Alexander DeLuca, M.D.
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"Is Smithers using "moderation management" in inpatient treatment?" 
Very short answer: NO.
--
[Note: Before this site was doctordeluca.com, it was the unofficial website of Smithers Addiction Treatment & Research circa 1999 when I was Chief and Medical Director there. Anyway, at that time, I offered a free 'Ask-an-Addiction Doctor' service; this document is the very last Ask-a-Doc answer... I was fired the next day, and this site became doctordeluca.com      ..alex... Alexander DeLuca, 11/11/2003.]

The following is a reply to an Ask-An-Addiction-Doc; 7/9/2000. (Alexander DeLuca, M.D., FASAM. Copyright © 1999/2000. All rights reserved.) question.
I am sending a copy of the reply to you, because of recent false and misleading articles in New York Magazine, the New York Post, and New York Times - the latter two repeating the mis-information published by the first.

Sorry to take so long to get back to you; I was on vacation this past week, and just getting around to catching up on Email today.

You asked:  "Is Smithers using "moderation management" in inpatient treatment?

Very short answer: NO.

First of all, Moderation Management (MM) is a self-help group, not a treatment. Smithers has no relationship with MM except that MM holds a weekly meeting on our site, a courtesy we have extended to Alcoholics Anonymous (AA) for decades. These meetings are held during hours the space is not being used by any Smithers program, and are in no way part of the Smithers Addiction Treatment and Research Center.

There is research that shows that patients who attend self-help groups regularly stay in treatment longer and have better outcomes. AA and NA (Narcotics Anonymous) are routinely recommended to all patients at Smithers, and MM or other self-help programs suggested if the patient refuses to try (or return to) AA or NA.

The 'treatment' at Smithers is cognitive-behavioral in general. Some groups, especially those for people thinking about coming into treatment or those ambivalent about returning to treatment after relapse, are 'motivational enhancement' groups. That is, they are manual-driven, group implementations of a psychological approach known as "Motivational Interviewing" (see book of same name, I think, by Miller et al). Smithers motivational enhancement groups are employed on both inpatient and outpatient services.

The core of the Smithers treatment is what we call the "Core-20" - twenty semi-structured, manual-driven, cognitive-behavioral, group sessions constituting what we feel provides the clinical basics of self-understanding, and psychological techniques to achieve and maintain an abstinence-based sobriety. Abstinence is, *by far,* the safest and best approach for people with significant alcohol or drug related problems.

What makes Smithers different from a lot of treatment centers is that we work with people's ambivalence about their substance-use and about treatment, and we do not refuse to work with people who are not sure they are "addicts or alcoholics."

For example, a patient might be having just a few substance-related problems, or a loved-one feels they have a problem but they are not convinced they need to quit entirely. If such a patient is not judged to be a danger to themselves or others, and is not so medically compromised that *any* continued use would result in serious risk of acute medical problem, and if such a patient refuses to take the suggestion of immediate abstinence-oriented treatment, then I will sometimes do an intervention known usually as "a trial of controlled drinking" which involves strict limitations on alcohol intake and patient recording of the circumstances and emotions regarding any deviation from the "controlled" intake.

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For example, the patient agrees to the instructions:

-- no more than two drinks on any drinking occasion, and

-- not more than one drinking occasion per day, and

-- if you have more alcohol than this, please write down a brief note including date, time, circumstances and feelings, so that we can review your experiences with this in (usually) two weeks.

The patient is often surprised that they are unable to stick to the limits and then has a better understanding of why they should strongly consider a 'trial of abstinence' :-) as their next therapeutic maneuver.

At Smithers, such a "trial of controlled drinking" is *ALWAYS* an outpatient procedure because, by definition, inpatient treatment is abstinence-oriented, and anyone sick enough to need inpatient treatment is usually too sick for a trial of controlled drinking.

Thanks for the question, _____. It has given me a chance to clear up some confusion resulting from recent very misleading New York Magazine and New York Post articles.

..alex...

Alexander DeLuca, M.D.; 7/9/2000
Chief, Smithers Addiction Treatment and Research Center

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[My dialog with this person continues below. As a visual cue, her text will be in smaller font and in italics.]

You wrote:

"This is a serious question. It strikes me that the  apparent "success rate"  for a two week trial would be quite high without
in  any way being predictive  of success at long-term moderation, while the client's attachment to continued drinking would be powerfully
 reinforced by  achieving this two week success which has been validated by a professional."
 

My reply (Alex DeLuca):

I appreciate the seriousness of your question,  and  you state it well. In fact, though, the 'success' rate, in my  experience,  is zero - no one that I have ever administered this intervention to has  'passed the test,' if you will., though several were certain they would.

This is true for several reasons:

First, the occasion to do a trial of controlled  drinking very rarely arises in the normal course of the clinical practice of  addiction medicine in an addiction treatment center. Most people present  for  treatment quite experienced with attempting controlled drinking - and most know from this bitter experience that they can't do it, nor do  they  aspire to it. The overwhelming majority of patients we see for the first time at Smithers have  tried to control or quit drinking several times  via  AA, or other treatment centers, or 'geographic cures' of various sorts such  as new jobs, new spouses, and so on. What I am saying is that,  with  the exception of the patients in our college outreach program, I  don't  meet many 'treatment virgins'.

To me, this is a problem, that in fact, people  do  not often seek the help of an addiction medicine professional until they  have  struggled themselves without help for too long. I think that one  reason  some people avoid treatment is that recovery is always presented  in  black and white terms. Maybe if we in the treatment field were more  open to  ambivalence and questioning, instead of being so quick to label people, so quick to "confront denial," so ready with the 'tough  love' -- maybe people would come in earlier? I don't know.

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Second, the diagnosis is usually quite clear after a  complete evaluation, especially one as objective and rigorous as ours  (we use nationally validated instruments and measures to the  greatest  extent that we can). Either the patient is experiencing multiple  alcohol-related problems or they aren't. The patient may in fact not understand  the  relationship between the problems and the substance abuse, but that  substance-related problems exist  (including withdrawal, medical complications,  psychiatric complications, social problems) is usually not a question. For  example, you would not want to or need to do a trial of controlled drinking  in a  person manifesting alcohol withdrawal syndrome.

Finally, I usually suggest such a trial only to patient's I am pretty sure can't drink in a controlled manner. I am not  doing  research here. That is why I do trials of controlled drinking with  patients  -- to help them come to  understand the degree of their dependence on  alcohol, that in fact they can't 'take it or leave it', or that if they do  stick to the limits of the trial they are in fact miserable, not happy  social  drinkers.

So I've never been in the position of validating  'success' with controlled drinking.

You also wrote:
"This is re: your FAQ answer concerning 'the  brief  trial of controlled drinking.' What do you do when the client  successfully controls his/her drinking for the "usually two weeks" you mention  as the duration of the trial? "

Did I use the word "brief"? I'll have to check.  I  didn't mean to imply that a trial of controlled drinking was itself a  treatment or that the intervention was over in two weeks or that a  trial  of controlled drinking  would ever constitute an entire evaluation and  treatment of a patient. I  mentioned two weeks because that is usually when  I schedule the next  appointment, not when I schedule a graduation party  celebrating the  discovery of another social drinker.

XXXX, I run an abstinence-oriented treatment  center  offering the entire  range of treatment from intensive hospital detoxification to low intensity  outpatient treatment and everything in between.  I  devote my professional  life to helping get and stay sober.

It is  interesting to me that the mere  mention of 'controlled drinking' or 'harm  reduction'  or the fact that *some*  (I didn't say 'all', I didn't say 'most') people who  meet criteria for  alcoholism do become people that can drink without  apparent problem (for example, many people meet criteria for diagnosis of  alcoholism as teens or  young adult and do not become lifelong alcoholics)  --- the mere mention of  such things is treated like some religious blasphemy and is met with  pathetic full page ad's in the NY Times and the like  (Sunday, page 19, I  think).

People of good will can disagree. If we can't discuss this like  professionals, if different points of view can't exist in our field, if discussion of research is met with cries of  'infidel!', then we don't  deserve to call ourselves professionals, or call our  field "medicine" or  "science", or charge for our services.

...alex...
A.F. DeLuca, M.D.
Chief, Smithers Center
adeluca1@bellatlantic.net

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