Can moderation join abstinence as an addiction therapy?


In 2001, as 25-year-old Adi Jaffe lay on the pavement in the intersection of Beverly Drive and Olympic Boulevard following a devastating motorcycle crash, his broken tibia and fibula were not his biggest problem. Rather, that would be the amount of cocaine he was carrying (and selling), which could easily have netted him 20 to 30 years in prison.

Unable to walk and in need of immediate medical attention, Jaffe was arrested on the spot. 

Thirteen years later, Jaffe is now executive director and co-founder of Alternatives Addiction Treatment, an outpatient rehab clinic focused on helping substance abusers, primarily alcoholics, who are losing — or have lost — control over their lives. 

Jaffe said in an interview in the center’s Beverly Hills office that he resisted entering a treatment program until his attorney informed him that if he did not admit to being a methamphetamine addict (which he was) and commit to a rehab program, he would face a long prison sentence. 

The Tel Aviv native entered a 12-step program while serving a one-year sentence at Los Angeles County Men’s Central Jail. After sobering up, Jaffe earned a doctorate in psychology from UCLA and is now a seasoned researcher and clinician, specializing in understanding how people fall into addiction. He’s also been successful at helping them recover.

One catch, though: While Jaffe himself went through a 12-step program — the consensus go-to treatment for overcoming addiction — and abstained for three years before slowly reincorporating alcohol into his life, he now believes that telling everyone with any dependence on alcohol that they must never drink again — a core tenet of the 12 steps — does more harm than good. 

Jaffe, along with clinical psychologist and recovered alcoholic Marc Kern, runs Alternatives, with treatment centers in Beverly Hills and Irvine. Their program operates on the notion that moderation, not abstinence, is often a preferable treatment option for alcoholics, or at least those in the early stages of dependence. For 40 years, the idea that people with drinking problems serious enough to need treatment would be able to learn to stop at just a few drinks has generated fierce debate and has failed to gain a foothold in the mainstream addiction recovery world. 

Today, Jaffe’s program, and a growing number of programs like it in the United States and Canada, is offering the option of a middle path, indicating a sea change may be developing, however slowly.

“Most people who struggle with drugs and alcohol are actually not those stereotypical addicts who need lifelong abstinence,” Jaffe said. “Most people don’t fall into that bucket; they just get dropped into it for lack of another bucket.”

The Alternatives program and other “controlled use” centers offer both a moderation and an abstinence track — the former, Jaffe believes and research indicates, is in fact more effective for alcoholics with severe dependence than abstinence tracks.

Jaffe likens the abstinence-only approach to a doctor advising a patient experiencing foot pain to amputate below the knee — the solution, he believes, may be an overreaction to the problem, and the all-or-nothing approach can scare away people who need treatment but aren’t willing to commit to forgoing alcohol for the rest of their lives.

“You really don’t want to go for the hardest, most restrictive version of treatment first,” Jaffe said. “Most diabetics don’t go to daily insulin right away.”

Jaffe and Kern opened Alternatives in 2013 and have so far graduated 29 people. According to Jaffe, of the clients still sending information to the center, 12 are now abstaining and eight to 10 are drinking in moderation.

In place of the 12-step model, which emphasizes an addict’s powerlessness over alcohol and the need for a God-based, spiritual element in recovery, Jaffe’s clients work on mindfulness training, neuro-feedback tests and other advanced science-based treatments that seek to change the habit-forming parts of an addict’s brain.

In their first week at the clinic, which Jaffe terms “boot camp,” clients have 32 hours of one-on-one time with Jaffe, Kern and their team of seven doctors, clinicians and mindfulness experts. The moderation track lasts six months and the abstinence track has both a two-month and six-month option — drinking with control, the co-founders believe, takes more work than not drinking at all. 

Following the initial week, treatments consist of 10 to 15 hours per week doing neurological feedback exercises, therapy sessions and group activities such as hikes, movies and beach visits.

A central social element of Western cultures and widely available in most countries, alcohol’s appeal is not far behind that of sex.So, Jaffe asks, why are alcohol addicts and sex addicts treated so differently? 

“Imagine for a second a treatment for people with sex issues that would dictate that they have to abstain for the rest of their life — nobody would ever go there,” Jaffe said. “But we do it to people with [alcohol] addiction all the time.”

A five-year study published in 2012 by Columbia University’s National Center on Addiction and Substance Abuse found that only about 10 percent of Americans older than 12 who have drug or alcohol addiction seek treatment. 

Modern research on the abstinence-only versus moderation debate dates back to a 1970s study of 20 patients at Patton State Hospital in San Bernardino, in which researchers Mark and Linda Sobell concluded that alcoholics who are taught controlled drinking techniques functioned better after two years than alcoholics taught to abstain. 

Although their study provoked a harsh response from researchers who believed in the 12-step model and accused the Sobells of publishing exaggerated or fraudulent claims, numerous recent studies have indicated a moderation approach can be more effective both in getting problem drinkers to enter into treatment and in keeping them from falling into a state of severe drinking. The Sobells currently run a recovery treatment center at Nova Southeastern University in Florida that bills itself as a “non-12-step alternative treatment.”

A 2006 study by the health research group Cochrane examined data from 40 years of worldwide alcohol treatment and found no evidence that “unequivocally demonstrated the effectiveness of” the 12-step approach in reducing dependence. A 2001-2002 epidemiological study by the National Institute on Alcohol Abuse and Alcoholism looked at 43,000 adult alcohol abusers in the United States and found that among the 35.9 percent of people considered “fully recovered” after one year, 18.2 percent were abstaining and 17.7 percent were “low-risk” (i.e. moderate) drinkers.

A major shift in how medical and treatment professionals view alcoholism is illustrated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (known as the DSM-V), released in 2013, which paints alcohol addiction as a spectrum — people with some form of addiction can either be mildly, moderately or severely dependent, which is a more segmented view of alcoholism than had been accepted in previous editions of the DSM. “Historically it was like an on and off switch,” Kern said. “Either you were addicted or you were not addicted.”

Mark Sobell, in a telephone interview from Florida, said that most existing alcohol treatment programs are geared toward people with severe dependence, who, he said, typically want to abstain and not moderate. They are not created with an eye on those who, as the DSM-V puts it, have mild or moderate alcohol problems — which Sobell said constitutes the majority of people with any form of drinking disorder.

Moderation advocates often point to the reportedly low success rate of 12-step abstinence-focused programs (estimates range from 5 to 10 percent) as one reason programs like Jaffe’s should, at the very least, not be considered taboo. Wayne Skinner, a clinical director at Toronto’s Centre for Addiction and Mental Health (CAMH), indicated in a telephone interview that the uniform abstinence treatment in the United States does not comport with the reality of alcoholism as a “continuum.”

“The treatment ideology in America is very strongly oriented to, ‘If you’ve got a problem you’re an alcoholic, and if you’re an alcoholic you should be abstinent for the rest of your life,’ ” Skinner said, adding that this ideology isn’t particularly helpful given that “the batting average of the abstinent-only approach hasn’t been terrific.” Skinner’s center at CAMH will accept patients who cannot commit to abstinence, or even moderation, but are concerned enough with their own bad habits to seek out treatment.

“[Moderation advocates] are not against people being abstinent, they just want to introduce the idea that for some people it might be possible to moderate your drinking,” Skinner said. “People who have less severe problems often do well with a moderation approach.”

Skeptics of controlled drinking programs, which includes the majority of clinicians in addiction recovery, say that moderation is simply not possible when it comes to a true addict. 

Peter Nathan is a clinical psychologist with an extensive background in alcoholism treatment and research, who once, but no longer, believed that controlled drinking would provide a major breakthrough in alcoholism treatment. He said that, like many junior alcoholism researchers, he began his career doubting the efficacy of 12-step programs, a treatment method he has since embraced.

“At the end of the ’70s I pretty much had come to the conclusion that it was not responsible to continue to provide this kind of treatment, because the data did not suggest that chronic alcoholics were able to get better, were able to resume a pattern of responsible controlled drinking,” Nathan said in a telephone interview. “It’s amazing that it’s still around.”

Distinguishing between alcoholics and those who get “carried away now and again,” Constance Scharff, director of addiction research at the Cliffside Malibu treatment center, believes problem drinkers can benefit from moderation treatment. “You might be able to learn some skills to keep your drinking in check,” she said.

However, while Scharff, like Nathan, considers moderation treatment a “disservice” for people with severe dependence on alcohol, she also does not consider the 12 steps to be an effective treatment method, notwithstanding the valuable camaraderie and support that Alcoholics Anonymous provides. 

“Twelve-step programs, I say it publicly and I’m sorry I have to, that is not treatment — that is not rehab,” she said. “What would we say about a cancer treatment that only had a 10 percent success rate? We’d say that’s terrible.”

Cliffside Malibu’s treatment regimen, which is highly influenced by Scharff’s research, focuses on the structure of an addict’s brain, which, she said, more or less necessitates a lifetime of abstinence if they want to lead productive lives. She pointed to actor Philip Seymour Hoffman, who died last February from a heroin overdose. He had relapsed in 2012 after remaining clean for 23 years. 

“Philip Seymour Hoffman is a great example of that. He hadn’t been using for 23 years, but his brain structure and biochemistry said, ‘You know you’re using like you used to use 23 years ago,’ ” Scharff said. “When you go back into addiction, that old structure of addiction is still there, and it just wipes people out.”

At a point in the abstinence versus moderation debate, terminology becomes a key factor, with some, like Scharff, saying that a “true” alcoholic cannot control his or her drinking, implying that those with some level of dependence who can nevertheless moderate are not technically alcoholics.

“When you tell an alcoholic that they can moderate, you’re lying to them,” Scharff said. Another point Scharff added is that addicts sometimes think, usually mistakenly, that their addiction won’t transfer between substances and that if they abstain say, from meth, they can try to use something else in moderation.

Jaffe, who said that for the past eight years he has consumed alcohol moderately — an average of a few drinks per week — without issue, has had people tell him that he was either never “truly” a drug addict (in addition to once being an alcohol abuser) or that he will eventually relapse because of his decision not to abstain. 

“I don’t know how to answer that,” he said. “Maybe they are right, maybe they are wrong.”