Treatment Trends: Abstinence vs. Moderation

It seems like simple common sense that one of the first steps in treatment for substance abuse is to get you to stop using the substance. Whether it’s alcohol, illegal drugs or prescription medications, the detox process is usually an important starting point of any program. Only after an individual is no longer under the influence can the real hard work of treatment begin. This idea is so ingrained, that it’s surprising to hear of a new line of reasoning that asserts that abstinence may not be necessary to achieve recovery.

Harvard Health Publications, part of Harvard Medical School, published an article titled “Alcohol Abstinence vs. Moderation” that suggests that it may not be possible to give up alcohol completely to control problem drinking. [1] The article, released in February 2009, may have seemed groundbreaking, but it was actually rooted in a debate that started in the 1960s. Clinicians and other treatment professionals agree that it is very common for those who enter treatment for alcohol abuse to question whether they can find a way to cut back on their drinking rather than abstain completely. That’s understandable, but that doesn’t mean it’s what’s best for patients.

Who It Helps, How It Works

Proponents of moderation in place of abstinence argue that this method may help convince some problem drinkers to seek help before they suffer painful consequences as there is less of a stigma to getting help. The research seems to back this up. Experts studying moderate or “controlled” drinking have found that this strategy can be successful for patients who have not yet developed a pervasive pattern of alcohol abuse, or who have experienced few negative consequences from drinking. [1] The way it works is to help patients set goals and drinking limits before they cross the line into dependence.

One study, for example, followed the outcomes of drinkers for three to eight years after they participated in behavioral self-control training, a therapy designed to instill moderate drinking behavior. The researchers found that as severity of dependence increases, likelihood of patients’ being able to reduce their drinking to moderate levels and keep it there goes down dramatically. It also concluded, “for the most dependent drinkers, abstinence may be the only option.”

Moderation may provide motivation for those with a drinking problem to try to control their intake, but as research shows, for those already battling addiction, the idea that they will be able to self-moderate for the long-term is unrealistic. Much of the moderation movement seems to center around letting the patient control the process. It asserts that a patient who expresses a desire to start drinking in a more controlled way is indicating a desire to change a behavior. At this point, motivational interviewing is employed to help clients set the agenda, with the therapist acting as a partner rather than an authority. That may sound reasonable in theory, but it is at odds with long-established treatment models that have proven successful.

Those in favor of moderation also argue that demanding abstinence too soon can drive away patients who are moving toward a place of being ready to deal with addiction issues. Some see it as a way to let patients discover for themselves if they need to employ a personal “abstinence only” policy. The idea is that those who try to limit their drinking and are unable to may become more open to the idea of cutting out all alcohol consumption. This realization would let them realize that they have developed a dependence and need to abstain going forward.

It’s not just alternative publications that are exploring this idea. A 2011 Psychology Today article titled “Abstinence Is Not the Only Option” questions the conventional wisdom of going “cold turkey.” [2]

Not For Everyone

That same research that shows that moderation could work for some drinkers clearly proves that moderation is unlikely to be successful for patients who already meet criteria for dependence. That means that allowing those in the throes of full-blown alcohol addiction to believe that they can return to drinking socially or occasionally without eventually relapsing could be very harmful.

While abstinence may be used as a marker of treatment success, the article suggests that consumption amounts don’t factor in aside from “using more than intended,” so he doesn’t think it should be a necessary part of the solution either, author Adi Jaffe, writes. [2]

These same ideas were espoused on Southern California Public Radio (SCPR) in a story titled “Offering Alternative to Sobriety Could Entice More to Rehab.” [3] While exploring the idea of moderation as a possible alternative, the SCPR piece admits that “addiction professionals are also skeptical moderation is an achievable goal for serious addicts. ‘It’s risky, for most people,’ says Emily Feinstein, policy director at Columbia University’s Center on Addiction and Substance Abuse.” [3] “I think it really only makes sense for people who don’t have a substance abuse disorder,” she adds.

Of course, addiction is different for everyone and requires a tailored treatment plan.

If you or a loved one is struggling with an addiction and a co-occurring disorder, call us today. We’re available 24 hours a day, seven days a week and can provide information on treatment programs, help with insurance and answer questions about the treatment process.

1. “Alcohol Abstinence vs. Moderation,” Harvard Health Publications/Harvard Medical School, February 2009, http://www.health.harvard.edu/family_health_guide/alcohol-abstinence-vs-moderation
2. “Abstinence Is Not the Only Option,” Psychology Today, 3.9.11, https://www.psychologytoday.com/blog/all-about-addiction/201103/abstinence-is-not-the-only-option
3. “Offering Alternative to Sobriety Could Entice More to Rehab,” Southern California Public Radio, http://www.scpr.org/news/2015/06/01/51967/offering-alternative-to-sobriety-could-entice-more/