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Abstinence vs. harm reduction

By Josh Thompson, Guest Contributor

Alcohol addiction is a complex problem with no easy answers.  Is alcohol abuse a mental illness?  Experts don’t agree. Even when it comes to peer-reviewed research on how to treat alcohol addiction, the studies are often conflicting. Yet the recovery community in the U.S. so often takes an “us against them” approach when it comes to discussing treatment methodologies.  So, what role should alcohol harm reduction techniques play in addiction recovery?  Perhaps no one should be claiming that a given methodology (abstinence) is the only path to recovery.  We review why here, and invite your comments at the end.

Abstinence vs Harm Reduction – Why There’s No “Right” Answer

When it comes to 12 step programs, the accepted orthodoxy is that abstinence is the only way; the mere mention of harm reduction or moderation will often draw attacks from 12 step proponents. Some treatment providers believe in the abstinence philosophy so strongly that they will actually expel addicts who relapse.

There certainly is a logic to the notion that abstinence is the only way. After all, if you’re a recovering alcoholic, alcohol is your enemy. And periods of abstinence can repair brain and central nervous system functions that were formally impaired. But having an alcoholic self-moderate their alcohol intake is like having the fox guard the hen house – it just seems like a really bad idea. The temptation of having “just one (1) drink” is a classic precursor to relapse.

In a study performed by the APA, addiction counselors who rejected moderation – even as an intermediate goal – cited 3 primary reasons for their beliefs:

1. They believed that moderation didn’t work.

2. They believed moderate drinking sent the wrong message.

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3. Decreased drinking was incompatible with their overall treatment philosophy.

Why Abstinence Isn’t The Only Answer

There are certainly many people dependent on alcohol for whom abstinence is the only realistic solution. The truth is that even in Moderation Management – a program dedicated to harm reduction –their own website states that 30% of their members go onto abstinence based programs. But just because abstinence may be the best approach for many alcoholics and drug addicts doesn’t mean that it’s the best approach in every situation.

Why are such vague notions like “it sends the wrong message” or “it’s incompatible with my overall treatment philosophy” sufficient to dismiss an entire treatment approach that has proven to work in some circumstances, for some people? Moderation as a treatment option for problem drinkers has certainly proven to be effective – perhaps even more effective than abstinence – in multiple peer reviewed studies. And while there are conflicting studies on the effectiveness of alcohol moderation (as there are in many aspects of addiction research) for full-fledged alcohol dependents, there are many countries where moderation and harm reduction – even for alcoholics – is widely accepted amongst addiction professionals.

Is The Abstinence vs Harm Reduction Argument A False Dichotomy?

Perhaps we need to ask ourselves, “Why is an affliction/behavior as incredibly complex as alcoholism being distilled down to a one-size-fits-all answer?” Even for professionals who have had tremendous success with a given methodology, does anyone really have the authority to claim that there is only one correct method in dealing with such a complex, multi-facetted issue?

The truth is that there should be room for both approaches. For some problem drinkers and many alcoholics, moderation simply doesn’t work. At the same time, moderation may benefit individuals who otherwise might not seek treatment. As an intermediate goal, it might help those who are unable to psychologically cope with the idea of attending/returning to an abstinence oriented recovery program. Closing our minds to moderation means that many individuals who may be ambivalent about quitting alcohol will be pushed away from seeking any form of treatment.

In sum, whether it’s used as an intermediate goal for alcoholics who need to ultimately work towards complete abstinence, or as an end goal for those who simply aren’t benefitting from an abstinence only approach, there needs to be room for moderation and harm reduction in the addiction treatment arsenal. But what do you think? Please send us your comments and feedback in the comment form below. We try to reply to each comment personally and promptly.

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Josh Thompson has been clean and sober since 2008. He blogs about the lessons he learned during recovery at Clean and Sober Live. You can also follow him on Twitter.

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9 Responses to “Abstinence vs. harm reduction
Mark Willenbring, MD
6:50 pm January 5th, 2013

Thanks for a thoughtful posting. I’d like to add that it’s even more complex than it seems, but that there are some good ways to predict success with one approach over another.

First, ditch the term “harm reduction” to describe anything other than some sort of idealistic, absolutist approach. Do we call diabetes treatment “harm reduction” because we aren’t able to cure or even arrest it? No, we call it “treatment.” “Harm reduction” implies not setting a goal of the best possible outcome. “Treatment” implies continuing to do what one can if a disorder is incurable or recurrent,

Recent research has shown that a significant proportion of people meeting DSM IV criteria for achieve what we now term “non-abstinent recovery,” which means never drinking more than 4 drinks in a day and having not alcohol-related problems. 20 years after onset, 40% are drinking in a low-risk fashion, while 1/3 are abstinent.

The best predictor of achieving non-abstinent recovery is how severe the addiction is. Basically, the more severe and lengthy the addiction, the less likely any goal short of abstinence will work. There is a spectrum of severity of addiction, and it’s only the milder, usually self-limiting forms where non-abstinent recovery is possible. And often, a period of abstinence is required first.

The reason AA is so rigid on this point is that only the most severely addicted end up in AA or rehab. So, for their members, abstinence is indeed the only way to success. But for the 3/4 of people who develop alcohol dependence but who never attend AA or go to rehab, but almost all of whom eventually recovery after a few years, non-abstinent recovery is a reasonable goal.

Josh
3:16 pm January 21st, 2013

Hi Mark,

Great point about the term “harm reduction”, I never really thought about it that way but you’re absolutely right. Its actually quite embarassing that I used a term that inherently reinforces the absolutist approach, in an article lambasting the absolutist approach. But thank you very much for pointing it out, I appreciate it.

Josh

Doug Manderbach
6:51 am January 23rd, 2013

Thank you for a very thought provoking post Josh. Many addictions counselors, AA and NA purists, as well as a considerable cross section of the public take a dim view of harm reduction methods of treatment. I have posed this very question many times and by and large the responses I have received seem to center on the idea harm reduction does not work because it enables the very behaviors it seeks to treat. Up to a point there is some validity to this argument. While I personally see harm reduction treatment modalities as being legitimate and sometimes necessary, I must admit that I feel this is an approach that should be avoided until other evidenced-based treatment methods have been exhausted.

One of the issues that many people seem to miss entirely is that we spend billions of dollars annually treating the ancillary health problems associated with alcohol/drug abuse and dependence. Many people who abuse or are alcohol/drug dependent have undiagnosed health problems that usually are only treated when those problems can no longer be avoided. Accidents that result from intoxication and requiring medical interventions probably rank high on this list. There are also considerable criminal justice costs in dealing with DUI, public intoxication, disorderly conduct, and the cost of incarceration. Added to this is the cost of personal tragedy from injury and even death. As a society we all shoulder these costs monetarily as well as in personal loss.

Harm reduction treatment methods reduce, if not eliminate many of these costs. Thus, from a purely economic standpoint if no other, harm reduction treatment should not be dismissed. One might argue that only a small percentage of people who have utilized harm reduction ever go on to achieve complete abstinence, but we could easily make the same argument about AA and NA. If we had reliable statistical data regarding the numbers of AAers or NAers who ever achieve complete abstinence I feel almost certain that the comparison between harm reduction and AA or NA would be proportionally similar. This is not to say that AA or NA have no value. They can be important adjuncts to evidenced-based treatment protocols. One needs to realize that positive therapeutic outcomes are only achieved when the client desires and actively participates in change, and this means dealing with the underlying causes that resulted in addiction whatever its form. Treating dependence/addiction is limited while the client is still actively engaged in addictive/dependent behaviors. Thus, anything we can do that stabilizes the individual, including utilizing harm reductions treatment methods, should be seen as a positive step towards abstinence.

Josh Golding
4:10 am April 8th, 2015

Hi Josh,

I realize this post is over 2 years old, but wanted to thank you for your words. I am part of a 12-step program, and have been for 8 years now. It has worked for me. But harm reduction has always fascinated me, and since learning about it, and delving into the topic a fair bit while I was in school, I have wanted to write about the false dichotomy between abstinence based programming and harm reduction. Looks like you already have! That is great.

Doug
2:07 pm April 13th, 2015

Josh, here’s another little something to add to your toolbox. There is no “one” way to sobriety, abstinence, or whatever one would like to call it. If one were to really research the history of AA they would find that there were and still are a great many political and social forces at work from both within and without. Marty Mann for instance set out with good intentions to quantify and qualify the various stages of alcoholism. Enter E. Morton Gelinick (Sp?) who first classified the four stages of alcoholism. His work stands to this day. However, Gelinick’s credentials were not what they were purported to be and thus cast a dim light on his work. He was a statistician. That his conclusions are today considered to be accurate, the misrepresentation of his credentials very nearly spelled doom for AA at the time. Incidentally, Marty Mann was the founder of the organization (I don’t remember its name), that is today the National Council on Alcoholism.

Also, there is a current move underway today (by custom and usage), that would elevate such groups as AA, NA, et al. to the level of being actual treatment protocols. This is, in my opinion, very dangerous ground in that such groups are and should remain support groups and nothing more. This is not meant to in any way suggest that the functions that such groups isn’t vital and important, or without considerable merit. Quite the contrary! I personally, and many others too have learned a great deal from such groups about living a great life. Unfortunately, AA, NA, et al., would all have one believe that they have the keys to sobriety. Albert Ellis started what is known as Rational Emotive Therapy (RET), which can be a very powerful tool for screening out what is often faulty perceptions from reality. And we all know that people suffering with active addition aren’t very adept at viewing reality objectively…. (Smile).

While I hesitate to say this I feel that honesty demands that I do. Today I occasionally have a glass of wine with a meal and there are times that I even smoke marijuana. There are some who say that I was not an alcoholic or addict. That idea simply does not stack up against 40 plus years of using and all the behaviors associated with it. To state it simply, for me, if sobriety in and of itself was the goal I would never have bothered. I wanted a LIFE plane and simple and I took the steps necessary for me to begin realizing that goal.

By the way, insofar as concerns harm reduction and my smoking marijuana or having an occasional glass of wine this is not a way of my getting a buzz while trying to skirt full blown addiction again. Actually, as I have told my doctor smoking pot is far less harmful for me than using the pain killers she wants to prescribe.

Allen
6:42 am October 1st, 2015

In the 21st century there is a need for evidenced-based treatment program. This means that treatment is to be multi-faceted and open to what the clients are wanting and willing to do. A large part of problems in the substance abuse counseling field is lack of willingness to step out of the traditional treatment box. It is easy to refer clients to 12-Step, have them acquire a sponsor and this is considered treatment in the vast majority of centers and programs. Unethically, clients are charge for what they could get for free. I do think we can be of help to people struggling with substance issues, but not if we remain tunnel-vision. To often we (counselors) overlook the expert on the client is not us, but the client. The client tells us about him/her, symptoms, what he/she wants and is willing to do. We are to work with the client from where he/she is willing to start and wanting to go. Once the client reach his/her goal in counseling, time to exit and move on with life. Yes, I strongly agree Harm Reduction, Moderation Management…SMART, WFS, SOS, 12-Step all should be used in treatment. The goal is to have the treatment fit the client, rather than trying to make the client fit into a treatment. There are pros and cons to any treatment modality and no one treatment modality fit all ranges of substance use disorders.

4:35 pm October 9th, 2015

I agree everything you said Allen. Treatment needs to be tailored based on each individual patient’s needs. There is definitely no one-size-fits-all when it comes to addiction help, and treatments need to be flexible. Thank you for your valuable contribution!

MLE
3:38 am August 18th, 2016

I started using at a young age. I was using marijuana at 12 and dabbling in harder drugs by 16. LSD, MDMA, cocaine. It wasnt until I started using opiates to the point of physical addiction that I feel something changed inside of me. I have always battled depression and feel like i used heroin to medicate my depression. Not knowing the harmful effects it was having on my brain chemistry and receptors.

I am now 27. I have been to 3 12 step based rehabs. I have attended AA meetings and took suggestions…sponsor, home group, commitment. After and only after completing a program was I able to benefit from AA. But I always took their information “cafeteria style” taking what i wanted and leaving the rest. I have completed the 12 steps with a sponsor and gave myself 9 months of real abstinence. I did change I started to get my life back but I feel like the thing that kept me sober that long was not letting to let other people down, not wanting to be judged and to loose my so called clean time. There was still that blank space in my soul. Eventually I got the case of fuck its and went back to using. Those 9 months were the longest periods of sobriety i had but i didnt enjoy the person I was. I started this recovery journey at 22 and its super hard for a 22 year old kid to feel joy in being different from everyone else. Using heroin has screwed up my chances to go to raves and have utterly amazing experiences, or screwed up ever being able to with pot or LSD. Its hard for my generation effected by this heroin epidemic to sign over our will and lives to a higher power and promise to stay abstinent.

After going to 3 12 step rehabs giving AA my all and still not being able to stay 100% abstinent. Has almost made me feel morally incapable of change. But then another voice in my head says “You cant be a junkie forever. You have goals and wants out of your life that are unobtainable in active addiction.

I have had abstinence from opiates while still using other drugs to combat the withdraws. Or while using other drugs recreationally. I wasnt striked to hell. And by no means do I feel like bc i smoke a joint or drop some LSD here or there will be the sole reason for returning to active addiction to my drug of choice.

Thanks for this article. I really believe now more than ever younger and younger people are using. There isnt one set of rules to how you change your life its your life. And just bc you fuck up doesnt mean you should be shunned or penalized.

All in all I dont use bc i dont love you…mostly its because i dont love me.

7:38 pm August 22nd, 2016

Hi MLE. Thank you for sharing your story. I know it will help others who read your comment to know that they are not alone. As for you, stay motivated and keep putting one foot in front of the other. I believe in you and that you will be 100% abstinent.

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