Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

This finding supplements the numerous studies that identify lack of readiness for abstinence as the top reason for non-engagement in SUD treatment, even among those who recognize a need for treatment (e.g., Chen, Strain, Crum, & Mojtabai, 2013; SAMHSA, 2019a). The position of ALCOHOLICS ANONYMOUS (AA) and the dominant view among therapists who treat alcoholism in the United States is that the goal of treatment for those who have been dependent on alcohol is total, complete, and permanent abstinence from alcohol (and, often, other intoxicating substances). By extension, for all those treated for alcohol abuse, including those with no dependence symptoms, moderation of drinking (termed controlled drinking or CD) as a goal of treatment is rejected (Peele, 1992). Instead, providers claim, holding out such a goal to an alcoholic is detrimental, fostering a continuation of denial and delaying the alcoholic’s need to accept the reality that he or she can never drink in http://www.xenoid.ru/materials/materials_psy/psy-book20.php moderation. While there have been calls for abstinence-focused treatment settings to relax punitive policies around substance use during treatment (Marlatt et al., 2001; White et al., 2005), there may also be specific benefits provided by nonabstinence treatment in retaining individuals who continue to use (or return to use) during treatment.

1.4. Risk reduction interventions

• Moderation techniques such as pacing yourself, choosing lower-alcohol options, or having alcohol-free days can be practical tools in this journey.
• Ultimately, nonabstinence treatments may overlap significantly with abstinence-focused treatment models.
• You’re here because you’ve taken the first brave step in acknowledging that your relationship with alcohol needs a change.
• Also, consider your health – excessive drinking can lead to serious conditions like liver disease or heart problems.
• The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.
• The current aims are to identify correlates ofnon-abstinent recovery and examine differences in QOL between abstainers andnon-abstainers accounting for length of time in recovery.

There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment. Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015). In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). The path towards moderation management comes with its unique set of challenges which can include social pressure or dealing with underlying emotional issues that contribute towards excessive drinking habits.

Furthermore, younger (under 40), single alcoholics were far more likely to relapse if they were abstinent at 18 months than if they were drinking without problems, even if they were highly alcohol-dependent. Thus the Rand study found a strong link between severity and outcome, but a far from ironclad one. Severity of alcoholism is the most generally accepted clinical indicator of the appropriateness of CD therapy (Rosenberg, 1993). Untreated alcohol abusers probably have less severe drinking problems than clinical populations of alcoholics, which may explain their higher levels of controlled drinking. But the less severe problem drinkers uncovered in nonclinical studies are more typical, outnumbering those who “show major symptoms of alcohol dependence” by about four to one (Skinner, 1990).

We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied. Looked at like that, the answer to the question of controlled drinking versus abstinence is obvious. Additionally, we offer exceptional continuing care so even after completing your programme; you’re never alone in this fight against alcohol addiction. Whether it’s through continued counselling or group meetings within the community -we’ll be there every step of the way- supporting you as much as needed so that recovery becomes less daunting and more hopeful.

How do untreated and treated alcoholics compare in their controlled-drinking and abstinent-remission ratios?

• 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).
• For some, attending was just a routine, whereas others stressed that meetings were crucial to them for remaining abstinent and maintaining their recovery process.
• But other research indicates that the pool of those who achieve remission can be expanded by having broader treatment goals.
• Donovan and colleagues(2005) reviewed 36 studies involving various aspects of QOL in relation to AUDand concluded that heavy episodic drinkers had worse QOL than other drinkers, that reduceddrinking was related to improved QOL among harmful drinkers, and that abstainers hadimproved QOL in treated samples (Donovan et al.2005).
• Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).

According to advocates of The Sinclair Method, drinking is a learned behaviour, and one example of conditioning. Although conditioning is useful for survival, this mechanism can also reinforce behavior and habits which are detrimental to the health of the individual, including alcohol dependence (as well as additional anti-social behavior). The Sinclair Method is a treatment for alcohol dependency designed to implement a pavlovian technique called pharmacological extinction.

In the broadest sense, harm reduction seeks to reduceproblems related to drinking behaviors and supports any step in the right directionwithout requiring abstinence (Marlatt and Witkiewitz2010). Witkiewitz (2013) has suggestedthat abstinence may be less important than psychiatric, family, social, economic, andhealth outcomes, and that non-consumption measures like psychosocial functioning andquality of life should be goals for AUD research (Witkiewitz 2013). These goals are highly consistent with the growingconceptualization of `recovery’ as a guiding vision of AUD services (The Betty Ford Institute Consensus Panel 2007). Witkiewitz also arguedthat the commonly held belief that abstinence is the only solution may deter someindividuals from seeking help. Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success https://atomplus.net/v-dorogu/3729-club-music-and-singles-tunnel-2cd-2016.html (Volkow, 2020).

What is Controlled Drinking or Alcohol Moderation Management?

Controlled drinking as well as abstinence is an appropriate goal for the majority of problem drinkers who are not alcohol-dependent. In addition, while controlled drinking becomes less likely the more severe the degree of alcoholism, other factors—such as age, values, and beliefs about oneself, one’s drinking, and the possibility of controlled drinking—also play a role, sometimes the dominant role, in determining successful outcome type. Finally, reduced drinking is often the focus of a harm-reduction approach, where the likely alternative is not abstinence but continued alcoholism. Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful.

4. Consequences of abstinence-only treatment

Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success. In the United Kingdom, where there is greater acceptance of nonabstinence goals and availability of nonabstinence treatment (Rosenberg et al., 2020; Rosenberg & Melville, 2005), the rate of administrative discharge is much lower than in the U.S. (1.42% vs. 6% of treatment episodes; Newham, Russell, & Davies, 2010; SAMHSA, 2019b). 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).

Controlled Drinking – Alcohol Dependence Treatment Method

This includes the use of an opiate block such as naltrexone which turns habit-forming behaviours into those which are habit erasing. The outcome is to reduce the urge to want to drink; thereby, returning the patient to a pre-heavy drinking state of mind. Our approach is not one-size-fits-all; instead, it’s grounded in empathy, respect for your individuality, and a deep understanding of how alcohol misuse impacts different people in different ways.

All the interviewees had attended treatment programmes following the 12-step philosophy and described abstinence as crucial for their recovery process in the initial interview, five years ago. In previous research, several indicators of whether CD is possible are mentioned (Klingemann and Rosenberg, 2009; Klingemann, 2016; Davis et al., 2017; Luquiens et al., 2011; Berglund et al., 2019). Clients reporting CD in the present study only met one of these criteria – an initial period of abstinence (Booth, 2006; Coldwell and Heather, 2006). Essentials mission is to renew lives impacted by addiction through personalized and complete behavioral healthcare.

Unfortunately, there has been little empirical research evaluating this approach among individuals with DUD; evidence of effectiveness comes primarily from observational research. For example, at a large outpatient SUD treatment center in Amsterdam, goal-aligned treatment for drug and alcohol use involves a version of harm reduction psychotherapy that integrates MI and CBT approaches, and focuses on motivational enhancement, self-control training, and relapse prevention (Schippers & Nelissen, 2006). Participants with controlled use goals in this center are typically able to achieve less problematic (38%) or non-problematic (32%) use, while a minority achieve abstinence with (8%) or without (6%) incidental relapse (outcomes were not separately assessed for those with AUD vs. DUD; Schippers & Nelissen, 2006). For example, in AUD treatment, individuals with both goal choices demonstrate significant improvements in drinking-related outcomes (e.g., lower percent drinking days, fewer heavy drinking days), alcohol-related problems, and psychosocial functioning (Dunn & Strain, 2013). Additionally, individuals are most likely to achieve the outcomes that are consistent with their goals (i.e., moderation vs. abstinence), based on studies of both controlled drinking and drug use (Adamson, Heather, Morton, & Raistrick, 2010; Booth, Dale, & Ansari, 1984; Lozano et al., 2006; Schippers & Nelissen, 2006). Rychtarik et al. found that treatment aimed at abstinence or controlled drinking was not related to patients’ ultimate remission type.

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. However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992).

The results suggest the importance of offering interventions with various treatment goals and that clients choosing CD as part of their sustained recovery would benefit from support in this process, both from peers and from professionals. Here we found that a number of factors distinguish non-abstainers from abstainersin recovery from AUD, including younger age and lower problem severity. A betterunderstanding of the recovery process and tools utilized by non-abstinent vs. abstinentindividuals would inform clinical practice; for example, is it more important for those inabstinent recovery to have abstinent individuals in their social networks?

Non-abstainers are younger with less time in recovery and less problem severitybut worse QOL than abstainers. Clinically, individuals considering non-abstinent goalsshould be aware that abstinence may be best for optimal QOL in the long run.Furthermore, time in recovery should be accounted for when examining correlates ofrecovery. Bill Wilson started with alcohol and learned the neurobiology of drugs is such that one drug or another has quite similar effects.” AA’s foundational text, The Big Book, emphasizes that an alcoholic has lost control and moderation.