Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). 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). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013).
The severity of these symptoms can vary widely depending on how much you are drinking, how frequently, and your overall physical health. 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.
- 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).
- The Alcohol Dependence Scale (ADS; Skinner & Allen, 1982) was used to assess severity of alcohol dependence.
- 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.
- 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.
- Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001).
4 Stepwise regressions: Quality of life (QOL)
Differentiating these concepts opens up for recovery without necessarily having strong ties with the recovery community and having a life that is not (only) focused on recovery but on life itself. Also, defining sobriety as a further/deeper step in the recovery process offers a potential for 12-step participants to focus on new goals and getting involved in new groups, not primarily bound by recovery goals. Further, describing recovery as a process also implies paying attention to contributing factors outside the treatment context, such as the importance of work, family and friends. 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). Our second goal was to examine differences in quality of life betweenabstainers and non-abstainers controlling for length of time in recovery.
What is Controlled Drinking or Alcohol Moderation Management?
Clinicians have long recognized that client’s attitudes and goals towards drinking change throughout the course of treatment. The dynamic nature of drinking goal may be an important clinical variable in its own right (Hodgins, Leigh, Milne, & Gerrish, 1997). The present study was limited to the assessment of drinking goal at the onset of treatment and future studies examining drinking goals over the course of treatment seem warranted. Likewise, further research should consider matching patients’ drinking goals to specific treatment modalities, whether behavioral or pharmacological in nature. Given the abstinence focus of many SUD treatment centers, studies may need to recruit using community outreach, which can yield fewer participants compared to recruiting from treatment (Jaffee et al., 2009).
Despite these obstacles, SSPs and their advocates grew into a national and international harm reduction movement (Des Jarlais, 2017; Friedman, Southwell, Bueno, & Paone, 2001). While there are many obstacles to the widespread acceptance of CD as a treatment approach (Sobell & Sobell 2006), it is important to note that not all individuals entering treatment do so with the goal of achieving abstinence. To that end, the use of abstinence as the dominant drinking goal across alcoholism treatment programs in the United States may in fact deter individuals who would otherwise seek treatment for alcohol problems should CD be proposed as an acceptable goal. Sobell et al. (1992) found that many patients entering an outpatient treatment facility for alcohol problems preferred self-selection of treatment goals, versus adoption of the goals selected by the therapist. Treatment programs that allow for and encourage patient-driven treatment goals may be more appealing, and may lead to greater treatment utilization and engagement. This is particularly important in light of the overall low treatment seeking rates for alcoholism, with only 27.8% of alcohol dependence cases seeking treatment in the past year (Cohen, Feinn, Arias, & Kranzler, 2007).
Taken together, these studies may inform a longstanding debate in the field concerning the risks and stability of non-abstinent recovery9 and the utility of broader conceptualizations of recovery that emphasize improvements in biopsychosocial functioning16,17. Together, these analyses seek to further elucidate the predictive utility of drinking goal as well as to identify specific treatment approaches that may be better suited for patients whose goals are abstinence versus non-abstinence oriented. Given the widespread recognition of individual differences in drinking goals for alcoholism treatment, as well as the accessible nature of this clinical variable to treatment providers, the potential clinical utility of such findings is high. 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).
Stephanie S O’Malley
A study conducted at the University of Gothenburg, Sweden found that the Reagans of the world are more successful in treatment than the Saras. Preparation of this manuscript was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (R01 AA022328, 2K05 AA016928, K01 AA024796, K01 AA023233, and T32 AA018108). Several said that starting drinking was preceded by concerns about whether an uncontrolled craving would occur.
In addition to evaluating nonabstinence treatments specifically, researchers could help move the field forward by increased attention to nonabstinence goals more broadly. For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type. There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge. 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.
Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). With these qualifications, the present study adds to evidence that non-abstinent AUD recovery is possible and can be maintained for up to 10 years following treatment. The findings support recent proposals to move beyond viewing abstinence as a central defining feature of AUD recovery and relying heavily on quantity-frequency measures of drinking practices as the primary outcome indicator. Future research that expands the scope of outcome indicators to include measures of biopsychosocial functioning and AUD diagnostic criteria50 is important for advancing understanding of the multiple pathways to recovery from AUD. Additional research should examine whether remission from AUD diagnostic symptoms, which were not examined in the current study, are useful in defining recovery or whether focusing on well-being and psychological functioning is sufficient to characterize recovery from AUD. Recent conceptualizations of the term ‘recovery’ have shifted to emphasize the broader biopsychosocial process of improvement that is related to, but not solely determined by, alcohol consumption.
The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge. For example, despite being widely what was eminem addicted to cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown.