by William R. Miller and Ricardo F. Muñoz
Guilford Press, 2013
Review by Sharon Packer, MD on May 6th 2014
Before I write another word, I should mention that this book claims center-stage on my desk. . Any patient who walks into my office, expressing concerns about a drinking problem, and yearning to change those patterns, is shown this book and encouraged to read it. What better endorsement can there be, except to say that I also strongly recommend this book to treaters.
Drs. Miller and Munoz deliver exactly what they promise, and more. This excellent book offers easy-to-use tools to make moderation work (for some people), yet it does not promise that moderation will work . . . for everyone. There is nothing evangelical or hyperbolic about this text; it is a "just the facts, ma'am" approach, straight shooting and levelheaded. These statistics-packed pages embed the data in narratives, to make it easier to absorb the multiple factoids that pepper the pages. It does not feel like a Ph.D. dissertation, even though it is based on literally decades of research performed by two seasoned psychology professors.
Interestingly, the authors confirm that those who follow the program outlined in their book for 20 weeks enjoy equal success rates as those who enter "counseling." The authors do not insist on AA, Smart Recovery or various 12-step groups, nor do they dismiss those traditions. Instead, they provide links to recovery-oriented groups, and suggest alternatives that have less emphasis on spirituality. They do recommend keeping cards to chart drinking patterns, and in this way they corroborate techniques that are detailed on the NIDAA.gov website about "rethinking drinking".
Without getting preachy, this book dispels the idea that "everyone drinks" (which is a comment that those of us who treat people who over drink often hear). Using easy to read graphs, the authors inform us that about 70% of women either do not drink at all or drink one drink or less per month. For men, this percentage drops to about 50%, but even that number is striking, given our expectations.
The authors admit that they over-sampled non-urban regions, leaving us wondering if their data capture drinking prevalence in major metro areas, such as NYC or LA. To boost our level of confidence, we can read data released by NYC restaurants with liquor licenses, published in the NY Times Food Section, pre-recession era. The Times concurs: 25% of New York diners do not order any alcohol at all.
The authors never mention the tragic story of a "moderation drinking promoter" who fervently opposed abstinence or AA. Her DWI inadvertently led to vehicular manslaughter of two persons, a father and his daughter. There is no room for gossip or sensationalism in this down-to-earth book, which admits that fewer than 25% of those who try moderation drinking will succeed this way, and that just as many will opt for abstinence after attempting moderation. This book makes helpful suggestions for those attempts and encourages readers to give this a fair shot. It also cites behavior traits and drinking patterns that lessen the likelihood of moderating drinking—without avoiding alcohol altogether.
My only point of contention concerns the few parenthetical paragraphs about medications available to help motivated drinkers minimize their drinking. This information is out-of-date, which should not be surprising, considering how quickly pharmacological advances occur. The authors state that an important medication (presumably injectable naltrexone) is unaffordable or not covered by insurance. That is true, but the generic oral form of this same medication, naltrexone, is within anyone's budget. Another medication, taken three times a day, is also available only as a brand name product, but studies published in the prestigious New England Journal of Medicine note that the lower cost, well-studied generic naltrexone outperformed the costlier and newer brand name competitor.
Plus, other meds show promising results in double-blinded studies. Anticonvulsants such as topiramate, zonisamide, and gabapentin are very helpful, especially in persons with specific genotypes. The January 2014 issue of American Journal of Psychiatry elaborates on these genetic links. The anti-nausea medication, ondansetron, helps reduce cravings and drinking days in otherwise hard-to-help, early onset drinkers who have strong family histories of alcoholism. Even the muscle relaxant baclofen has benefits. While I agree that some expensive brand name meds disappoint (and often do not show as good success rates as more affordable alternatives), I strongly urge readers to reevaluate the potential benefits of psychopharmacology. There are far more options than the old (and often unsafe) Antabuse.
At the same time, I strongly recommend this book to both health care practitioners and potential patients alike. For busy PCPs who want to give their patients a head start at heading off drinking problems (especially if medical consequences are apparent), this is a way to go. For mental health or addiction specialists who learned to think in absolutes, this flexible model is refreshing. Prescribers who provide medications to persons with alcohol problems will welcome this companion.
It would be fascinating to use this excellent book in conjunction with medications that have shown success in a high enough proportion of the population. Even if we do not see 100% remission of alcohol overuse in 100% of those who try to reduce their drinking, any extra benefits would be a boon. I hope that the authors decide to collaborate with other practitioners to study this combined approach.
© 2014 Sharon Packer
Sharon Packer, MD is a psychiatrist who is in private practice in Soho (NYC) and Woodstock, NY. She is an Asst. Clinical Professor of Psychiatry and Behavioral Sciences at Albert Einstein College of Medicine. Her books includeDreams in Myth, Medicine and Movies (Praeger, 2002), Movies and the Modern Psyche (Praeger, 2007) and Superheroes and Superegos: The Minds behind the Masks (Praeger/ABC-Clio, 2010). In press or in production areSinister Psychiatrists in Cinema (McFarland, 2012) and Evil in American Pop Culture (ABC-Clio, 2013, co-edited with J. Pennington, PhD.) She can be contacted at firstname.lastname@example.org .