‘Once an alcoholic, always an alcoholic’ is outdated. Here’s why

By Kristen Rogers, CNN

(CNN) — Brad Pitt’s recent revelation that he’s drinking again in “a more restrained manner,” after seven years of sobriety following heavy drinking, sparked intense pushback. The actor’s past behavior aside, the larger controversy was in challenging the long-held idea that someone who struggled with alcohol in the past can’t ever drink normally — that recovery is defined solely by sobriety.

The controversy Pitt stepped into comes down to old versus relatively new approaches to dealing with drinking problems. What makes someone “recovered” from alcohol addiction has seen “an evolution in health care,” said Dr. Smita Das, addiction psychiatrist in the Addiction Medicine Dual Diagnosis Clinic at Stanford University in California.

Relevant medical fields in recent years have widely embraced the idea of a spectrum of recovery, including sobriety and non-abstinence, but some clinicians, abstinence support organizations (most notably Alcoholics Anonymous), and patients with alcohol issues haven’t caught up to the science — or are downright opposing it.

Pitt simply gave voice to the expanded understanding of recovery from what is commonly called alcohol addiction or alcoholism, but has been officially known as alcohol use disorder, or AUD, since 2013, according to the DSM-5. That’s the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — the authoritative handbook of mental disorders published by the American Psychiatric Association and used by mental health professionals in the United States.

The body of research on non-abstinent recovery has been growing as well. A small study in February examined how low to moderate drinking can be part of successful recovery for some. Compared with the abstinent group in that study, those who continued to drink felt more confident they could limit their intake. Participants who drank also felt that positive life changes and supportive relationships bolstered their efforts to maintain recovery.

In a larger 2025 study about non-abstinent recovery, about 1,900 participants reported drinking in the past month — and their health and functioning were similar to those of abstinent participants, though they were slightly more likely to be experiencing psychological distress.

Redefining alcohol use disorder and recovery

Alcohol use disorder is defined by the DSM-5 as “frequent or heavy alcohol drinking that becomes difficult to control and leads to problems such as in relationships, work, school, family, or other areas.”

Someone can have mild, moderate or severe AUD depending on how many criteria they’ve experienced in the past year. This definition was a broader move away from previous DSMs’ binary diagnoses of alcohol abuse and alcohol dependence. The “abuse” diagnosis required that a patient was experiencing severe or dangerous consequences such as alcohol-related legal problems or failure to fulfill major obligations. The “dependence” diagnosis referred to serious but less severe issues, such as abandoned interests and repeatedly failed attempts to quit drinking.

The DSM-5 definition of AUD supports the idea that sobriety “is a part of the definition of recovery, but it is not the whole thing,” Das said — since patients can also reach remission by reducing drinking and whatever criteria that led to their diagnosis.

Researchers with the US National Institute on Alcohol Abuse and Alcoholism, or NIAAA, published a paper on a new definition of recovery from AUD in 2022 — calling it a process or outcome in which someone pursues or achieves both remission from AUD and cessation of heavy drinking.

Remission requires that a patient have no AUD criteria besides craving. Someone who hasn’t had any criteria for up to three months is in initial remission — three months to one year is early remission, one to five years is sustained, and more than five years is stable. For men, cessation of heavy drinking means having no more than four standard drinks on a single day or 14 drinks weekly, and for women, maximum three drinks on one day or seven drinks weekly, the authors wrote.

The fulfillment of basic needs also factors into recovery, the authors added, as do enhancements or improvements in social support, spirituality, physical and mental health, and other aspects of well-being.

Before, while some studies had examined non-abstinent recovery in various ways, there wasn’t an operational or measurable definition that would help researchers better chart and study recovery. This lack meant “we really had no systematic studies on what constitutes recovery, how long it lasts and, more importantly, how to improve recovery,” said Dr. George Koob, NIAAA director and senior author of the paper. He and his coauthors worked with other researchers, clinicians and recovery specialists and incorporated the DSM-5 criteria.

The NIAAA definition has been accepted by many medical authorities and has been facilitating research, as the authors hoped, experts said.

The DSM-5 and NIAAA work increase access to care by not making patients feel like they have to be perfect to be considered recovered, which can be intimidating and prevent effort to heal, experts said. The work also lowers barriers in technical ways — the ability to be diagnosed with mild or moderate AUD makes you eligible for insured care before you hit rock bottom and need more expensive and intensive help. Not defining recovery by abstinence only is also aiding efforts to develop or broaden access to AUD medications.

But is abstinence still better?

Abstinence works best for most people, experts say. And those choosing abstinence experience the most progress in physical health, quality of life and psychosocial functioning, which is the ability to manage one’s daily life, psychological well-being and social environment, the NIAAA researchers wrote. But, they added, a growing body of evidence shows that remission from heavy drinking also is linked to meaningful, long-term improvements.

Another study, from 2019, found those who achieved abstinence and people who achieved just remission from heavy drinking had similar health care costs five years after treatment, and similar psychosocial functioning at one year and nine years post treatment. A 2025 study on recovery attempts as defined by NIAAA, however, found that participants who still drank were more likely to relapse.

There isn’t much research on predictors for who can drink normally, said Das, who is also a clinical professor of psychiatry and behavioral sciences at Stanford’s School of Medicine. But per her clinical experience and the 2025 study, light or moderate consumption of alcohol may be more feasible for people who didn’t have severe AUD, for those who don’t have underlying mental health issues or have healed or learned to manage them, for those who have been sober for years, or for individuals no longer in the situation in which they started drinking.

Of course, regarding overall health, no amount of alcohol is good for you, as even low consumption has been linked with higher risk for issues including dementia, cancer, high blood pressure and stroke.

‘Once an alcoholic, always an alcoholic’

Much of the general public, however, hasn’t caught up to these developments, which remain strongly discouraged and criticized by the abstinence support group space — especially proponents of AA.

The ideas of “once an alcoholic, always an alcoholic” and that abstinence is the only way to recovery stem from the predominant messaging and influence of AA, which began in 1935, said Dr. Michael Joshua Ostacher, a member of the American Psychiatric Association’s Council on Addiction Psychiatry.

“‘Alcoholic’ is a term that’s adopted by Alcoholics Anonymous to identify its own members, and by which their own members identify themselves,” added Ostacher, who is also a professor of psychiatry and behavioral sciences at Stanford’s School of Medicine.

This approach is based on the idea that AUD is an incurable illness, Das said, and, in some people’s minds, that all cases result from a brain already prone to addiction. Hence the belief — and often lived experience — that even just a sip of alcohol can make anyone relapse regardless of any recovery work done or number of years sober. These factors have created a culture in which people who return to normal drinking are often told by sober people that if they can do so without their consumption becoming excessive and destructive, they were never an “alcoholic” or “true addict” in the first place — maybe just someone who was emotionally dependent on alcohol.

On one hand, while the “always an alcoholic” phrase “is clinically outdated,” for vulnerable people it’s a protective behavioral boundary preventing them from attempting risky experiments, Das said.

Abstinence and 12-step programs, including AA, have proven to be significantly effective for many people worldwide, Ostacher said — AA had nearly 2 million active members and more than 120,000 groups worldwide as of 2021, according to the organization’s data.

The more nuanced reality

On the other hand, the debate reflects a clash between the medical and cultural frameworks used to make sense of addiction, Das said.

“Addiction is not universally a fixed, unchangeable neurological state,” Das said. Someone can meet criteria for severe AUD at age 21, and then, with treatments, brain maturation, lifestyle changes and/or years of abstinence, be diagnosis-free at age 40. The brain is a muscle with adaptable neurocircuitry that can be healed by those interventions, Das added — but there are also people whose deeply affected neural reward and habit pathways may not heal entirely.

“To claim someone who went through that hard work ‘never had a problem’ minimizes the real medical struggle they overcame,” Das said. “It would be like telling someone who was obese and now thin after a lot of hard work, that they never were obese.”

Additionally, AA and its principles don’t work for everyone, experts said. But “from AA’s perspective, it didn’t work for them because they didn’t work the program hard enough, or they weren’t honest enough to work the program,” Ostacher said.

A setting wherein one drink is a violation of recovery and necessitates starting over can make people feel ashamed, even if they’re really trying — which can lead to more serious relapses. Kenneth Anderson, a 68-year-old man from Philadelphia, said, “I never drank as much in my life as when I was in AA.”

The requirement for belief in a higher power also doesn’t resonate with everyone. Anderson, an atheist, added that he felt the insistence that “humans are powerless and can only be rescued from alcohol by an omnipotent deity” was a “terrible, damaging message.” Anderson struggled with AUD from roughly the 1980s to 2000s, but now has only one or two drinks every few months if he wants, while practicing other important elements of recovery. For him, those include managing the online HAMS (Harm Reduction, Abstinence and Moderation Support) group he founded that has more than 13,000 members.

Importantly, various factors contribute to AUD and may not be addressed by AA, experts said. Those include genetics, neurological vulnerabilities, life stressors and mental health issues — 50% of people with a substance use disorder have a mental health condition.

Honest self-assessment

When a patient who has recovered and improved their life asks Das about drinking again, she asks about their true motives, any potential risks and the behaviors that sustain their goals.

Sometimes a patient wants to have a drink with friends to feel included or less anxious. In those cases, Das might recommend they buy a mocktail or practice coping skills instead. If they’re thinking alcohol could help them unwind, Das encourages them to consider what else might relax them and maybe even benefit them in other ways.

Part of the risk is that alcohol inherently reduces our ability to make wise judgments, including whether we have had enough or more than planned, Das said. And even if you can drink and still be clinically recovered, there may be other reasons to choose abstinence — maybe your issues harmed loved ones, and they would be emotionally destabilized or offended by you drinking again.

“If they are very set on returning to drinking, then we have a conversation about, ‘OK, what are the things that you’re going to do to try to reduce the consequences that occurred before?’” Das said. She reviews with the patient the DSM-5 criteria they previously met so that they can recall the situations that led to problems — for example, if drinking alone makes them drink too much and spiral emotionally. “So then we say, ‘OK, drinking is only in social situations, and you have a limit,’” Das added. She and the patient then schedule follow-up appointments and keep a log of how everything’s going.

If you drink, watch for signs that it may be becoming problematic again, experts said — such as if you’re often not sticking to your rules or making them too flexible. If you’re currently struggling with alcohol, know that 1 in 10 Americans ages 12 and older have AUD, Das said. Discussing it honestly can lead you to the right treatments: outpatient or inpatient rehab, medications and therapies including cognitive behavioral therapy with relapse prevention, which is the most used therapy.

Both abstinence and moderation support groups can be helpful. Moderation Management, a member-run nonprofit founded in 1994, is a popular and professionally endorsed alternative to the abstinence approach. It has virtual and in-person sessions and encourages members to follow a nine-step program. They include doing an initial 30-day period of sobriety, examining how drinking has affected one’s life, making positive lifestyle changes and setting moderate drinking limits.

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