Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment https://ecosoberhouse.com/ effectiveness. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation. Future research should assess the dynamic nature of drinking goal in predicting treatment outcomes.
Controlled Drinking in the Alcoholic a Search for Common Features
If you believe that harm reduction therapy may help, you may be interested in our alcohol addiction program. In other studies of private treatment, Walsh et al. (1991) found that only 23 percent of alcohol-abusing workers reported abstaining throughout a 2-year follow-up, although the figure was 37 percent for those assigned to a hospital program. According to Finney and Moos (1991), 37 percent of patients reported they were abstinent at all follow-up years 4 through 10 after treatment. Clearly, most research agrees that most alcoholism patients drink at some point following treatment. There were 41 respondents (50% male, 50% female), who identified themselves as nurses (42%), physicians (32%), counsellors (13%) or another type of healthcare provider (13%, e.g. behaviour therapist, occupational therapist).
Days to Relapse to Heavy Drinking
This would probably reduce the risk of negative effects while still offering the positive support experienced by the majority of the clients in the study. Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010). These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006).
Clinical Assessment of Alcohol Use Disorders
Some participants reported relative consistency in goal or at least stretches of goal consistency (e.g., Participant examples A, D, E, and I), where others are less consistent. 1 and and22 demonstrate the importance of considering both between- and within-person patterns in daily goal setting. Where between-person patterns may suggest similar variability across goal types, within-person patterns may reveal stretches of consistency in goal setting that vary across person and goal type. In the context of “harm reduction,” individuals may make positivechanges in their lives that do not include reduced alcohol use and may consider themselves“in recovery” even though their AUD status remains unchanged (Denning and Little 2012).
Strengths and limitations of this review
Individuals with greater SUD severity tend to be most receptive to therapist input about goal selection (Sobell, Sobell, Bogardis, Leo, & Skinner, 1992). This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment. In the 1980s and 1990s, the HIV/AIDS epidemic prompted recognition of the role of drug use in disease transmission, generating new urgency around the adoption of a public health-focused approach to researching and treating drug use problems (Sobell & Sobell, 1995). The realization that HIV had been spreading widely among people who injected drugs in the mid-1980s led to the first syringe services programs (SSPs) in the U.S. (Des Jarlais, 2017).
While abstinence is still considered the safest treatment goal, moderation is increasingly recognized as a viable pathway to reduce alcohol use and its related negative health and social consequences among individuals with AUD (Rosenberg and Melville, 2005; van Amsterdam and van den Brink, 2013). Treatment programs and other settings that offer brief interventions for AUD (e.g., brief advice in primary care) are increasingly providing individuals the opportunity to choose their drinking reduction goals as a way controlled drinking vs abstinence to increase engagement and reduce harm (Rosenberg and Melville, 2005). Further, reductions in drinking risk levels are important outcomes for alcohol pharmacotherapy trials and may be more consistent with patient goals (Falk et al., 2019). As a result, there is a strong need to understand and develop goal setting guidelines for drink reduction. Tailoring treatment approaches to patients’ goals, whether complete or conditional abstinence or controlled drinking may have positive results on treatment outcome.
- To that end, an important feature of this study is the accessibility and clinical appeal of the drinking goal measure, which can be readily applied to a wide variety of treatment settings.
- This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment.
- The first, Medical Management (MM), consisted of nine brief sessions delivered by a licensed health care professional, and was intended to approximate a primary care intervention.
- Severity of alcoholism is the most generally accepted clinical indicator of the appropriateness of CD therapy (Rosenberg, 1993).
- In addition, Helzer et al. identified a sizable group (12%) of former alcoholics who drank a threshold of 7 drinks 4 times in a single month over the previous 3 years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records.
- Except for the subset (17/62; 27.4%) of respondents who recommended abstinence in all cases, recommendations of controlled drinking or abstinence varied as a function of both clients’ social class and their drinking history.
Abstinence From Alcohol
To account for drinking and problem severity, (average) drinking over the 21 days and the sum score from the baseline Alcohol Dependence Scale (ADS, Skinner and Allen, 1982) were employed as covariates. The ADS included 25 items assessing alcohol withdrawal symptoms, tolerance to alcohol’s effects, impaired control over drinking, awareness of a compulsion or want to drink, and alcohol-seeking behavior. Scores above 9 are indicative of alcohol-related problems, and scores above 13 are indicative of meeting criteria for AUD (Doyle and Donovan, 2009; Ross et al., 1990).
Over a longer term, Miller and colleagues (1992a, 1992b) reported a tendency for people who had earlier achieved non-problem drinking to gravitate to abstinence, perhaps because drinking had become less salient in the behavioural repertoire over time or possibly in response to lack of success in limiting intake on drinking occasions. While this change was not statistically significant, it does suggest that, combined with the larger increase in good outcomes in the non-abstinence preference group than in the abstinence preference group (see Table 1), a learning effect may be occurring in the non-abstinence group leading to somewhat better outcomes over time. The higher proportion of successful outcomes among the abstinence goal group in categorical terms was supported by significantly greater levels of percentage days abstinence at both 3 and 12 months’ follow-up. The differences between groups on this measure remained highly significant at both follow-up points when baseline differences between the groups were controlled for in the analysis. On the other hand, the superiority for the abstinence goal group on DDD was significant only at 3 months’ follow-up and only when covariates were not controlled for. Thus, it appears that the greater likelihood of successful outcome in the abstinence goal group may be primarily the result of reduced frequency of drinking rather than reduced drinking intensity.
Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991). In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001). 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.
Risk of bias within included studies
It was hypothesized that patients whose drinking goals were oriented towards complete abstinence would have better treatment outcomes as indexed by a greater percentage of days abstinent, longer period until relapse, and an overall higher global clinical outcome. These hypotheses were supported by the present study, such that participants with a self-reported goal of complete abstinence had better overall clinical outcomes following 16 weeks of alcohol dependence treatment. Participants with a goal of controlled drinking had the worst drinking outcomes, whereas those with a conditional abstinence goal comprise an intermediate group between complete abstinence and controlled drinking. In addition to the primary outcome variables of the COMBINE study, post hoc analysis of drinks per drinking day revealed that patients with a goal of controlled drinking reported fewer drinks per drinking day while those oriented towards complete abstinence as a goal reported greater drinks per drinking day. These findings were conceptualized in the context of the abstinence violation effect, whereby an initial lapse triggers heavier within-episode drinking among abstinence-oriented individuals (Marlatt & Gordon, 1985).