Expanding the continuum of substance use disorder treatment: Nonabstinence approaches PMC

And even if you don’t plan to quit, you may find that you lose interest in alcohol after practicing moderation. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the definition of moderate alcohol use differs for men and women. This study also found that TAU+SP showed a significant effect on the change in DDD with high certainty of direct evidence. SP is rarely used independently, and its components are often used as a part of community conventional treatment or other psychological therapies.41 It can be operated face-to-face and can also provide remote support (like studies Agyapong 2012, Lucht 2014, O’Reilly 2019).

Strengths and limitations of this review

These results suggest that carefully considering drinking goals at treatment entry represents an important aspect of the initial assessment. As noted by Adamson and colleagues (2010), treatment goals may change over the course of treatment and must be continuously evaluated in order to promote the best possible outcomes. The current study was a secondary data analysis and was limited by the measures assessed in the original Project MATCH study. Most notably, there were no measures of drinking goals and all of the Project MATCH treatments were delivered under the assumption of an abstinence goal. It is unclear whether the same patterns of drinking would be found among clients with low risk drinking goals.

• Thus the Rand study found a strong link between severity and outcome, but a far from ironclad one.
• Together, these findings suggest that naltrexone may be better suited to a controlled drinking approach and thus may be more effective among patients with controlled drinking goals.
• Though sobriety has a clear definition, you may still be asking yourself, what is sobriety, and what will it mean to me?

Approaches to Alcoholism Treatment

• 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.
• TAU+PLC (67.5%) had the highest probability of being best accepted, followed by TAU+SP (44%) and TAU+CBT (40.6%).
• The Rand study quantified the relationship between severity of alcohol dependence and controlled-drinking outcomes, although, overall, the Rand population was a severely alcoholic one in which “virtually all subjects reported symptoms of alcohol dependence” (Polich, Armor, and Braiker, 1981).
• Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches.
• Donovan and colleagues(2005) reviewed 36 studies involving various aspects of QOL in relation to AUDand concluded that heavy episodic drinkers had worse QOL than other drinkers, that reduceddrinking was related to improved QOL among harmful drinkers, and that abstainers hadimproved QOL in treated samples (Donovan et al.2005).

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). A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. 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 effectiveness.

Overview of studies

Additionally, SP previously showed an effect on abstinence improvement in AUD,42 so it also needs to be treated as a kind of active and effective psychological intervention. In terms of changes in DDD, available for 28 treatment arms (1121 participants), all 11 active and 3 control interventions (naltrexone+TAU, TAU, TAU+PLC) were included (Figure S10A). The top four most likely to be accepted were naltrexone+MET (55.4%), naltrexone+CBT (37.8%), PLC+MET (16.5%), and PLC+CBT (18.7%). Among the SUCRA rankings, naltrexone+MET, sertraline+CBT, and naltrexone+CBT were ranked 2.6, 5.1, and 5.2, respectively.

Third, consumption-based thresholds have not been well-validated in clinical or general population samples. Research has found that consumption cutoffs lack sensitivity and specificity for predicting problems related to alcohol use and they do not differentiate individuals based on other measures of health or functioning (Pearson et al., 2016; Wilson et al., 2016). Cutpoints also ignore the influence of weight, sex, and health status in determining the effects of different levels of alcohol consumption (e.g., blood alcohol level) (Pearson et al., 2016) and are based on single-episode drinking, whereas recovery is better conceptualized as a process of change (SAMSHA, 2011). Both Fan and colleagues (2019) and Dawson and colleagues (2005) used a 4+/5+ drinks per day cutoff for defining “high-risk” drinking. This cutoff has numerous limitations when applied to examining recovery from AUD (see Pearson et al., 2016 for a review). First, alcohol consumption levels are not used as a criterion in accepted diagnostic schemes for AUD (APA, 2013), and it is therefore unclear why a drinking practices dimension would be included in definitions of recovery from AUD.

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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). 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).

Indeed, this argument has been central to advocacy around harm reduction interventions for people who inject drugs, such as SSPs and safe injection facilities (Barry et al., 2019; Kulikowski & Linder, 2018). It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). 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 alcohol abstinence vs moderation 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. Research indicates that while the likelihood of avoiding heavy alcohol consumption is highest in abstinence-focused individuals, those with moderation objectives were also able to reduce their alcohol use. An individual’s ability to avoid excessive drinking is also influenced by other factors such as past alcohol consumption, as reflected by an alcohol use disorder diagnosis.

The present study was limited to the assessment of drinking goal at the onset of treatment and future studies examining drinking goals over the course of treatment seem warranted. Likewise, further research should consider matching patients’ drinking goals to specific treatment modalities, whether behavioral or pharmacological in nature. These results suggest that drinking goal represents a highly predictive clinical variable and should be an integral part of the clinical https://ecosoberhouse.com/ assessment of patients with alcohol dependence. Assessment of patients’ drinking goals may also help match patients to interventions best suited to address their goals and clinical needs. In parallel with the view on abstinence as a core criterion for recovery, controlled drinking (CD) has been a recurring concept and in focus from time to time in research on alcohol problems for more than half a century (Davies, 1962; Roizen, 1987; Saladin and Santa Ana, 2004).

This finding is consistent with an abstinence violation effect wherein abstinence oriented participants are more likely to engage in heavy drinking following an initial lapse (Marlatt & Gordon, 1985). While CBI should theoretically reduce the impact of the abstinence violation effect by providing the opportunity to accurately process a lapse, the results presented herein did not support this effect (i.e., no goal × CBI interaction was observed). As a data check, all outcomes presented in the primary COMBINE manuscript were replicated prior to any model testing for this study. Additionally, drinking goal was initially analyzed as a five-level variable keeping all possible self-report responses separate. Visual inspection of these results supported our classification system (i.e., controlled drinking, conditional abstinence, and complete abstinence) in that the two possible responses for both controlled drinking and conditional abstinence clustered together across outcomes. Since drinking goal is a three-level variable, following the omnibus test, planned analyses were conducted to test differences between the three drinking goal groups for effects observed on all outcome variables.

• On the other hand, as the group expressed positive views on this specific treatment, they might question the sobriety goal in a lesser extent than other groups.
• Heterogeneity was assessed using the results of the pairwise analyses, and between study variance for the network meta-analyses (τ2).
• You’re not alone, and it’s important to remember that there is no one-size-fits-all solution when it comes to managing alcohol use.