To the Editor:
In a commentary on our paper examining long-term outcomes of treatment for alcohol use disorder (AUD),1 Kelly and Bergman2 raised a number of questions, concerns, and areas worthy of future inquiry. Although they agreed with several of our conclusions, they noted concern with our findings that suggested occasional heavy drinking might be part of the recovery process for certain individuals with AUD. They also mischaracterized our explicit emphasis on the importance of both functional and drinking outcomes in defining long-term recovery from AUD.
The Kelly and Bergman commentary2 fails to consider the drinking reductions in the heavy drinking high functioning profile. Drinking reductions are associated with improvements in health and functioning in general population and treatment-seeking samples.3–5 We agree that excessive toxicity should be considered2 and highlight that toxic levels of alcohol use were reduced in our sample.6 Reductions in drinking, even if above somewhat arbitrary thresholds for low-risk drinking,7 should not be discounted.
A myopic focus on abstinence can create undue shame and stigma for those who experience lapses to heavy drinking after treatment (the norm, not the exception), and restricts the potential reach of treatment. Given that most individuals with AUD do not seek treatment and many do not want to abstain, it is imperative to acknowledge the benefits of decreased consumption and increased functioning as acceptable treatment and public health goals. Our empirical findings indicate that reductions in heavy drinking are achievable and maintained, and that the reductions are associated with considerable improvements in health and functioning.
Kelly and Bergman2 seem to be of 2 minds when considering definitions of recovery that emphasize life functioning and quality of life.8,9 They2 agree that definitions of recovery should consider life functioning measures, and point to intrapersonal examples (happiness, self-esteem, irritability) and interpersonal examples (social harms to children and partners.) However, they seem resistant to including high functioning occasional heavy drinkers in their conceptualization of a recovery process, despite our findings that this profile endorsed low levels of depression, high levels of relationship satisfaction, and high levels of life satisfaction. We certainly agree with Kelly and Bergman's call for more research on collateral social damage and further study of individuals who achieve reductions in alcohol consumption without improvements in functioning.10 But continued exclusive focus on abstinence and alcohol consumption metrics, which have dominated AUD research and treatment, does not consider broader life-health functioning and fails to address the needs of those attempting recovery who require additional support, as well as larger social system changes.
In sum, the high standards of sustained abstinence or remission of all AUD symptoms cannot serve as sole criteria for success. Focusing primarily on abstinence and remission trivializes lesser but substantial reductions in alcohol consumption, the full dimensionality of recovery, the spectrum of severity of AUD, and ultimately provides a bridge to nowhere, with limited impact on public health and the lives of millions of people with AUD.
1. Witkiewitz K, Wilson AD, Roos CR, et al. Can individuals with alcohol use disorder sustain non-abstinent recovery? Non-abstinent outcomes 10 years after alcohol use disorder treatment. J Addict Med
2. Kelly JF, Bergman BG. A bridge too far: Individuals with regular and increasing very heavy alcohol consumption cannot be considered as maintaining “recovery” due to toxicity and intoxication-related risks. J Addict Med
3. Hasin DS, Wall M, Witkiewitz K, et al. Change in non-abstinent WHO drinking risk levels and alcohol dependence: A 3 year follow-up study in the US general population. Lancet Psychiatry
2017; 4 (6):469–476.
4. Witkiewitz K, Hallgren KA, Kranzler HR, et al. Clinical validation of reduced alcohol consumption after treatment for alcohol dependence using the World Health Organization risk drinking levels. Alcohol Clin Exp Res
2017; 41 (1):179–186.
5. Witkiewitz K, Kranzler HR, Hallgren KA, et al. Drinking risk level reductions associated with improvements in physical health and quality of life among individuals with alcohol use disorder. Alcohol Clin Exp Res
2018; 42 (12):2453–2465.
6. Witkiewitz K, Wilson AD, Pearson MR, et al. Profiles of recovery from alcohol use disorder at three years following treatment: Can the definition of recovery be extended to include high functioning heavy drinkers? Addiction
2019; 114 (1):69–80.
7. Pearson MR, Kirouac M, Witkiewitz K. Questionning the validity of the 4+/5+ binge or heavy drinking criterion in college and clinical populations. Addiction
2016; 111 (10):1720–1726.
8. Ashford RD, Brown A, Brown T, et al. Defining and operationalizing the phenomena of recovery: A working definition from the recovery science research collaborative. Addict Res Theory
2019; 27 (3):179–188.
9. Witkiewitz K, Montes KS, Schwebel FJ, Tucker JA. What is recovery? A narrative review of definitions of recovery from alcohol use disorder. Alcohol Res Curr Rev
2020; 40 (3):1–12.
10. Witkiewitz K, Pearson MR, Wilson AD, et al. Can alcohol use disorder recovery include some heavy drinking? A replication and extension up to nine years following treatment. Alcohol Clin Exp Res
2020; 44 (9):1862–1874.