Though programs like Alcoholics Anonymous and other well-known programs meant to aid in the recovery from alcohol use disorders and alcohol misuse require or encourage full abstinence, these are not the only solutions known to help people quit or control drinking. In Britain and other European and Commonwealth countries, controlled-drinking therapy is widely available (Rosenberg et al., 1992). The following six questions explore the value, prevalence, and clinical impact of controlled drinking vs. abstinence outcomes in alcoholism treatment; they are intended to argue the case for controlled drinking as a reasonable and realistic goal. Regarding the app “Appstinence” that was used by participants in our study, future research should examine whether this app is actually able to assist AUD patients with ending a return to alcohol use or even with preventing a return to alcohol use in risk situations. These hypotheses need to be tested in an appropriate study design by implementing a quantitative approach and using an adequate sample size.
- Yet, there is a lack of research on what happens to abstinence motivation after the return to substance use.
- The following six questions explore the value, prevalence, and clinical impact of controlled drinking vs. abstinence outcomes in alcoholism treatment; they are intended to argue the case for controlled drinking as a reasonable and realistic goal.
- While the pandemic seems to have triggered substantial increases in alcohol consumption, and in alcohol abuse, this is true on a macro level.
- When your goal is only one drink instead of no drinks at all, the temptation to stray can become less powerful and you can more often enjoy positive reinforcement from your successes.
- Yet, this prior work did not address the question of whether those who achieve low risk drinking during treatment can maintain functional improvements for multiple years following treatment, which is important given concerns that low risk drinking may be a less stable outcome (Ilgen et al., 2008).
2 Quality of life and recovery from AUD
Here we provide a brief review of existing models of nonabstinence psychosocial treatment, with the goal of summarizing the state of the literature and identifying notable gaps and directions for future research. Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review. We first describe treatment models with an explicit harm reduction or nonabstinence focus.
Low Risk Drinking Outcomes and Longer Term Functioning
Therefore, for those clients who find complete abstinence to be overwhelming, we will come up with specific rules around their drinking. “It is essentially a practical approach; success is not measured by the achievement of an “ideal” drinking level or situation (i.e., abstention or low-risk levels), but by whether the introduction of the prevention measure reduces the chance that adverse consequences will occur” (NCBI). When your drinking is under control, you may have the internal bandwidth to accept the professional psychological support that can help you develop healthier ways of coping. You could also get help to better manage your emotions, address past trauma, and understand how anxiety, depression, or other emotional difficulties have powered your alcohol abuse.
What is Harm Reduction?
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. 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.
Study design
While harm reduction can be effective and successful in helping a person be more cognizant of their drinking behaviors and therefore decreasing them, it is not for everyone. While, of course, no one is perfect, and we expect “mistakes” or “hiccups” along the way, there are some individuals who try harm reduction and are able to recognize they cannot exercise this type of self-control. In those cases, harm reduction can be a helpful tool as a last resort, to help the individual come to the conclusion themselves that abstinence is the right avenue for them, rather than having it enforced upon them at the start of treatment. Learning to drink in moderation can be the goal, or it can be a way station on the way to abstinence. Once you are able to allow yourself some alcohol in controlled circumstances, you may ultimately choose to give up drinking entirely.
Participants were also encouraged to use a daily abstinence and craving tracker in which they were asked to self-report whether they had been abstinent the day before and how intense their craving was on a 5-point Likert scale ranging from very weak to very strong. The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD). In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature. A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs.
The findings suggest that abstinence motivation seems to generally increase after the return to alcohol use for participants in an app-based guided intervention for treatment of AUD. Future interventions should focus on motivation to deliver better support before and after a return to alcohol use and thereby potentially improve adherence and treatment outcomes. Furthermore, future studies need to reach out to individuals who drop out of the intervention after the return to alcohol use and to those with an early return to alcohol use. Alcohol use disorder (AUD) as defined by the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) ranges from mild to severe forms based on the bruises: symptoms causes diagnosis treatment remedies prevention amount of fulfilled criteria [1], is prevalent, often chronic and linked to negative physical and mental health [1,2,3]. Evidence-based treatments including pharmacotherapy, withdrawal management, cognitive behavioral therapy, motivational interviewing, and prevention of the return to substance use exist [4,5,6,7] and recommendation on treatment indication are compiled in national treatment guidelines [8]. Despite the existence of various treatment forms there is room for improvement in the current treatment landscape reflected by high lifetime rates of the return to substance use for substance use disorders [9, 10], low treatment retention, and general treatment barriers [11,12,13].
This is not surprising as respectful and supporting feedback and interactions are also part of Motivational Interviewing which has already been shown to be effective in the treatment of substance use disorder [25]. Altogether it might be that a return to alcohol use could only have a motivational impact if the return to alcohol use was adequately addressed and if affected individuals were supported in an appreciative manner. Yet, this has to be examined systematically, for example by comparing intervention and control group regarding their motivation after the return to alcohol use. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019).
Classification precision (defined by relative entropy) was used to evaluate how well the final latent profile solution classified individuals into latent classes and values of entropy greater than .80 were considered good classification precision (Nylund et al., 2007). 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). However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to treatment. Alternatively, researchers who conduct trials in community-based treatment centers will need to obtain buy-in to test nonabstinence approaches, which may necessitate waiving facility policies regarding drug use during treatment – a significant hurdle. It is essential to understand what individuals with SUD are rejecting when they say they do not need treatment. In this model, treatment success is defined as achieving and sustaining total abstinence from alcohol and drugs, and readiness for treatment is conflated with commitment to abstinence (e.g., Harrell, Trenz, Scherer, Martins, & Latimer, 2013).
We combined the qualitative information with quantitative data in order to get to a more complete picture of the investigated research questions [46, 47, 62]. In this mixed-methods study, we examined abstinence motivation and app use behavior teen drug abuse: signs risks and treatment after the return to alcohol use and aimed to identify the perceived supporting aspects regarding abstinence motivation. Overall, the results show an increase in abstinence motivation after the return to alcohol use and a stable app use.
The controversial past of controlled drinking is slowly giving way to a hopeful future in which individuals are less likely to be forced into an abstinence-only treatment scenario. The enhanced accessibility of effective controlled-drinking interventions should significantly expand the treatment options of individuals within the full spectrum of alcohol-related problems. Some people aren’t ready to quit alcohol completely, and are more likely to succeed if they cut back instead.
Model fit was examined using the Lo Mendell Rubin Likelihood Ratio test (LRT), the Bootstrapped Likelihood Ratio Test (BLRT), Bayesian Information Criterion (BIC) and sample-size–adjusted BIC (aBIC). A significant LRT and BLRT indicates a significantly better fit for a k profile model (e.g., 3 profiles) versus a k-1 profile model (e.g., 2 profiles), and a non-significant LRT and BLRT indicates that adding an additional profile does not significantly improve model fit (Nylund, Asparouhov, & Muthen, 2007). In addition, lower BIC and aBIC indicates a better fitting model (Nylund et al., 2007) and the smallest class of any class-solution should not contain less than 5% of the sample (Nagin, 2005).
The position of ALCOHOLICS ANONYMOUS (AA) and the dominant view among therapists who treat alcoholism in the United States is that the goal of treatment for those who have been dependent on alcohol is total, complete, and permanent abstinence from alcohol (and, often, other intoxicating substances). By extension, for all those treated for alcohol abuse, including those with no dependence symptoms, moderation of drinking (termed controlled drinking or CD) as a goal of treatment is rejected (Peele, 1992). Instead, providers claim, holding out such a goal to an alcoholic is detrimental, fostering a continuation of denial and delaying the alcoholic’s need to accept the reality that he or she can never drink in moderation. Such reductions are very often the goal of treatment and as such, show some possible promise for the treatment of individuals with alcohol abuse problems. Indeed, the participants in the study are what I would consider very heavy drinkers and are likely more representative of common drinking problem behavior than the really severe, chronic, poly-substance dependent patients that often present to residential treatment. Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful.
Demographics, baseline dependence severity (as measured by the Alcohol Dependence Scale (Skinner & Horn, 1984)), and treatment condition by latent classes are presented in Table 3. Individuals in the low risk drinking classes (Classes 5 and 6) had lower dependence severity than those in the mixed heavy drinking classes (Classes 2 and 4). Individuals who received MET were more likely to be in the heavy and low risk drinking classes (Classes 3 and 5) and those who received CBT art and creativity in addiction recovery were less likely to be in the abstinent and heavy drinking class (Class 3). Parameters were estimated using a weighted maximum likelihood function, and all standard errors were computed using a sandwich estimator (i.e., MLR in Mplus; B. O. Muthén & Satorra, 1995). The robust maximum likelihood estimator provides the estimated variance-covariance matrix for the available outcome data and, therefore, all available drinking data during treatment were included in the models.
1We also examined low risk drinking definitions using weekly limits of 7 and 14 drinks for women and men, respectively. Results were not substantively changed when weekly limits were analyzed, thus we report the results using daily limits. In the results, we mention that there were a few IPs that were younger, with a background of diffuse and complex problems characterized by a multi-problem situation. Research on young adults, including people in their thirties (Magaraggia and Benasso, 2019), stresses that young adults leaving care tend to have complex problems and struggle with problems such as poor health, poor school performance and crime (Courtney and Dworsky, 2006; Berlin et al., 2011; Vinnerljung and Sallnäs, 2008). Thus, this is interesting to analyse further although the younger IPs in this article, with experience of 12-step treatment, are too few to allow for a separate analysis. However, they will be included in a further analysis on young adults based on the same premises as in present article but with experience from other treatments than the 12-step treatment.