Total Alcohol Abstinence vs Moderation: Which One Wins in the End?

Limited social drinking is a realistic goal for some people who struggle with alcohol, and should definitely be considered by people who have not been able to successfully adhere to abstinence. Multivariable stepwise regressions (Table2) show that younger individuals were significantly more likely to benon-abstinent, and movement to the next oldest age category reduced the odds ofnon-abstinence by an average of 27%. Importantly, the confidence intervals were narrow andextremely similar across models, implying that the effect of age was robust to modelspecification. In regard to help-seeking and problem severity, having attended at leastone 12-step meeting and the number of DSM-IV dependence symptoms were both significantlyrelated to non-abstinence. In the fully saturated models, any twelve-step attendancedecreased odds of non-abstinence by 57–76% (Model 4), while each additional DSMsymptom decreased odds of non-abstinence by 73–89% (Model 4).

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Yet, this has to be examined systematically, for example by comparing intervention and control group regarding their motivation after the return to alcohol use. Recent work used an empirical approach to deriving subgroups of individuals based on probability of endorsing abstinence, low risk drinking (less than 4/5 drinks for women/men), and heavy drinking (4/5 or more drinks for women/men) (Witkiewitz, Pearson, et al., 2017; Witkiewitz, Roos, et al., 2017). This approach allows for exceeding the cutoff on some occasions and still provides guidance about overall patterns of drinking over time. 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). The goals of the current paper were to address limitations of prior work by examining the association between empirically derived patterns of abstinence, low risk drinking, and heavy drinking during the treatment episode and outcomes at three years following treatment.

Low Risk Drinking Outcomes and Longer Term Functioning

controlled drinking vs abstinence

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). For example, among the 2005and 2010 National Alcohol Survey respondents, 18% of current drinkers who identified as“in recovery” from alcohol problems (who do not use drugs) are DSM-IValcohol dependent, and 26% of current drinkers who also use drugs are DSM-IV alcoholdependent. Thus relying on DSM criteria to define a sample of individuals in recovery mayunintentionally exclude individuals who are engaging in non-abstinent or harm reductiontechniques and making positive changes in their lives. Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success.

Controlled Drinking vs Abstinence Addiction Recovery

Here we discuss exploratory analyses of differences between abstinentand nonabstinent individuals who defined themselves as “in recovery” fromAUDs. A better understanding of the factors related tonon-abstinent recovery will help clinicians advise patients regarding appropriatetreatment goals. There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment.

For example, in AUD treatment, individuals with both goal choices demonstrate significant improvements in drinking-related outcomes (e.g., lower percent drinking days, fewer heavy drinking days), alcohol-related problems, and psychosocial functioning (Dunn & Strain, 2013). Additionally, individuals are most likely to achieve the outcomes that are consistent with their goals (i.e., moderation vs. abstinence), based on studies of both controlled drinking and drug use (Adamson, Heather, Morton, & Raistrick, 2010; Booth, Dale, & Ansari, 1984; Lozano et al., 2006; Schippers & Nelissen, 2006). 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).

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. I’m a big supporter of the idea that improvements in quality of life, in addition to or instead of measures of abstinence, need to be incorporated broadly into addiction treatment research. The way I see it, our goal in treating addiction is to help a client improve their functioning, which is often being hampered by substance abuse but that is not necessarily completely dependent on it. I can’t even think of how many times I’ve heard the notion that complete, total, abstinence should be the only goal for all people who abuse drug or alcohol. This idea is so pervasive that most addiction treatment providers actually expel clients for relapsing, a notion that makes no sense to me especially if you believe in the idea that addiction is a chronic disease.

  • Furthermore, qualityof life appeared significantly better among abstainers than non-abstainers.
  • 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).
  • Moderation management offers face-to-face and online meetings, a listserv, a forum, online alcohol drinking limit guidelines, a self-help book that can be ordered through the site, and an online calendar where users can report their drinking.

Abstinence Vs. Moderation Management: Success and Outcomes

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). 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.

Individuals with expected membership in Class 5 (low risk and heavy drinking) had a low probability of abstinence days during treatment, whereas individuals in Class 6 (abstinence and low risk drinking) had a higher probability of abstinence days throughout treatment. Some days of abstinence during treatment may be important for longer term functioning among those engaging in low risk drinking during treatment. Those with greater dependence severity were unlikely to be classified as low risk drinkers during treatment and clinicians may consider assessing dependence severity in developing intervention strategies and collaborating with patients regarding the selection of abstinence or low risk drinking goals.

A considerable number of clients reported changed views on the programme, some were still abstinent and some were drinking in a controlled way. Some of the abstainers still attended meetings because of a fear of what might happen if they stopped, although they questioned parts of the philosophy. For these clients, the recovery process, aiming to reach sustained recovery in the broader sense covering parts of their lives other than the SUD, was in part at odds with the ongoing participation in AA. These results indicate that strict views on abstinence and the nature of alcohol problems in 12-step-based treatment, and AA philosophy may create problems for the recovery process. Previous studies suggests that these strict views might prevent people from seeking treatment (Keyes et al., 2010; Wallhed Finn et al., 2014).


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