For some individuals, learning to moderate their alcohol consumption can be an effective way to reduce alcohol-related harm while maintaining a level of social drinking. In sum, research suggests that achieving and sustaining moderate substance use after treatment is feasible for between one-quarter to one-half of individuals with AUD when defining moderation as nonhazardous drinking. While there is evidence that a subset of individuals who use drugs engage in low-frequency, non-dependent drug use, there is insufficient research on this population to determine the proportion for whom moderation is a feasible treatment goal.
2. Established treatment models compatible with nonabstinence goals
In 1990, Marlatt was introduced to the philosophy of harm reduction during a trip to the Netherlands (Marlatt, 1998). He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002).
Historical context of nonabstinence approaches
These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006). Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008). Important features common to these groups include low program barriers (e.g., drop-in groups, few rules) and inclusiveness of clients with difficult presentations (Little & Franskoviak, 2010). Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992). For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986).
We defined age of initiation of regular substance use as the age at which participants started regularly using any substance. A representative controlled drinking vs abstinence addiction recovery subset of 39,809 individuals from the GfK KnowledgePanel were sent the screening question via email, to which 25,229 responded (63.4%). This response rate is similar to other nationally representative surveys (Grant et al., 2015, Center for Behavioral Health Statistics and Quality, 2016, Centers for Disease Control and Prevention, 2013). Data were weighted using the method of iterative proportional fitting so as to represent the US civilian population (Battaglia et al., 2009). About half of Americans who self-identify as having resolved an AOD problem continue to use AOD in some form. It appears that although abstinence is, for many, not a requisite for overcoming an AOD problem, it is likely to lead to better functioning and greater well-being.
- We also connect you to sober living options, Alcoholics Anonymous, Moderation Management, and other peer support groups for ongoing support and community.
- The question of whether total abstinence is the only viable path for individuals struggling with alcoholism is a complex and highly debated topic within the realms of addiction treatment and recovery.
- Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence.
- In conclusion, while abstinence remains a critical goal for many in alcohol treatment, the concept of moderation in recovery offers an alternative perspective.
- However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD.
Quality of Life in Former Problem Drinkers: Abstinence Versus Non-abstinence
Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. It is essential to understand what individuals with SUD are rejecting when they say they do not need treatment. In this model, treatment success is defined as achieving and sustaining total abstinence from alcohol and drugs, and readiness for treatment is conflated with commitment to abstinence (e.g., Harrell, Trenz, Scherer, Martins, & Latimer, 2013).
Alcohol Safe Limits: How Much Should I Be Drinking?
Many people who report resolving an alcohol or other drug (AOD) problem continue some level of substance use. Little information exists, however, regarding the prevalence of this resolution pathway, or how continued substance use after resolving an AOD problem, relative to abstinence, relates to functioning, quality of life, and happiness (i.e., well-being). Greater knowledge of the prevalence and correlates of non-abstinent AOD problem resolution could inform public health messaging and clinical guidelines, while encouraging substance use goals likely to maximize well-being and reduce risks. Our second goal was to examine differences in quality of life betweenabstainers and non-abstainers controlling for length of time in recovery. In conclusion, abstinence programs can be highly successful for alcohol treatment, particularly when tailored to the individual’s needs and supported by comprehensive care. Success rates vary widely, with inpatient programs and those incorporating multifaceted support systems generally outperforming less intensive approaches.
This approach acknowledges that not all individuals with alcohol-related issues may require or benefit from complete abstinence. 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). 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. For example, in one study testing the predictive validity of a measure of treatment readiness among non-treatment-seeking people who use drugs, the authors found that the only item in their measure that significantly predicted future treatment entry was motivation to quit using (Neff & Zule, 2002). The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004).
1.1. Harm reduction treatments specific to alcohol use disorder
About 10% of individuals who report cannabis use in the past year meet criteria for a cannabis use disorder, while this proportion increases to 18%, 19%, 58%, and 65% of those with past year use of cocaine, opioids (misuse), methamphetamine, and heroin, respectively. These data suggest that non-disordered drug use is possible, even for a substantial portion of individuals who use drugs such as heroin (about 45%). However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD. Some programs, like Moderation Management, advocate for controlled drinking, but these are not widely recommended for those with severe alcohol dependence. Support systems, including family, friends, support groups, and healthcare professionals, play a pivotal role in helping alcoholics navigate their journey towards recovery. One of the primary functions of these support networks is to provide a sense of community and understanding.
- It encourages individuals to explore the reasons behind their drinking habits and make positive lifestyle changes.
- This model both accelerated the spread of AA and NA and helped establish the abstinence-focused 12-Step program at the core of mainstream addiction treatment.
- Healthcare professionals and treatment providers play a vital role in guiding patients towards the most suitable path, whether it be abstinence or moderation, based on their unique needs and circumstances.
- Additionally, abstinence-based programs often emphasize behavioral changes, coping strategies, and lifestyle modifications that support long-term recovery.
- For instance, a person might aim to limit their drinking to certain days of the week or to a specific number of drinks per occasion, thus preventing excessive consumption and related harms.
- This method can be particularly appealing to those who do not identify as severely dependent on alcohol or who have not experienced significant negative consequences due to their drinking.
Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). The question of whether total abstinence is the only viable path for individuals struggling with alcoholism is a complex and highly debated topic within the realms of addiction treatment and recovery. While the traditional approach, often advocated by programs like Alcoholics Anonymous, emphasizes complete sobriety as essential for long-term recovery, some argue that moderation or controlled drinking might be a feasible alternative for certain individuals.
The debate between harm reduction and abstinence-based approaches in alcohol treatment is a critical one, reflecting differing philosophies on how to address alcohol use disorder (AUD). Abstinence, the traditional cornerstone of programs like Alcoholics Anonymous (AA), posits that complete cessation of alcohol consumption is the only path to recovery. This approach views any alcohol use as a relapse and emphasizes personal responsibility, often within a 12-step framework. In contrast, harm reduction focuses on minimizing the negative consequences of alcohol use rather than mandating total abstinence. It acknowledges that complete sobriety may not be achievable or desirable for everyone and seeks to meet individuals where they are, offering practical strategies to reduce harm, such as controlled drinking, safer drinking practices, and access to medical and psychological support.
Our main purpose is to provide services and education to the client and family that will support long lasting recovery of mind, body, and spirit. There\’s a risk that attempts at controlled drinking may lead to a return to problematic drinking patterns. Even if you invest in rehab for abstinence, it is only a temporary cost that you have to bear compared to the longer-lasting costs of alcoholism. Controlled drinking also becomes heavy on the pocket when it becomes regular, especially when you factor in other health complications.
Given that non-abstinence has been shown to be a less stable form of alcohol use disorder remission, it is possible a subset of these individuals will ultimately try the abstinent pathway. Multivariable stepwise regressions (Table2) show that younger individuals were significantly more likely to benon-abstinent, and movement to the next oldest age category reduced the odds ofnon-abstinence by an average of 27%. Importantly, the confidence intervals were narrow andextremely similar across models, implying that the effect of age was robust to modelspecification. In regard to help-seeking and problem severity, having attended at leastone 12-step meeting and the number of DSM-IV dependence symptoms were both significantlyrelated to non-abstinence. In the fully saturated models, any twelve-step attendancedecreased odds of non-abstinence by 57–76% (Model 4), while each additional DSMsymptom decreased odds of non-abstinence by 73–89% (Model 4). Non-abstainers are younger with less time in recovery and less problem severitybut worse QOL than abstainers.
Goodwin, Crane, & Guze (1971) found that controlled-drinking remission was four times as frequent as abstinence after eight years for untreated alcoholic felons who had “unequivocal histories of alcoholism”. Results from the 1989 Canadian National Alcohol and Drug Survey confirmed that those who resolve a drinking problem without treatment are more likely to become controlled drinkers. At one extreme, Vaillant (1983) found a 95 percent relapse rate among a group of alcoholics followed for 8 years after treatment at a public hospital; and over a 4-year follow-up period, the Rand Corporation found that only 7 percent of a treated alcoholic population abstained completely (Polich, Armor, & Braiker, 1981).
This tailored approach allows for a more nuanced understanding of each patient’s journey, fostering a healthier relationship with abstinence as a treatment goal. Vaillant (1983) labeled abstinence as drinking less than once a month and including a binge lasting less than a week each year. Given data demonstrating a clear link between abstinence goals and treatment engagement in a primarily abstinence-based SUD treatment system, it is reasonable to hypothesize that offering nonabstinence treatment would increase overall engagement by appealing to those with nonabstinence goals. Indeed, there is anecdotal evidence that this may be the case; for example, a qualitative study of nonabstinence drug treatment in Denmark described a client saying that he would not have presented to abstinence-only treatment due to his goal of moderate use (Järvinen, 2017). Additionally, in the United Kingdom, where there is greater access to nonabstinence treatment (Rosenberg & Melville, 2005; Rosenberg & Phillips, 2003), the proportion of individuals with opioid use disorder engaged in treatment is more than twice that of the U.S. (60% vs. 28%; Burkinshaw et al., 2017). In some religious traditions, alcohol consumption is forbidden or strongly discouraged, reinforcing the idea of abstinence as a moral imperative.