Should addiction treatment prefer abstinence?

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I was perusing past year’s articles in Alcoholism Treatment Quarterly and came across these two:

Achieving a 15% relapse rate

Article one, as the title suggests, examines Collegiate Recovery Programs (CRPs) and Physician Health Programs (PHPs), their outstanding outcomes, their common elements, and discusses their potential for application to other populations. The abstract introduces them this way [Emphasis mine. The reason will be obvious later.]:

The CRP and PHP models involve long-term, comprehensive components of care and ancillary services oriented toward highly transformative abstinence-based recovery.

The text of the article adds this:

Both models hold the maintenance of long-term abstinence as the general outcome of choice.

The closing discussion opens this way:

Is a 15% relapse rate attainable? Evidence would suggest that common factors among pockets of highly successful recovery may hold the ingredients needed to ensure low relapse rates for all addiction treatment. CRPs in particular provide an example of recovery supports that facilitate long-term recovery through addressing recovery and quality of life concerns concurrently, while the individual works to achieve greater social capital through education.

Expanding services and support to include broader depth and coverage of socioeconomic, ethnic, and other disparities that exist in the current system is of paramount importance if we are to see real societal change and test the efficacy of the PHP and CRP models. PHP clients, consisting of licensed professionals, obviously garner esteem, social credibility, and seem “worthy” of saving from addiction. In the same way, so do young people who have the wherewithal to engage in treatment and be successful in higher education.

“Motivational Interviewing cannot be used in its fidelity in abstinence-based treatment”

Article two makes the following argument:

A major underpinning of motivation interviewing is to“meet clients where they are at,”and tailor interventions to their specific stage of change. In abstinence-based programs, however, clients are immediately placed in the action stage of change, even skipping the preparation stage of change that is essential to maintain recovery. Furthermore, this choice is made for them, not only evidencing the inability to do MI, but also the lack of individualized treatment. Despite this disconnect, the abstinence-only approach is still used in many treatment facilities in the United States, with 72% of facilities providing 12 Step-based programs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017), which are abstinence based and noted as what someone must achieve it to attain recovery, according to the National Institute on Drug Abuse (NIDA; 2016). It is important to highlight, however, that our position is not that 12-Step programs are not useful or ineffective. Conversely, 12-Step programs have withstood the test of time and are a valuable resource for many. What we are suggesting is that 12-Step programs are not for every client and, therefore, should not be the core of treatment programming. Rather, we propose individualized treatment consistent with the underpinnings of MI, which includes assessments, treatment planning, and counseling sessions based on harm reduction, not abstinence. Although abstinence is an excellent goal for recovery, the culture of a treatment agency cannot determine the goals for clients, which obviously is the opposite of individualized treatment. The clients themselves must determine their own treatment goals. MI continues to gain popularity and was reportedly being used in 90% of treatment programs (SAMHSA, 2017). Based on these findings, it seems that many facilities are employing an abstinence-based philosophy while also attempting to use MI. The following sections discuss how MI cannot be used in its fidelity in abstinence- based programs, despite many claiming to do so.

I’d argue that the framing here leaves a lot to be desired.

First, they cite that 90% percent of programs report using MI, but argue that most cannot be implementing MI with fidelity to MI principles because 72% report “providing 12 step-based programs.” IF these are incompatible, who’s to say that the infidelity is on the MI side? Couldn’t it be on either side?

Second, it’s worth noting that the SAMHSA report does not report on programs “providing 12 step-based programs.” Rather, the report tells us how many programs report using “12 step facilitation” (TSF). That distinction is important. The difference between a program that reports “providing 12 step-based programs” and one whose toolbox includes TSF is significant. The former implies that the 12 steps are the foundation for the entire program and are used with 100% of patients. The latter implies that TSF may (or, may not) be used with patients. In fact, the report indicates that 47% of programs report using TSF “always or often.” The survey provides no definition or guidance for “often”, leaving it pretty subjective.

Why would the authors characterize the data in this way? IDK

Further, earlier in the article they present the Minnesota model as representative of contemporary treatment services. However, the same report indicates that residential/inpatient treatment represented only 9% of all admissions in the report, and who knows what portion of that 9% received services resembling the Minnesota model? Another confusing, rather than clarifying, representation.

Treatment goals

So, article two appears to say that services with a goal of abstinence cannot be faithful to MI.

Is abstinence an appropriate goal in treatment? And, how should providers determine what goal(s) they want to organize their programs around?

A lot of this comes down to the nature of the problem you are treating, whether the problem is a behavior or a disease.

If we’re treating addiction (whose hallmark is impaired control), then abstinence is the goal that’s going to provide quality of life. AND, as the first article demonstrates, we have approaches that can deliver high rates of success.

If you’re addressing a lower severity problem, harm reduction or moderation are often good ends to focus on. These kinds of users can probably reduce harm and maintain a good quality of life.

Imagine we were discussing some other illness with severe physical, psychological, social, familial, occupational, and spiritual consequences. Further, imagine there are treatments what deliver relapse rates as low as 15%. Imagine there are barriers to engagement and retention in these treatments, and you wanted to use MI to improve engagement. Would it be inappropriate to have services organized around the goal of engaging and supporting patients in these effective treatments?

Which goals should take priority? Engagement rates in these successful treatments, or fidelity to the MI model?

What would we think about a cancer treatment program that takes no position on treatment options, and prioritizes symptom reduction and patient choice over remission?

To me, the authors of the MI article seem to be focused on AOD use as a behavior rather than a symptom of a disease.

It’s possible that they are focused on lower severity SUDs, or they don’t believe addiction is a disease, or they don’t believe there are meaningful differences in good care for addiction and lower severity SUDs.

It’s worth noting that the word “disease” appears only once in the article, and only when describing the Minnesota model.

I have no quarrel with their high-fidelity version MI model for lower severity SUDs, and I have no problem with it as a model to engage high severity SUDs (addiction) into other effective treatment models. (See posts about gradualism and recovery-oriented harm reduction.)

What are we treating? What are we seeking recovery from?

I imagine, maybe incorrectly, that the authors and I disagree on addiction as a disease.

I believe that addiction is a brain disease, and I like the American Society of Addiction Medicine’s definition:

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Within the field, however, there once again seem to be growing doubts about addiction as a disease.

Some see it as an outdated metaphor or useful fiction, while others see it as an artifact of stigma, and others see it as a social ill. (It’s paywalled, but the NEJM just published an argument that addiction is a learning disorder and not a disease.)

Many of these models of understanding started outside of the field, but are being brought into the field, knowingly or unknowingly, by new professionals and advocates.

The problem is made worse by the DSM 5’s movement toward a continuum model which puts all AOD problems on one continuum/category. No longer are low severity problems and high severity problems categorized as different kinds of problems. Rather, they are now one kind of problem with different severities.

Fuzzy thinking?

I’m not an expert in MI, but I’m not sure I buy the argument that fidelity to MI demands that practitioners and programs be agnostic on abstinence as the ideal outcome for addiction. And, if it does, I wouldn’t want my loved one in a program that is neutral on the outcome associated with the highest quality of life.

So . . . what’s going on then?

Dirk Hanson offered a helpful observation a few years ago about the relationship between harm reduction advocacy and the disease model.

For harm reductionists, addiction is sometimes viewed as a learning disorder. This semantic construction seems to hold out the possibility of learning to drink or use drugs moderately after using them addictively. The fact that some non-alcoholics drink too much and ought to cut back, just as some recreational drug users need to ease up, is certainly a public health issue—but one that is distinct in almost every way from the issue of biochemical addiction. By concentrating on the fuzziest part of the spectrum, where problem drinking merges into alcoholism, we’ve introduced fuzzy thinking with regard to at least some of the existing addiction research base. And that doesn’t help anybody find common ground.

UPDATE: I suppose it comes down to whether one sees MI as a complete treatment.

No one would ever consider MI a treatment for cancer, but we might think of it as good practice to engage patients into treatment.

If you see your patient’s SUD as a behavioral issue, MI is the complete package.

If you see it as a disease, for which there are effective treatments, it’s a treatment engagement model.

10 Comments

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10 responses to “Should addiction treatment prefer abstinence?

  1. Bart

    Well put, Jason

  2. Larry Hajdasz

    You give me pause for thought. I appreciate the disclaimer/differentiation between “full-blown addict/low bottom drunk” and people who can’t handle the stuff. I for one was full-blown/low bottom and can assure you complete abstinence from the hair of the dog is the only solution.

    • Totally disagree. I was a full blown IV heroin junkie for 5 years, and went the total abstinence route for 3 straight years. It works for some, but it’s not a one size fits all approach, and it can even be downright dangerous. It took me years to deprogram my brain and realized it wasn’t the only approach (but I know plenty who went out and died because they were under the impression that abstinence was the only way). I’ve since, for years now, taken a harm-reduction approach. I don’t shoot, or do, heroin anymore, but I’m not 100% abstinent from all substances. My quality of life has improved greatly. When I’m a junkie, and when I’m 100% abstinent, I have no quality of life, can not maintain a job, can not make it to class, etc – and this was the case for me when using, and when totally clean for 3 years. Since, I’ve finished my bachelors, and gotten into a top school in the country, studying addiction and drug policy reform, all while maintaining a job. I couldn’t have done this without moderate, responsible, therapeutic use of particular substance, and recovery shows that addicts ARE totally changeable – this doesn’t just mean we can achieve total abstinence, but that we can also achieve responsible use. My own experience, along with my own academic studies, has further sealed the sentiment that preaching 100% abstinence as the only way to be in recovery is downright dangerous.

      • Congrats on your success. I wish you continued success. Thanks for sharing your experience.

      • John Moir

        This is why we need to define what recovery is. If I am a member of AA and haven’t had a drink in 10 years but I smoke cannabis, am cheating on my wife with my best friends girlfriend and I lost my entire paycheck at the casino last night am I in recovery? I would say not. Just because I can attend school, get a job and not get arrested does not mean I am in recovery.

      • Jason, thank you!
        John, thank you for highlighting how AA can be a kind of cult, and is often downright dangerous. You chose a few examples to show someone not being in recovery, despite attending AA, and perhaps that’s a fair analysis, but it falls in line with the dangerous sentiment I’m talking about. When my friends in AA found out I was smoking, they completely cut me out of their lives. So much for practicing the 12th step on a daily basis, amirite? I can’t even count how many in AA I came across that were totally abstinent from everything, and widely recognized as being in recovery – but were completely miserable folks with lives I would certainly never aspire to have. How about if one is: no longer a member of AA, uses cannabis responsibly, and takes medication as directed to treat pain (important to distinguish between addiction/substance abuse, and physical dependency, too). The other aspects of their life resemble normalcy. I.e. Not cheating on their wife, not gambling constantly (examples you chose, for whatever reason), being present in their families life daily, helping people on a daily basis, showing up to work, showing up to class, furthering their career, nearing graduation at a top grad school, working out/taking care of themselves physically, and just generally being a law-abiding, moral, productive member of society? You seem to hold a definition similar to 12-step programs of what recovery is. This is likely why we continue to see such poor outcomes in the US regarding policy and drug use. I hold a definition that falls more in line with Portugal’s, where recovery has a lot more to do with one’s quality of life, than their use, which is but a symptom of substance abuse disorder – which is likely why they’ve seen such beneficial outcomes since decriminalizing all drugs, and taking a harm-reduction approach that isn’t centered on an abstinence-only approach.

      • Also, John, let’s pick this apart a bit more, first eradicating the logical fallacies from your response. We’re going to assume you never mentioned cheating on one’s wife, and gambling away a pay check, since that was never mentioned in my post. I did mention using cannabis, as well as my success with school and work; so that’s what we’ll focus on and elaborate:

        Does smoking cannabis automatically mean one is not in recovery? It seems you think it does (even though you had to add in the qualifiers of cheating on wife and gambling). I’m of the opinion that it’s far more nuanced. Somebody who uses cannabis may, or may not, be in recovery – you have to account for far more variables.

        As for school and work: does holding a job and completing school automatically demonstrate one is in recovery? Of course not. But when taken into account (see my earlier comment on “accounting for far more variables”) with the aggregate of one’s entire life, it’s certainly an aspect to be considered. When someone like myself is unable to hold a job, and unable to successfully get through school, when they are either a full blown addict, or entirely abstinent, then we have to ask ourselves why that is, and address it. If responsible and therapeutic use, as directed, (like cannabis, or even opiates), can improve one’s quality of life to the extent that they are finally able to do something, widely considered “normal,” that they were unable to do when clean, or in active addiction, than that is a success. If one can manage to live a happy and successful life as a law-abiding, productive member of society, than that is surely evidence enough that they are in successful recovery, regardless of what their substance use looks like (whether it’s totally abstinent, or responsible use — irresponsible use and abuse is mutually exclusive from these qualifiers of “living a happy/successful live as a law abiding productive member of society).

  3. Thank you for this in depth article! is addiction a “disease”? Would we call all ex smokers who learned to give up the hardest substance “diseased’? NO! Smoking cigarettes is a learned behavior and coping mechanism that can be UNLEARNED! Since most people have experienced addiction to something…whether it’s drugs, alcohol, gambling, overeating…to avoid feeling pain…we would have to classify everyone as being “diseased”! We have to stop putting those people who happened to find relief in substances in a different category. The drugs are the LEAST of the problem so by focusing on them we have completely missed the mark. It’s all the rest that is important..once people get the much needed relief from past traumas and abuse the need to self medicate diminishes naturally. And research shows that many can then return to using in moderation like the rest of the world. You find out rather quickly whether you need to abstain from everything and you decide that this is what is right for you as opposed to having someone who doesn’t even know you force you to abstain in order to get any help. It should be obvious to anyone who has studied human behavior which way works better!

    • John Moir

      Ignores recent brain science. Would like to see data that justifies your contention that addicts can return use in moderation. Definitely not my experience in over 35 years in the field.

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