Dr. Stanton Peele, recognized as one of the world’s leading addiction experts, developed the Life Process Program after decades of research, writing, controlled drinking vs abstinence addiction recovery and treatment about and for people with addictions. Moderate drinking is a harm-reduction strategy – it allows you to enjoy alcohol in social settings while also minimizing the negative effects that come with heavy drinking. Controlled drinking, also referred to as moderation, involves consuming alcohol occasionally without exceeding safe limits. According to the Centers for Disease Control and Prevention (CDC), this means no more than 2 drinks per day for males and 1 drink per day for males.

Quality of life / Functioning

  • Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation.
  • A representative subset of 39,809 individuals from the GfK KnowledgePanel were sent the screening question via email, to which 25,229 responded (63.4%).
  • Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a).
  • This approach acknowledges that not all individuals with alcohol-related issues may require or benefit from complete abstinence.
  • AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008).

For these individuals, alternative treatments, such as harm reduction or moderation management, may be more appropriate. Despite this, abstinence-based treatment remains a gold standard for many, particularly in cases where previous attempts at controlled drinking have failed. It is important to note that the effectiveness of support systems can vary depending on individual needs and preferences. Some people may find that total abstinence is the best approach for them, while others might benefit from a harm reduction strategy that focuses on reducing alcohol consumption to safer levels. Support groups and healthcare providers should offer a range of options and respect the autonomy of the individual in choosing the path that aligns with their goals and values. Ultimately, the role of support systems is to empower alcoholics to make informed decisions about their recovery, providing the necessary tools and encouragement to achieve and maintain a healthier relationship with alcohol.

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. The question of whether abstinence should be the primary goal in alcohol treatment is a contentious and multifaceted issue, sparking debates among healthcare professionals, researchers, and individuals affected by alcohol use disorder (AUD).

This study sought to extend this previous research using a nationally representative sample capturing the continuum of substance use statuses, incorporating all substances used (i.e., alcohol and/or other drugs), with consideration given to the AOD that individuals indicated as their primary substance. 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). To date, research examining associations among abstinent and non-abstinent substance use status and well-being, has focused primarily on treatment-seeking individuals with alcohol use disorder. Subsequently, the authors found that abstinence in this sample at three years did not predict better psychological functioning at ten years (Witkiewitz et al., 2020). In conclusion, abstinence-based treatment is a highly effective approach for many individuals with AUD, particularly those with severe or chronic conditions.

4. Current status of nonabstinence SUD treatment

  • Integrative models that combine elements of both approaches—such as offering harm reduction strategies while also supporting abstinence for those who seek it—may provide the most comprehensive and compassionate care.
  • However, its effectiveness is contingent on individual readiness and commitment, as well as the availability of comprehensive support systems.
  • Peer support, a common feature of abstinence-based programs, has been identified as a critical factor in maintaining sobriety, as it provides individuals with a sense of belonging and shared purpose.
  • Cultural perspectives on alcohol also influence our attitudes towards its use and misuse, shaping norms around what constitutes acceptable levels of consumption.

Thus, abstinence rates may be higher among individuals with problem recognition versus those who meet criteria for SUD based on a structured clinical interview (e.g., First et al., 2015), but who may not recognize a problem. Indeed, 54.0% in the National Recovery Study also sought lifetime assistance for their substance use problem (Kelly et al., 2017) versus 19.8% among those with alcohol use disorder in the NESARC (Grant et al., 2015). National Recovery Study rates of abstinent recovery were lower, however, relative to the 88.0% with alcohol problems in the What is Recovery Study (Subbaraman and Witbrodt, 2014). Abstinence rates may be higher in samples where individuals identify as ‘in recovery’ (Kelly et al., 2018) as well as those recruited mostly through treatment-oriented organizations, as was the case in the What is Recovery Study (Subbaraman and Witbrodt, 2014). Ultimately, the choice between harm reduction and abstinence should be guided by individual needs, preferences, and clinical assessment.

How useful is abstinence alone in understanding the effectiveness of SUD treatment?

Once again, in the context of moderation vs abstinence, abstinence is the preferred route for those with alcohol use disorder, frequent relapses, and other health complications. The role of nutrition should also not be overlooked as maintaining a balanced diet can help restore physical health damaged by excessive alcohol consumption. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied.

Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.

This shift in mindset is crucial, as it moves the individual from a place of powerlessness over addiction to a position of active agency in their recovery journey. By setting a clear goal of complete sobriety, individuals are less likely to engage in ambiguous or risky drinking behaviors that could lead to relapse. This binary approach—either drinking or not drinking—eliminates the potential pitfalls of controlled or moderate drinking, which can be challenging for those with AUD. Additionally, abstinence-based programs often emphasize behavioral changes, coping strategies, and lifestyle modifications that support long-term recovery. For individuals with a strong commitment to sobriety, these programs can be transformative, offering a sense of community and accountability that fosters lasting change.

What Is Controlled Drinking or Moderation?

Healthcare professionals and treatment providers play a vital role in guiding patients towards the most suitable path, whether it be abstinence or moderation, based on their unique needs and circumstances. This personalized approach to alcohol treatment can lead to more effective and sustainable recovery outcomes. The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. For example, despite being widely cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown. In addition to evaluating nonabstinence treatments specifically, researchers could help move the field forward by increased attention to nonabstinence goals more broadly.

Campaigns that portray abstinence as the sole solution can reinforce this belief, while those that highlight the possibility of controlled drinking in certain cases can broaden public understanding. Cultural representations of alcoholics in film, literature, and other media also influence societal perceptions, often either stigmatizing them or offering nuanced portrayals of recovery. By examining these influences, it becomes clear that the question of whether total abstinence is the only choice for alcoholics is deeply tied to the cultural and social contexts in which they live, suggesting that a one-size-fits-all approach may not be appropriate.

However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. 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. Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015). In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). 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).

Sample

These alternatives recognize that recovery is not one-size-fits-all and that different individuals may require different methods to achieve and maintain sobriety. Abstinence-based treatment can be highly effective for many individuals, particularly those with chronic or severe AUD. However, research shows that other approaches, such as moderation management or medication-assisted treatment, can also be effective for certain individuals.

In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021).

Clinically, individuals considering non-abstinent goalsshould be aware that abstinence may be best for optimal QOL in the long run.Furthermore, time in recovery should be accounted for when examining correlates ofrecovery. Polich, Armor, and Braiker found that the most severely dependent alcoholics (11 or more dependence symptoms on admission) were the least likely to achieve nonproblem drinking at 4 years. Furthermore, younger (under 40), single alcoholics were far more likely to relapse if they were abstinent at 18 months than if they were drinking without problems, even if they were highly alcohol-dependent. Despite the reported relationship between severity and CD outcomes, many diagnosed alcoholics do control their drinking.

It’s heartbreaking to see loved ones caught in the grip of addiction, but there’s hope – research shows that many people find success with programmes aimed at reducing consumption. Alcohol moderation management programmes are often successful when tailored to an individual’s specific needs and circumstances. The effectiveness of these programmes can greatly vary depending on several factors such as treatment duration, individual factors, and programme challenges. 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.