How do you manage patients with alcohol use disorder who express interest in moderation rather than full abstinence?

In the past, I would try to engage these patients in complete recovery—AA, etc. Today, having read the literature on harm reduction and perhaps being more experienced and tolerant with age, I engage the patient in healthcare activities like exercise, sleep, and diet, and discuss recovery from alcoholism not in absolutes but in a graded manner. If the patient keeps "coming back" to me, we have a chance to improve his/her health gradually. Needless to say, this approach does not work with individuals who have severe end-organ damage from their alcoholism, for which drinking should not continue.

With humility. I don't have a crystal ball, and I can't say how any one particular patient will do with an attempt to reduce their use. I have crossed paths with people who do moderate their use, and their life improves (fewer symptoms of AUD).

That said, I think it's also my responsibility to share the experience of other patients I've learned from. It's rather rare that I've seen someone who can go back to being a "casual" drinker, and by that I mean a person who can enjoy an alcoholic beverage or two and not have to think more about it. I do see some who can become "controlled" drinkers, by which I mean they can very carefully monitor what and how much they're drinking and adhere to their limit. That's not the light and casual experience...

Great question.

In my shared clinical experience with colleagues, the vast majority of patients with alcohol use disorder are not seeking full abstinence but prefer to become more 'sensible drinkers'. The WHO published guidelines some years ago that showed if treatment for AUD can help a person drop their drinking levels from severe (20+ drinks a week) to moderate or, better still, mild levels, then health benefits from reducing use become manifest. Abstinence was not the goal.

As Dr. @Dr. First Last noted above, harm reduction, improving health status, getting the individual functional, and maintaining lifelong treatment are the fundamentals of any substance use disorder treatment.

Regards.

Present evidence shows we can help someone become a controlled drinker with the help of naltrexone. The difference is that, in contrast with social drinking, the controlled drinker still obsesses about the "drink." Still much better, less harmful, and more acceptable. Naltrexone is obligatory.