Alcohol use disorder (AUD) is a serious, chronic medical condition involving a problematic pattern of alcohol use leading to distress or impairment. Understanding the nature of this disorder and the profound biological changes it causes is necessary to appreciate the risks involved in attempting to return to drinking.
Understanding Alcohol Use Disorder
Alcohol Use Disorder (AUD) is the current clinical term, replacing “alcoholism.” Diagnosis is based on meeting specific criteria within a 12-month period, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). These criteria include strong cravings, an inability to control alcohol use, and continuing use despite persistent problems in major life areas like work or relationships.
The severity of AUD is determined by the number of criteria an individual meets, ranging from mild to severe. AUD is recognized as a chronic brain disease, not a moral failing, where the brain’s reward, motivation, and memory circuits become dysregulated. This neurological shift fundamentally alters the individual’s relationship with alcohol, driving compulsive use despite negative consequences.
The Standard of Abstinence in Recovery
For individuals diagnosed with moderate to severe AUD, abstinence from alcohol is the standard recommendation among medical and therapeutic professionals. The primary goal of recovery is to halt the disease’s progression and allow the brain to begin healing from the chemical changes caused by chronic alcohol exposure. Removing the addictive substance entirely is considered the safest and most reliable path to achieving this goal.
A significant biological risk factor supporting the abstinence model is the “kindling effect,” caused by repeated cycles of intoxication and withdrawal. Each subsequent withdrawal episode tends to be more severe than the last. This neuroadaptation increases the brain’s excitability, raising the risk of life-threatening events like seizures and delirium tremens with every relapse. The kindling effect also intensifies emotional symptoms like anxiety and craving, making a return to controlled drinking dangerous for those with a history of alcohol dependence.
Exploring Controlled Drinking Models
Despite the medical recommendation for abstinence, some individuals with AUD explore controlled drinking models. These approaches aim for a reduction in alcohol consumption to low-risk levels rather than complete sobriety. Controlled drinking is considered only for individuals with mild AUD who have never developed physical dependence or experienced significant withdrawal symptoms.
Research suggests that success is most likely for those whose baseline alcohol consumption and overall AUD severity are lower. However, for those with moderate or severe AUD, the attempt to moderate is high-risk because the core feature of the disorder is the loss of control. Once drinking begins, the neurological changes associated with AUD often override the intention to stop, leading back to heavy consumption.
Biological Factors Affecting Relapse
The difficulty in maintaining controlled drinking stems from neurobiological changes caused by chronic alcohol exposure. Alcohol dysregulates the brain’s reward pathway. Acute alcohol consumption causes a surge in dopamine, reinforcing the behavior, but chronic use leads to a decreased overall dopamine function in the brain.
This dopamine dysregulation results in a state of anhedonia, which contributes to the intense craving for alcohol. Chronic alcohol use also impairs the prefrontal cortex, the area responsible for executive functions like impulse control and decision-making. The resulting cognitive impairment and weakened “Stop” system make it challenging to resist the impulse to drink, even when fully aware of the negative consequences.
Foundational Support Systems for Long-Term Sobriety
Once the decision for abstinence is made, establishing a support system is paramount for long-term recovery. Support includes behavioral therapies, medication, and mutual support groups. Professional psychological counseling, such as Cognitive Behavioral Therapy (CBT), helps individuals identify triggers and develop coping strategies to manage cravings and stress.
Medication-Assisted Treatment (MAT) involves using medications like naltrexone or acamprosate to reduce craving and block the rewarding effects of alcohol, which lowers the risk of relapse. Mutual support groups, such as 12-step programs or alternatives like SMART Recovery, provide a community of peers and a structured framework for sustained sobriety. These layers of support—medical, therapeutic, and peer-based—form the foundation necessary to navigate the challenges of recovery and maintain sobriety.