Abstinence Is Not the Only Option

Here we provide a brief review of existing models of nonabstinence psychosocial treatment, with the goal of summarizing the state of the literature and identifying notable gaps and directions for future research. Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review. We first describe treatment models with an explicit harm reduction or nonabstinence focus. While there are multiple such intervention approaches for treating AUD with strong empirical support, we highlight a dearth of research testing models of harm reduction treatment for DUD. Next, we review other established SUD treatment models that are compatible with non-abstinence goals.

• These are all valid reasons, and many can accomplish their goals without needing a treatment center.
• Given the field’s historical emphasis on abstinence-based approaches, key individual factors to treatment outcome remain more of a mystery when it comes to moderation-focused treatment, sometimes called “harm reduction”.
• These goals differ from person to person and range from total abstinence to reduced alcohol consumption.
• Furthermore, this article did not include multiple follow-up time points for analyses due to the limited outcome designs of the eligible studies.
• For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment.
• Regarding SUD treatment, there has been a significant increase in availability of medication for opioid use disorder, especially buprenorphine, over the past two decades (opioid agonist therapies including buprenorphine are often placed under the “umbrella” of harm reduction treatments; Alderks, 2013).
• Treatment professionals can advise if supervised detox is required, and provide next steps tailored to your needs.

Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically. However, to date there have been no published empirical trials testing the effectiveness of the approach. This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD. We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms. We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research.

The Illusion of Control

Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. This study conducted a systematic review and network meta-analysis (NMA) of psychotherapies for AUD, which will provide a reference for clinical application and evidence-based research directions of psychotherapy for AUD.

Please feel free to get in touch with me to book a FREE phone or Zoom consultation using the link below. Taking the time to focus on yourself and your mental health is essential for successful recovery. Exercise can help to reduce stress and anxiety, while rest can help to restore energy and focus. Seeking therapy or counseling can provide a safe space to process emotions and gain insight into your triggers. A lapse is a brief return to drinking or using drugs, but the individual quickly stops again. Relapsing is when the individual returns to drinking or using drugs after a period of sobriety.

Abstinence vs moderation: What’s best for you?

This team of researchers undertook to compare self-identified members of Moderation Management with self-identified members of Alcoholics Anonymous (AA). They looked at demographics—who attends AA versus who attends MM—as well as the relative severity of the drinking problems in the two groups. Expert opinions on safety and levels of alcohol consumption have generally varied over the years, with some studies even citing the potential benefits of an occasional cocktail or glass of wine. You might wonder if there’s a healthy way to drink, how much alcohol consumption is considered moderate, and how much is too much. A permanent commitment to abstinence means we no longer have to fight a battle with moderation; but rather devote ourselves to sobriety permanently. Ours is a “no excuses” program, we are responsible for our decisions and behaviors; we have a choice.

For changes in craving, available for 12 treatment arms (259 participants), all 4 active interventions and 2 controls (TAU and TAU+PLC)) were included (Figure S10B). TAU+PLC (67.5%) had the highest probability of being best accepted, followed by TAU+SP (44%) and TAU+CBT (40.6%). Among the SUCRA rankings, TAU+PLC, TAU+SP, TAU+CBT, CBT, and TAU+VSTN were ranked 1.4, 2.4, 2.8, 4.0, and 5.1, respectively, alcohol abstinence vs moderation and TAU was the lowest (5.3). No treatment showed a significantly better effect than TAU or TAU plus PLC (Figure S11C and Table S12B). Three authors (T.P. and Z.C. and P. Z.) separately assessed the quality of all reports using the Cochrane risk-of-bias tool for randomized trials (RoB)27 to evaluate study methodological rigor with low, high, or unclear risk of bias (ROB) ratings for each domain.

Is abstinence the only way?

In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013).

• A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021).
• When your drinking is under control, you may have the internal bandwidth to accept the professional psychological support that can help you develop healthier ways of coping.
• In contrast to the holistic approach of harm reduction psychotherapy, risk reduction interventions are generally designed to target specific HIV risk behaviors (e.g., injection or sexual risk behaviors) without directly addressing mechanisms of SUD, and thus are quite limited in scope.
• Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches.

You may be able to gradually decrease the amount you drink without needing to go for full abstinence from alcohol. 12-step programs alone do not usually address the underlying need that’s been suppressed through alcohol. Without addressing those needs, it’s like trying to cap an active volcano with a giant boulder. Sooner or later, the pressure will build up and the volcano will explode—or you will relapse. If you use alcohol to manage stress or self-medicate, fear of how you’ll cope without alcohol might hamper your efforts to regain control of your drinking. If you consider alcohol as a coping strategy, then it makes sense why heading straight to abstinence would be terrifying.

One Glass a Day? The Impact of Low Volume Drinking on Mortality Risk

Keeping alcohol in your life in a healthy way can be really challenging, especially for people who have exhibited more severe drinking habits and patterns. Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). To date, however, there has been little empirical research directly testing this hypothesis. Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment. This literature – most of which has been conducted in the U.S. – suggests a strong link between abstinence goals and treatment entry.