In the present article, descriptions of abstinence and CD and views on and use of the AA and the 12-step programme were analysed. Questions on main drug and other problematic drug use were followed by the interviewer giving a brief summary of how the interview person (IP) had described their change process five years earlier. With this as a starting point, the IP was asked to describe the past five years in terms of potential so-called relapse and retention and/or resumption of positive change. The interview guide also dealt with questions on treatment contacts during the follow-up period controlled drinking vs abstinence (frequency, extent and type), the view of their own and others’ alcohol consumption and important factors to continue or resume positive change. Abstinence from alcohol and other drugs has historically been a core criterion for recovery, defined by the Betty Ford Institute as a “voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship” (Betty Ford Institute Consensus Panel, 2007, p. 222). As recovery processes stretch over a long period, it is suggested that stable recovery is obtained after five years at the earliest (Hibbert and Best, 2011).
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). The higher proportion of successful outcomes among the abstinence goal group in categorical terms was supported by significantly greater levels of percentage days abstinence at both 3 and 12 months’ follow-up. The differences between groups on this measure remained highly significant at both follow-up points when baseline differences between the groups were controlled for in the analysis.
Controlled Drinking in the Alcoholic a Search for Common Features
Moreover, strictly abstinence-oriented organizations such as Alcoholics Anonymous (AA), implying abstinence as the treatment aim, and describing individuals with drinking problems as suffering from a disease might lead to the (unintended) stigmatization of people with substance use disorder (SUD) (van Amsterdam and van den Brink, 2013). In turn, stigma and shame have been reported as a reason for not seeking treatment (Probst et al., 2015). Although research indicates that CD may be a possible option for sustained recovery, at least for certain groups and at least later in the recovery process, it seems as if the dominating approach of treatment systems is still abstinence. The 12-step approach is widely adopted by alcohol treatment facilities (Galanter, 2016) endorsing total abstinence as the treatment goal.
- Unfortunately, a similar distinction is not possible in the present analysis because clients were not asked about their specific aims when stating their preference of drinking goal.
- There was no longer a significant association between drinking goal and type of successful outcome at 3 months, while the association at 12 months remained significant.
- Developed for Project MATCH, the Form 90 incorporates aspects of TLFB and grid-averaging methodologies in order to accurately assess participants’ alcohol consumption.
- The facilities were geographically convenient to either Bangor, North Wales, UK or Bowling Green, Ohio, US.
- If you believe that harm reduction therapy may help, you may be interested in our alcohol addiction program.
- While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use.
- However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to 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).
Delayed reward discounting predicts treatment response for heavy drinkers receiving smoking cessation treatment
Moderate or “controlled” drinking is a harm reduction approach tailored toward people with a drinking problem who do not exhibit the symptoms of physical dependence on alcohol. Total abstinence versus controlled drinking as a treatment goal for the alcoholic is a controversial issue which is currently receiving a great deal of attention. Two opposing camps seem to have evolved over the question and each puts forward convincing arguments essentially representing divergent views on “what is and makes an alcoholic”.
- However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD.
- In the present article, descriptions of abstinence and CD and views on and use of the AA and the 12-step programme were analysed.
- Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992).
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). Unlike most UK, Norwegian and Australian alcohol service agencies, abstinence is apparently the predominant outcome goal prescribed for alcohol misusers and other problem drinkers in US alcoholism treatment programmes. Rosenberg and Davis (1994) surveyed a nationwide sample of US agencies and found that controlled drinking was considered unacceptable for clients in almost every responding residential agency (including inpatient detoxification and rehabilitation services, as well as halfway houses). However, almost half of the responding outpatient programmes (including services for drunk-driving offenders) reported moderate drinking as appropriate for a minority of their clientele.
2. Established treatment models compatible with nonabstinence goals
Goal abstainers were more likely to achieve a successful outcome (abstinence/non-problem drinking) than goal non-abstainers at 3 months, with a trend in the same direction remaining at 12 months (Table 1). Among those in the successful outcome category, the majority of those preferring abstinence achieved a successful outcome by abstaining while the majority of those preferring a non-abstinent goal achieved a successful outcome with non-problem drinking, with these relationships highly significant as shown in Table 1. 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 professionals.
After five years, the majority remained abstinent and described SUD in line with the views in the 12-step programme. For some, attending was just a routine, whereas others stressed that meetings were crucial to them for remaining abstinent and maintaining their recovery process. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied. The goal of a moderation program is to support a person’s journey toward understanding their drinking behavior and create a safe environment for them to explore how to drink moderately. The analytical strategy for the present study was consistent with the primary COMBINE report (Anton et al., 2006).
It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). Advocates of managed alcohol programs also note that individuals with severe AUD and structural vulnerabilities often have low interest in and utilization of abstinence-oriented treatment, and that these treatments are less effective for this population (Ivsins et al., 2019), though there is limited research examining these claims. In the 1970s, the pioneering work of a small number of alcohol researchers began to challenge the existing abstinence-based paradigm in AUD treatment research. In 1973, alcohol researchers Sobell and Sobell published the first of several studies examining behavioral treatment for inpatients with AUD aimed at “controlled” drinking (defined as days during which 6 oz. or less of 86-proof liquor or its equivalent were consumed, or any isolated 1- or 2-day sequence when between 7 and 9 oz. were consumed).
- First, in view of the superior outcomes shown by those preferring abstinence as a goal, the findings show that clients who state a preference for abstinence should be confirmed and supported in that preference, irrespective of the severity of the alcohol problem or any other clinical feature.
- The Swedish treatment system has been dominated by total abstinence as the goal, although treatment with CD as a goal exists (e.g., Agerberg, 2014; Berglund et al., 2019).
- The evaluation consists of 11 yes or no questions that are intended to be used as an informational tool to assess the severity and probability of a substance use disorder.
- Critically, Hall et al. (1986, 1990) examined participants with an abstinence goal allowing for occasional slips and found that these participants did not fare as well as participants with complete abstinence goals.
- These findings were such that participants committed to complete abstinence took longer to slip and longer to relapse, defined as drug use on four or more days in a week.
- The current paper aims to contribute to this literature and, given the associations between goal preference and client characteristics identified in the accompanying paper (Heather et al., 2010), to refine the analyses to see to what extent any association with outcome is moderated by other clinical features.
UKATT was a multi-centre, randomized controlled trial comparing an adaptation of Motivational Enhancement Therapy (Miller et al., 1992b) and Social and Behavioural Network Therapy (Copello et al., 2002, 2009). As this was a pragmatic trial, exclusions were kept to a minimum so that the sample comprises clients aged ≥16 years attending alcohol or addiction services in the UK for treatment of a primary alcohol problem and without severe psychotic illness, severe cognitive impairment or illiteracy. Further details of the sample, treatment, therapists and trial procedures are given in the companion paper (Heather et al., 2010) and in UKATT Research Team (2001, 2005). The Alcohol Dependence Scale (ADS; Skinner & Allen, 1982) was used to assess severity of alcohol dependence.