically based guidelines for moderate drinking.

Dr. Reid Hester, a researcher and clinician who supports MM and SMART (short bio here), also offered this definition of moderate drinking in 2000:

It’s no more than 2 or 3 standard drinks per drinking episode, no more than 9 drinks per week for women and 12-14 for men. Also, moderate drinking means limiting how fast you drink and, as a result, keeping your blood alcohol concentration (BAC) below .045-.055.

Evidence of Low Risk at Higher Levels

Dr. Stanton Peele and Dr. Archie Brodsky published a paper on the psychological benefits of moderate drinking. In it, they noted the challenges of defining moderate drinking.

Within the U.S., …the level of drinking linked with lowest mortality has sometimes been measured to be substantially higher than [the one/two drink daily limit] (Greenfield et al., 1999). …Rehm and Bondy (1998) reported, “Heavier-drinking cohorts tend to display their minimum risk at relatively higher levels of alcohol intake than cohorts with lower alcohol consumption” for which there was “no satisfactory explanation” (p. 223).

Cohorts? I tell ya, the number of cohorts lurking in my daily vocabulary is … ahhh … well … none. To me, the basic point is that some folks drinking above the one/two daily threshold have not experienced a proportional increase in risk.

Related to its three/four unit recommendation, the U.K. Sensible Drinking report noted (emphasis added):

The problem drinker

(10.7) Our recommendations are for the individual drinker in the normal drinking population. They are not framed particularly to influence clinical treatment of problem drinkers or indeed their recognition. We wish to move away from a culture of advice on consumption levels which has been interpreted by some as categorising all those who drink above the currently recommended levels as heavy or problem drinkers when, clearly, the vast majority of them are not.

In The Natural History of Alcoholism, Dr. George Vaillant spoke of a study which followed 204 men from their sophomore year of college — 1940 — through 1980:

The men in the College sample have reported their alcohol use relatively accurately every 2 years for 40 years. Between the ages of 40 and 60, several men regularly recorded drinking six ounces (four drinks) of whiskey a day — or more than a gallon a month — for more than 20 years without problems. However, no man in our College sample reported drinking over five drinks a day without reporting unwanted symptoms and concern over his capacity to control his drinking.

So, in this limited sample (men aged 40-60 who had attended an elite college), a 20-year pattern of four drinks per day — equal to MM’s daily limit, but double the MM and USDA weekly limits — produced no measurable consequences.

Finally, ICAP (the International Center For Alcohol Policies) analyzed moderate drinking recommendations around the globe, and published the results in this report supplement (31K PDF). A table on the second page of the report notes that recommended moderate levels in Austria, Canada, Denmark, New Zealand and Romania are in ranges roughly similar to those in the U.S. and U.K, while those in Australia, Italy, and Japan are higher.

Summary

The Food Pyramid gives us a structure within which to understand what our bodies typically need to be healthy. It is based on some of the best data we’ve got, and yet it’s not the only data we’ve got. It doesn’t dictate the only valid path we can take — some of us have rearranged it substantially to follow low-carb or vegan diets, for example — nor does it make value judgments if we choose to eat more pizza or fewer vegetables than recommended.

(In round numbers, the guidelines in the official food pyramid document use the word “can” about 40 times, “should” 20 times — 3 of them related to drinking — and an unconditional “must” only once, when noting that vegans must supplement with B₁₂.)

That seems like a good model, to me, for understanding its one/two daily drink guideline. If we want to compete as athletes, survive the rigors of medical residency, qualify as astronauts, or other endeavors requiring top-notch physical conditioning, we will need to heed the pyramid, including the drink limits. Those of us who seek reasonably good (but less than Olympian) health and functioning should understand the risks of stretching the pyramid’s boundaries, but there is some wiggle-room built in: Consuming a little more pizza, few less vegetables, or a bit more wine is generally not going to turn an otherwise contented life sour and short.

Balance, of course, is the key. The best way to create it is by examining the experts’ recommendations in the context of our values and goals so that we can make well-informed choices.

(Companion page: Moderate Drinking: Beyond the Numbers.)

Oprah Questions Denial

I caught an intriguing verbal exchange on the topic of denial a couple months back on Oprah. The episode was called Moms Who Drink Too Much.

The expert featured that day was Debra Jay, who is an addiction specialist, a professional interventionist, and author. She and Jeff Jay published Love First: A New Approach to Intervention for Alcoholism and Drug Addiction, in 2000.

They had talked earlier with:

• Sarah, who identified as an alcoholic for the first time and agreed that treatment was necessary.
• Amber, who had spoken about drinking wine nightly, generally not more than 2 glasses while her children were awake.

During the “After The Show” featuring the same folks, after Amber mentioned taking responsibility for herself (as she had done during the main show, as well), the conversation turned to denial:

Debra: [T]his is what’s hard for people to get: You’ll never see [alcoholism] coming. You’ll never see it coming. People always say, “I’m watching it,” and I’m thinking, “What are you watching? What are you waiting for? What do you think you’re going to see?”

Oprah: See, now I don’t get that…

Amber: So, would it be irresponsible…

Oprah: I don’t get that, I don’t get that, Debra, because…

Debra (to Sarah): Did you see it coming?

Oprah: You would see it coming…

Debra: No, you don’t. Did you see it coming?

Oprah: You would see it coming if you blacked out.

Debra: No.

Oprah: You would see it coming if you get to the point where you’re …

Debra: No.

Oprah: …confrontational, your personality is altered. You would see…

Debra: Remember what I said earlier was, the first thing that goes is your ability to be self-aware. That’s the first part of the brain that the alcohol hits.

Oprah: You would see it coming if your husband is saying, “Look, you’ve got a problem.”

Debra: You and I, listen, you and I would see it coming, but an alcoholic cannot see it coming. Can’t see it. Cannot see it. I’ll tell you, I just worked with somebody, got him into treatment, and his first assignment was, “Tell us how your personality changed,” and he said, “Not at all,” and then they said, “Well, call your family.” And, boy was he surprised at what he heard…

Oprah: OK.

Debra: …totally different story.

Oprah: OK, I’m not, I’m not buying it, Debra.

Debra: It is tough. No, it is a tough one.

Oprah (to Sarah): You didn’t see this coming?

Sarah: I knew blacking out wasn’t normal, but still couldn’t think I was an alcoholic. I just kept trying to find a way to control it - eat a little more, switch to this drink, I just kept trying. But, I mean yeah, there were huge, huge red flags. My family said from the very beginning, “You drink alcohol and your personality changes.” Well, everyone thought that but me.

Debra: The word for it is denial. That’s the hallmark of addiction: Denial.

This intrigues me. Ostensibly, the show was reaching out to mothers with a word of warning about drinking problems, and yet Debra Jay seemed to be suggesting that it is impossible for folks to see a problem developing and be proactive about circumventing it.

She makes it clear that she’s referring to alcoholics here, and had just said to Amber, “I’m not telling you, ‘You have an alcohol problem.’” At the same time, daily drinking and detailed rule-making, both of which described Amber, had been named as potential red flags, signs that alcoholism could be developing even though external consequences were not yet occuring.

Update: August 7, 2004

I used an email address at the site hosted by Debra and Jeff Jay to contact Debra to ask if she’d be interested in clarifying things or adding to the conversation:

From: Bose [bose@sensibly.org]
Sent: Tuesday, July 27, 2004 6:55 AM
To: [The contact address offered at LoveFirst.net]
Subject: Ms. Debra Jay: Question

Dear Ms. Jay,

Hi. I’m a freelance writer focusing on wellness and substance abuse issues.

I got to see the Oprah show titled “Moms Who Drink Too Much” a couple months back. I hope things came together for Sarah in terms of treatment and recovery.

I got confused, though, in the “After The Show” segment when you spoke of alcoholics’ inability to see addiction coming. I wrote about it a bit at my alcohol-related website, and I was wondering if you’d be interested in clarifying your thoughts.

The piece is here:
http://live.sensibly.org/2004/07/27/oprah/

Feel free to respond at your convenience by email, or by posting a comment at my site.

Thanks, so much, for your assistance. Have a great day!

Sincerely,

Steve Boese
bose@sensibly.org
Washington DC

To date, I haven’t heard anything back from her. The offer is still open — I welcome her comments here or direct reply by email. If there is anything she would like to add to the conversation, it’s important to me that she have that opportunity.

And, to be clear, I am not going to single any one person out. Everything I see tells me Ms. Jay is an accomplished professional whose focus appears to be folks who are struggling at the severe end of the alcohol issues spectrum, and I have no doubt that she has served her clients well.

Stages of Change: Core Concepts

On the Stages of Change: Background page, we established that none of these, on their own, are consistent predictors of change:

• New Years resolutions
• Hitting bottom
• Willpower
• Specific psychotherapy approaches
• Breaking denial

(Of course, any of these may contribute to change, but none is an absolute prerequisite.)

Instead of using any single technique, Prochaska and his colleagues found that successful changers moved through an identifiable series of stages. I’ve drawn the summary information in this table from chapter 2 of the Stages Of Change book as well as my own experience, naming typical perceptions, intentions, motivations, potential pitfalls, and emotions at each stage:

Some of the lessons learned from following people through the stages have included:

• Don’t want to change? That is to be expected. Looking at how this works and understanding the options may plant seeds for future change.
• Feeling stuck? Been hoping to change for years? That’s no surprise. There are options for us to consider that will help us get unstuck.
• Mired in hopelessness? Relax for a bit. Feeling dejected is normal in the first stage, but is not permanent.
• Are we pressuring ourselves to leapfrog — skip over or rush through — the early stages? That is neither necessary or wise.
• Is the action stage scary or overwhelming? No problem. The only requirement is for us to (1) Determine which stage we’re at; and, (2) Take baby steps toward the next stage.
• Prefer self-guided change? Professional assistance or coaching? Some of both? All of those are valid paths.

In a world innundated with self-help gurus offering one-size-fits-all formulas, the stages of change model breaks the mold. It says that any number of specific methods are likely to work, and that tailoring our timeframe and methods to our unique needs and coping skills increases our chances of success. It gives us room to ask questions and make conscious choices, and it meets us exactly where we’re at.

Coming next: Stages of Change: The Processes

Stages of Change: Background

New Years resolutions are a time-honored tradition. After eating our way through the holidays, we promise to change our diet or pick up a new exercise routine. Statistics don’t offer us much hope, though — few resolutions stick with us for long, except for those of us who have made the same resolutions, year after year, without making much progress in between.

Watching Oprah and reading self-help books brings us into contact with another supposed trigger of change: Hitting bottom. The bottom can be high (not-so-severe consequences), low (homeless, lying in a gutter), or in between, but the common wisdom is that we’re likely to change afterward. But, if that’s the case, why have addiction treatment success rates (measured as continuous abstinence for a year) generally fallen under fifty percent?

James Prochaska wondered about those kinds of things as he watched his dad struggle with depression and addiction, and die prematurely. His questions about how we might better understand what is working when folks do change their behavior propelled him deeper into his psychology research. If we could just understand the common characteristics of those who have changed, how might the folks who are still struggling use that to improve their odds?

He started by taking a broad look at all of the major approaches to psychotherapy. Lester Luborsky set the stage for his work in 1975, noting that:

when patients are professionally treated, they get better, but symptomatic improvement is not related to the type of therapy they receive, […with] the improvement [being] about the same whether patients receive psychodynamic psychotherapy, cognitive therapy, behavioral therapy or pharmacotherapy.

In 1979, Prochaska published the first edition of Systems of Psychotherapy: A Transtheoretical Analysis, in which he showed that most therapeutic approaches rely on a few core processes.

But the fact remained that rates of actual change were low — only 10-25% of folks with drinking, obesity, or mental health issues seek out therapy, and 45% of those who do drop out prematurely. (And many of the folks who never get help change independently anyway.)

Dr. Prochaska and his colleagues, John Norcross, Ph.D., and Carlo DiClemente, Ph.D., decided to turn the question around. Instead of starting by looking at specific therapies and processes, they studied folks who had changed their behavior successfully. Since none of the familiar factors — New Years resolutions, hitting bottom, or specific therapies or programs — would explain behavior change consistently on their own, what might the successful changers have in common?

They laid out their results, in readable form for laypeople like you and me, in their 1994 book, "Changing For Good". It turns out that 80% of us who could benefit from change are not acting on it at any given time because we’re not yet fully prepared. And, the effective changes we make (with professional help or independently — success rates are comparable for both) generally follow well-defined stages.

On page 14 of the book, Dr. Prochaska described the existing approaches to change as the “action paradigm,” which:

has dominated behavior change programs for the past three or four decades. Following this model, clients are enrolled in relatively brief programs designed to conquer smoking, weight, alcohol, or other problems; within weeks they are expected to take action and adopt healthier lifestyles. If they fail to take or maintain action, the clients themselves are blamed for lack of willpower or motivation.

Does that scenario sound as familiar to you as it does me? Ever bought a promising self-help book that never got finished, or produced only limited action? Signed up for a weight-loss program but still see the same numbers on the scale? Made a genuine promise to yourself, only to wonder later if you were in denial? Ever blamed — or shamed — yourself when things didn’t come together as hoped?

But that’s the outdated perception of how change works. Here’s the more accurate, evidence-based understanding: Most of us follow a predictable series of stages on our way to change. Willpower has little to do with our success; it is much more about whether we invest sufficient time and energy in the preparatory stages.

Continue reading: Stages of Change

Binge

Usage of the word “binge” has evolved in recent years.

Binge: The Dictionary Version.

Merriam-Webster defines it this way:

a drunken revel : SPREE; an unrestrained and often excessive indulgence <a buying binge>

Princeton’s WordNet 2.0 speaks of immoderate indulgence:

The noun “binge” has 2 senses in WordNet.

1. orgy, binge, splurge — (any act of immoderate indulgence; “an orgy of shopping”; “an emotional binge”; “a splurge of spending”)
2. bust, tear, binge, bout — (an occasion for excessive eating or drinking; “they went on a bust that lasted three days”)

The verb “binge” has 1 sense in WordNet.

1. gorge, ingurgitate, overindulge, glut, englut, stuff, engorge, overgorge, overeat, gormandize, gormandise, gourmandize, binge, pig out, satiate, scarf out — (overeat or eat immodestly; make a pig of oneself; “She stuffed herself at the dinner”; “The kids binged on icecream”)

Twenty-four Hours: A Short Binge?

In the substance abuse field, the longest-standing definition of “binge” refers to an episode of heavy drinking, usually lasting more than a day. In the NIAAA’s ETOH database glossary we find:

A pattern of heavy drinking that occurs in an extended period set aside for the purpose of drinking. In population surveys the period is usually defined as more than one day of drinking at a time. The activity of binge drinking also is referred to as “bout drinking” or “spree drinking.” The term “drinking bout” is used to refer to the occasion. A binge drinker or bout drinker is one who drinks predominantly in this fashion, often with intervening periods of abstinence.

My buddy Brian was a binge drinker in this sense of the word. He would buy 2-5 bottles of Scotch (and not small ones) and start drinking at while playing at the computer, and later, watching TV. A gap of a couple hours between drinks was possible when passed out, but the heavy drinking continued not too long after getting up. When we were closest, in the mid 1990s, a 24-hour binge was less common and most of them fell in a range of 36 to 72 hours. Then, as in the definition, abstinence would prevail for several weeks.

College Binge Drinking: The 5/4 Definition

In the early 1990s, studies of alcohol use on college campuses began adapting the use of “binge” to describe having 5 or more drinks “in a row”, without specifying a timeframe.

The College Alcohol Survey, which collected data from over 17,000 students on 140 campuses in 1993, led by Dr. Henry Wechsler, Ph.D. with support from the Robert Wood Johnson Foundation, split the definition to account for gender differences. Its report titled "Health and Behavioral Consequences of Binge Drinking in College" in the Journal of the American Medical Association noted:

(p. 1674, col 1) Binge drinking was defined as the consumption of five or more drinks in a row for men and four or more drinks in a row for women. …the term “binge drinker” is used to refer to students who binged at least once in the previous 2 weeks.

(p. 1673, col 2) The use of [“in a row”], without specification of a time elapsed in a drinking episode, is consistent with standard practice in recent research on alcohol use among this population.

(p.1672, col 3) [Previous] studies of college alcohol use … [have generally] used the same definition of binge drinking for men and women, without taking into account sex differences in metabolism of ethanol or in body mass.

The 5/4 definition has resonated in the media and among public health advocacy groups, but failed to win widespread acceptance among academics and researchers. The International Center for Alcohol Policies questioned it in a 1997 report:

Defining a drinking pattern solely by the number of drinks consumed … falls short of being adequate. This approach fails to take into account the context of drinking, the individual engaging in the behavior (a 250-lb male is likely to experience very different consequences from five drinks than is a 100-lb female), and the salience of alcohol within the drinking occasion. The time interval over which the drinks are consumed is a critical variable, but also one on which there is no consensus. The effects of consuming five drinks over the course of a three-hour dinner are likely to manifest themselves very differently from the effects of consuming five drinks in rapid succession over half an hour.

An October 2000 press release by the Higher Education Center for Alcohol and Other Drug Prevention noted:

Most researchers in the field are now rejecting use of the word “binge” to describe having 5/4-plus drinks over some unspecified period of time. It is true that various government reports use it, but the National Institute of Alcoholism and Alcohol Abuse (NIAAA), the federal government’s primary research institute in this area, never does, nor does the Journal of Studies on Alcohol, which is the lead journal in the field. Moreover, a special panel on alcohol prevention and treatment in higher education convened by NIAAA voted unanimously last year not to use the term “binge” in this way.

NIAAA’s 2004 Binge Definition

During its February 4-5, 2004 meeting, the National Advisory Council on Alcohol Abuse and Alcoholism (which advises the NIAAA), unanimously approved this updated definition:

A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to .08 grams percent or above. For the typical adult this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society.

• A drink is defined as half an ounce of alcohol (e.g., one 12 oz. beer, one 5 oz. glass of wine, one 1½ oz. shot of distilled spirits).
• Binge drinking is distinct from “risky” drinking (peak BAC between .05 and .08 grams percent) and “benders” (2 or more days of sustained drinking to intoxication).
• For some individuals (e.g., older people; those taking other drugs or certain medications), the number of drinks needed to reach a binge-level BAC is lower than for the “typical adult.” People with risk factors for the development of alcoholism have increased risk with any level of alcohol consumption, even that below a “risky” level.
• For pregnant women, any drinking presents risk to the fetus.
• Any drinking by persons under the age of 21 is illegal.

So, using what we know about blood alcohol content, this definition tells us that binge starts at a level of slight impairment of balance, speech, vision, reaction time, and hearing. In general terms, the binge threshold of .08 is half-way to the “sloppy drunk” characteristics of .16. BAC tables like these suggest that the binge threshold could be reached by:

• A 120-lb woman having 2½ drinks in an hour
• A 220-lb woman having 8 drinks in 5 hours
• A 160-lb man having 4 drinks in an hour
• A 240-lb man having 11 drinks in 5 hours

Dodes, Lance

Dr. Lance Dodes (DOE-dess), MD is a psychiatrist with more than a quarter-century of clinical experience. He takes a psychoanalytic approach to working with substance abuse, as described in his 2002 book, The Heart of Addiction: A New Approach to Understanding and Managing Alcoholism and Other Addictive Behaviors.

An article at HippoPress.com, expands on his qualifications:

He teaches at Harvard Medical School and directs the Boston Center for Problem Gambling. He has treated hundreds of addicts and directed various alcoholism treatment units in New England.

And it describes his thoughts on powerlessness:

People with addiction, believes Dodes, need to feel less powerless. This seems to conflict with the Alcoholics Anonymous credo that alcoholics need to admit they are powerless over alcohol… Dodes finds value in AA, but takes issue with this tenet.

On page 4 of his book, Dodes says:

Virtually every addictive act is preceded by a feeling of helplessness or powerlessness. Addictive behavior functions to repair this underlying feeling of helplessness. It is able to do this because taking the addictive action (or even deciding to take this action) creates a sense of being empowered, of regaining control over one’s emotional experience and one’s life.

And, the HippoPress article sums up his response to powerlessness this way:

AA’s injunction to surrender your power “is clearly not for everyone. However, along with other AA concepts, the ‘surrendering’ notion is often described as the only way to address alcoholism … and that is a myth that is both wrong and hurtful.”

Read more about Dr. Dodes in this 3-page PDF at the Harvard Medical School website.

London psychotherapist James Hamilton, whose specialties include addiction and smoking cessation, named Dodes’ book “the most important book on addiction to be written in the last ten years.”

He also explains a key Dodes concept here in the context of a commuter who has fought large crowds and late trains on his trip home after a long day:

Lance Dodes notices something very important that I had missed entirely. He spotted that addicts of all stripes … start to feel better at the moment they have decided to indulge their addiction, not at the time when the addiction action actually takes place. So my commuter, who has decided to get drunk, starts to feel better not at the time of the first drink, but at the moment he or she decides to get drunk i.e. somewhat earlier. There is a moment when the addict, experiencing frustration and helplessness, says “f*** it! I’m just going to drink/inject/smoke/gamble/ring a sex line”; and it’s then that they start to feel better.

David: Life at the Extremes

David describes himself as “addicted to almost everything”, prefacing that by noting:

Addiction. What is it? Im sick of the word. Its never really been defined for me anyway.

He seems to have some powerful ambivalence going, as he continues later:

Heres the thing, my addictions make me feel weak and vulnerable; like a failure, someone unable to control his own impulses and desires. Yet I know, deep down that these impulses and desires are the seat of my power. The only true power I have. At one point or other in my life I have given up everything I was addicted to; booze, sex, drugs, computer games, sugar, exercising, gambling. They just keep coming back. So Im currently in a mode of indulging those addictions that I am unwilling to give up but keeping them contained. Hows it going, you ask? Not well. But Im not willing to castrate myself from myself and make some ridiculous, hygienic choice to purify my soul and rid myself of my desires, which in turn almost always turn into my addictions. Theres got to be a way; a way to dance with the Devil; a way to give the Devil his due and still walk in the light for most of the time. I suppose there is and I suppose its different for every single one of us, finding that balance.

The dynamics he describes are familiar to me, some of them from the first half of 2000 and earlier when I was in my 6-8 beers-per-night phase:

• Feeling weak and vulnerable at times, wanting better control.
• Feeling empowered and finding value in not living life as a purity campaign.
• Refusing self-shame and -castigation.
• Being determined to pursue better balance.

Dr. Lance Dodes, MD talks about folks for whom the decision to indulge in an addictive act can actually be empowering. To me, it’s not limited solely to addictive behaviors. Choosing to do something, breaking free of feeling stuck and having no options, can be helpful even when the specific choice is less than optimal.

In 2000, drinking too much on a generally daily basis, and making little or no progress when I tried to scale it back, was tiring and frustrating. I sometimes wondered if a power larger than me was assuming control, but found it counter-intuitive and counter-productive to indulge those sorts of thoughts for long.

In fact, the first couple beers of the evening did good things for me. They relaxed me, lightening my mood. My thinking grew more expansive, and the brainwaves that had been racing at breakneck speed all day seemed to slow down. I would re-ground myself with the reminder that life was about more than just producing, it was about appreciating many simple gifts. (Separate but relevant point: My current life includes just as much good stuff, but with a fraction of the beer.)

I hear echoes of those kinds of thoughts in David. Something deep, something meaningful is touched with the behaviors he describes as addictions, even as he identifies it as “dancing with the Devil.”

Prolific blogger Dean Esmay, who made a very public switch from active alcoholic to non-drinker in February and has since written a bit on AA alternatives, responded by describing his experience:

I can’t tell you the shame I have in realizing that’s where I was. Where I could even see the physical toll it was taking on my body and my soul, and still said, “fuck it, fuck everything, I just want more, I need to numb out the other shit that’s bugging me and I need more of this pleasure. It makes the bad go away and makes everything else feel good.”

That’s when you’re to the point of addiction my friend. When you consciously or unconsciously are making that destructive choice.

And the point of salvation? Where you have that moment of clarity when you realize that’s what you’re doing, and decide you must put a stop to it.

And the point of damnation? When you have that moment of clarity and realize that’s what you’re doing—and say “fuck it” and keep doing it anyway.

That is the choice between salvation and damnation, I truly believe.

The black and white, salvation-or-damnation, clarity is central to a lot of folks’ experience with substance use that became abuse and finally dependence. Behavior that escalated to extremes drew them into an extreme response, and framing the issue in blacks and whites helps to keep the focus on a worthwhile target.

But that’s not the only valid or viable response for everybody.

David wants to find balance apart from living a pure, hygienic life. One of the challenges I think he’s up against, as I described in my introduction to this site, is that so much of the public conversation about abuse and dependence focuses on the extremes, seldom appreciating middle ground.

Plenty of folks understand 12-step-based abstinence, as well as the idea that some folks abstain or moderate relatively effortlessly. But how many can talk about taking pragmatic steps to reduce harm, which most of us have done in some fashion? How many of us have avoided talking about intentionally moderating our drinking because some experts consider setting rules for controlling our drinking to be a sign of having lost control?

David is smart, in my book, to be consciously thinking about balance and noting that we’re not all going to find it the same way. At some point, even though it’s unpalatable now, he may find that abstinence is a better direction to go on some or all of the the indulgences that attract him.

In the short term, though, he probably stands a better chance of making progress by other means. When I find myself in a place similar to his, I find it helpful to stick to the simple stuff:

• Figure out what sorts of things are bothering me most
• Highlight those that are causing the most trouble
• Look for ways to scale the trouble or harm back by:
  • planning, and learning to enjoy, more frequent abstinent days
  • taking the non-abstinent days more slowly
  • taking action — doing things that matter more to me than drinking
  • recognizing, but not obssessing about, possible catastrophes and worst-case scenarios

Most of us know the stories about folks who have hit the extremes of addiction and abstinence, damnation and salvation. But how many of us also recognize the more boring, ordinary stories of folks who have matured out of their excessive behavior?

Sometimes the best thing we can do is to take genuine stock of ourselves and focus on making simple steps forward. Chances are good that our choices will trigger neither a lottery jackpot nor a lightning strike, but we can take a lot of small steps in better, neutral, or less harmful directions.

Why Would I Care about the NIAAA?

As a layperson, why in heck would the National Institute on Alcohol Abuse and Alcoholism (NIAAA) matter to me? Here are a few reasons:

• As a U.S. citizen and taxpayer, it spends almost a half billion bucks of my money every year.
• Like other parts of the National Institutes of Health (NIH), it is supposed to provide a scientific foundation for understanding health issues.
• The NIAAA is a key player in setting standards, definitions, and thresholds for things like moderate drinking, binge drinking, and treatment.
• Research, as funded and interpreted by the NIAAA, has a lot to do with the kinds of information, support, and treatment that are available to me.
• Like any organization, the quality of the results produced and/or funded by the NIAAA is going to be as good (or as limited) as the expectations set for it by the public (i.e., me and you).
• The NIH is not immune from conflicts of interest and other flaws.

So, if the NIAAA assigns a low priority to understanding the full spectrum of options (harm reduction, motivational enhancement, moderation) for folks who abuse alcohol like I have in the past, the chances that other folks will have those sorts of options available to them decreases.

If the NIAAA emphasizes research into relapse among folks who pursue all available treatment options any yet don’t reverse the severity of their binges, the chances of finding more effective options increases.

And, if the primary focus of the NIAAA is on discovering genetic markers which appear to contribute to drinking problems, there is likely to be less focus on how to help folks assert personal responsibility in the face of alcohol abuse.

In other health issues, it has often been the folks most directly affected who have driven research concerns. Parents of kids with autism have challenged the NIH to look closely at the possibility that common vaccines have contributed to their kids’ challenges. Breast cancer survivors, and family members of those who did not survive, have been the most effective advocates for increasing the dollars devoted to prevention and treatment research.

If I want to see alcohol-related care shift, I gotta be one of the folks standing up and challenging the research gurus to cover all of the bases, and holding the folks in charge accountable for spending public dollars.

Medline Plus

Medline Plus is an online health database maintained by the National Library of Medicine.

The seeds of Medline Plus were planted with the creation of MEDLARS (the Medical Literature Analysis and Retrieval System) in 1964. Medline began serving medical professionals and libraries with online access to a subset of the MEDLARS database starting in 1971.

Medline Plus was launched in 1998 as a pilot project to give internet users free access to consumer health information.

The National Library of Medicine (NLM) was established in 1836 as the Library of the Office of the Surgeon General of the Army. By the end of the nineteenth century it was recognized as a national resource of biomedical literature. In 1968 the NLM was brought under the umbrella of the National Institutes of Health (NIH), of which the National Institute on Alcohol Abuse and Alcoholism (NIAAA) is also a part.

The NLM is now the world’s largest medical library, collecting “information and research services in all areas of biomedicine and health care.”