Expanding the continuum of substance use disorder treatment: Nonabstinence approaches PMC

Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010). 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). 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. 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.

Behaviors linked to addiction

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. However, these interventions also typically lack an abstinence focus and sometimes result in reductions in drug use. Unfortunately, there has been little empirical research evaluating this approach among individuals with DUD; evidence of effectiveness comes primarily from observational research.

Is Harm Reduction Right for Me?

Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005). 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). Next, future studies should include individuals who dropped out of the intervention directly after the return to alcohol use, i.e. participants who returned to alcohol use but do not report this in the app, to prevent potential selection bias. Presumably, a better personalization of content to meet individual needs may be crucial to attain this goal.

1. 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).
2. Some no longer attended meetings but remained abstinent with a positive view of the 12-step programme.
3. We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field.
4. While abstinence refers to behaviour, sobriety goes deeper and concerns the roots of the problem (addiction) and thereby refers to mental and emotional aspects.

Helpful and hindering factors of the intervention regarding abstinence motivation

A plausible reason for this could be that someone who returns to alcohol use earlier might be generally less motivated and might therefore stop using the app earlier – even if there is a possible increase in motivation at first. The findings also raise the question why some people tend to stop participating in the intervention earlier than others and if an early return to alcohol use might predict an earlier discontinuation of an intervention. If an early return to alcohol use was found to be a predictor for an early intervention dropout it could be helpful to lengthen the abstinence period so that participants would use the intervention for a longer time and thus do more exercises.

Current Study

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).

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 compare different sober houses approach is widely adopted by alcohol treatment facilities (Galanter, 2016) endorsing total abstinence as the treatment goal. In the present article, clients treated in 12-step programmes were reinterviewed five years after treatment. All the interviewed clients reported a successful treatment outcome, i.e. total abstinence six months after treatment.

By the same token, controlled drinking may be the more common outcome for untreated remission, since many alcohol abusers may reject treatment because they are unwilling to abstain. In regard to my therapeutic approach to harm reduction as a clinical psychologist, I usually start by understanding my client’s goals for drinking. We then start the process by monitoring their drinking as is, to understand the baseline they are starting at. This will include logging numerical data, but more importantly, triggers and impulses behind those drinks to better understand their motives.

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. Rather, when people with SUD are surveyed about reasons they are not in treatment, not being ready to stop using substances is consistently the top reason cited, even among individuals who perceive a need for treatment (SAMHSA, 2018, 2019a).

A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982). Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995). alcohol and the etiology of depression american journal of psychiatry Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985). Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). Rychtarik et al. found that treatment aimed at abstinence or controlled drinking was not related to patients’ ultimate remission type.

While AUD treatment studies commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity). Consistent with previous research, behavioral self-control training continues to be the most empirically validated controlled-drinking intervention. Recent research has focused on increasing both the accessibility/availability and efficacy of behavioral self-control training. Moderation-oriented cue exposure is a recent development in behaviorally oriented controlled drinking that yields treatment outcomes comparable to behavioral self-control training.

Results from this study support the need for a broader conceptualization of the clinical course of AUD (Maisto, Witkiewitz, Moskal, & Wilson, 2016) that does not rely solely on binary cutoffs to determine treatment success (e.g., abstinence). Research is needed to explore time-varying predictors of low risk drinking and alternative definitions of reduction outcomes (e.g., World Health Organization risk levels; Witkiewitz, Hallgren, et al., 2017) that may promote beneficial longer term functioning. Such findings would aid in refining AUD treatment and would provide more information for clinicians to improve clinical decision-making. There is less research examining the extent to which moderation/controlled use goals are feasible for individuals with DUDs. The most recent national survey assessing rates of illicit drug use and SUDs found that among individuals who report illicit drug use in the past year, approximately 15% meet criteria for one or more DUD (SAMHSA, 2019a). 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.

Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013). In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008). Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation. The current study was a secondary data analysis and was limited by the measures assessed in the original Project MATCH study. Most notably, there were no measures of drinking goals and all of the Project MATCH treatments were delivered under the assumption of an abstinence goal. It is unclear whether the same patterns of drinking would be found among clients with low risk drinking goals.

Booth, Dale, and Ansari (1984), on the other hand, found that patients did achieve their selected goal of abstinence or controlled drinking more often. Miller et al. (in press) found that more dependent drinkers were less likely to achieve CD outcomes but that desired treatment goal and whether one labeled oneself an alcoholic or not independently predicted outcome type. In addition, Helzer et al. identified watch out alcohol and anxiety a sizable group (12%) of former alcoholics who drank a threshold of 7 drinks 4 times in a single month over the previous 3 years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records. Vaillant (1983) labeled abstinence as drinking less than once a month and including a binge lasting less than a week each year.