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. 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. 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%.
3. Summary of the state of the literature
- In addition to shaping mainstream addiction treatment, the abstinence-only 12-Step model also had an indelible effect on the field of SUD treatment research.
- Much can be learned from research that investigates how reducing or quitting alcohol provides benefits in terms of individuals’ day-to-day lives.
- For example, do the individuals in the high functioning profiles—including those engaging in heavy drinking—maintain this level of functioning in subsequent years?
- This means addressing not just the physical symptoms of addiction but also the psychological, emotional, social, and spiritual aspects as well.
- In a previous Bulletin, we reviewed a study that took a look closer at this issue, which concluded that abstinence is still likely to be the safest strategy when it comes to mortality risk over time.
We believe in the power of personalised therapy, where our experts tailor a recovery plan suited to your needs and circumstances. CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript. SD assisted with conceptualization of the review, and SD and KW both identified relevant literature for the review and provided critical review, commentary and revision.
Even the body of studies finding that very mild drinking could have cardio-protective effects appear to be somewhat in doubt. In a previous Bulletin, we reviewed a study that took a look closer at this issue, which concluded that abstinence is still likely to be the safest strategy when it comes to mortality risk over time. Based on 8 studies, the research suggests that abstinence may be needed for individuals with harmful drinking – defined in this review as drinking at least 3-4 drinks on average per day in men and 2-3 in women depending on the study – or alcohol use disorder, to achieve social benefits.
What Are the Signs of Addiction?
For example, do the individuals in the high functioning profiles—including those engaging in heavy drinking—maintain this level of functioning in subsequent years? A limited number of studies with follow-up intervals longer than three years suggest this is the case. For example, using follow-up data from the COMBINE Study24, we found that individuals who were high functioning at three years post-treatment, regardless of level of alcohol consumption, had the best self-reported health and fewer hospitalizations at 7–9 years post-treatment25.
In addition, Helzer et al. identified 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. Individuals with greater SUD severity tend to be most receptive to therapist input about goal selection (Sobell, Sobell, Bogardis, Leo, & Skinner, 1992). This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment. 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).
3 Stepwise regressions: Non-abstinence
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). In the 1980s and 1990s, the HIV/AIDS epidemic prompted recognition of the role of drug use in disease transmission, generating new urgency around the adoption of a public health-focused approach to researching and treating drug use problems (Sobell & Sobell, 1995). The realization that HIV had been spreading widely among people who injected drugs in the mid-1980s led to the first syringe services programs (SSPs) in the U.S. (Des Jarlais, 2017). Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991). In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001).
Abstainers
This approach underestimates the compulsive nature of addiction and the neurological changes that occur with prolonged alcohol misuse. For individuals with severe alcohol dependence, abstinence remains the most effective and safe strategy to avoid the devastating consequences of alcohol-related health issues, social disruption, and the potential for relapse. Some clients expressed a need for other or complementary support from professionals, whereas others highlighted the importance of leaving the 12-step community to be able to work on other parts of their lives. The descriptions on how the tools from treatment were initially used to deal with SUD and were later used to deal with other problems in the lives of IPs can be put in relation to the differentiation between abstinence and sobriety suggested by Helm (2019). While abstinence refers to behaviour, sobriety goes deeper and concerns the roots of the problem (addiction) and thereby refers to mental and emotional aspects.
Perhaps the most notable gap identified by this review is the dearth of research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. Given low treatment engagement and high rates of health-related harms among individuals who use drugs, combined with evidence of nonabstinence goals among a substantial portion of treatment-seekers, testing nonabstinence treatment for drug use is a clear next step for the field. This could include further evaluating established intervention models (e.g., MI and RP) among individuals with DUD who have nonabstinence goals, adapting existing abstinence-focused treatments (e.g., Contingency Management) to nonabstinence applications, and testing the efficacy of newer models (e.g., harm reduction psychotherapy). Ultimately, nonabstinence treatments may overlap significantly with abstinence-focused treatment models. Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness).
The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985). 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). Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt how to smoke moonrocks 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).
The ability to control drinking varies significantly from person to person and is influenced by a range of factors including genetics, environment, emotional state, and individual psychology. For people suffering from alcohol use disorders, trying to moderate drinking isn’t advised and total abstinence is always recommended. While you may see the appeal in a programme that allows for some level of drink intake, it’s crucial to consider the potential drawbacks that could come with this approach. Even moderate drinking can lead to long-term health problems such as liver disease, heart disease, and increased risk of certain cancers.
While individuals who achieved both high functioning and abstinence/non-heavy drinking (profile 4) at three years had optimal long-term outcomes as a whole, individuals who have a combination of high functioning and more frequent heavy drinking (profile 3) also showed favorable long-term outcomes in psychosocial functioning. A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs. 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. Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged.