Recovery: Abstinence vs. Moderation

Addiction Recovery
abstinence-moderation

Comparing abstinence to moderation management and harm reduction programs

Typically, the first thing that comes to mind when thinking about addiction recovery is how to quit using or abusing a substance forever. There are proponents of another theory though, that one can control addiction through moderation management (MM) behaviors, and there is evidence to support this theory, too.


Abstinence

Abstaining is the most traditional treatment method surrounding drug and alcohol abuse. This method involves completely avoiding substance use and abuse. While abstinence has long been held as the only way to resolve an addiction problem, and it may be highly effective when achieved, actually reaching the goal of abstinence seems to be the biggest problem.

High Relapse Rates


A Scottish study of 695 participants carried out in 2006 reported just a mere 5.9 percent of females and 9 percent of males as having been completely abstinent for at least 90 days prior to the interview 33 months after recruitment.[1]

Abstinence is an effective method of treatment when maintained. Among individuals who remain abstinent for one to three years, only around 34 percent will end up relapsing. This number drops to 14 percent among those who manage to remain abstinent for five years.[2]

Those who are seeking abstinence will be most likely to reach this goal through professional treatment. Past-year data from 2012 supports long-term abstinence as possible and more likely if the addict has sought treatment at some point. The data reflects 56.1 percent of individuals who had begun to engage in alcohol abuse 20 or more years prior and sought treatment at some point were abstinent, compared to 24.5 percent who were never treated being abstinent.[3]

relapse rates
heroin

Similar data for heroin, cocaine and amphetamine abusers showed that at least 27 percent of the 899 participants one study began with were no longer living 20 years later, and among them, just 27 percent were abstinent from the aforementioned drugs and methadone for at least four months since they initiated such drug use 20 years before.[4]


Moderation Management

Believe it or not, abstinence isn’t the only path people try to take to sobriety. While it may sound like a bit of an oxymoron, some believe that addicts and substance abusers can achieve sobriety while still drinking alcohol or using drugs on occasion. The theory behind this is that it may work best for those substance abusers who are not physically dependent on drugs or alcohol and who have suffered few negative side effects from their substance abuse behaviors, such as delirium tremens or substance cravings.

alcoholism

This theory supposes that the common alcoholic — something 17.7 million people were classified as in 2012[5] — can manage their addiction by limiting how much and how often they drink.

When it comes to drug abusers, the theory carries less weight. While a single episode of binge drinking can lead to death — of the 38 million admitted binge drinkers, there were 2,200 deaths due to alcohol poisoning[6] — it’s far more likely that a person would die from a single use of hard, illicit substances like heroin. In 2013, 8,260 people died following the use of heroin in the United States.[7] Thus, moderation management can be dangerous when used to end certain drug habits.

deaths overdose

Only 2.5 million of the 23.1 million people in America who needed treatment for a substance abuse problem got it in 2012.[8] Many addicts claim the reason they don’t pursue treatment is due to not feeling like they’re ready to stop using — combined data from 2010 to 2013 shows that 24.5 percent of the millions of individuals who needed treatment but didn’t get it reported this being the reason why.[9] Among problem drinkers, nine out of 10 resist seeking traditional treatment on purpose.[10]
in need of treatment
moderate drinking okay

But moderation in recovery is not advised by many in the treatment community. Over the years, treatment views toward substance abuse have changed, even in the eyes of treatment providers. In 1994, around 25 percent of the 913 counselors interviewed claimed that an occasional drink was okay for alcohol abusers who wanted to decrease how much they drink without totally quitting; that figure has risen to 50 percent as of 2012.[11] In one study focused on the duration of abstinence rates among 1,222 participants, only just 418 of them achieved abstinence for a year or longer following treatment.[12]

The Moderation Management organization came along in 1994 as a controversial counterpart to the more traditional and abstinence-minded Alcoholics Anonymous. Its founder, Audrey Kishline, felt her alcohol use was a problem, but not so much that she thought of it as a disease or chronic illness. Although she would later end up confessing openly that moderation didn’t work out for her, she still fully supported it as an option for others, and since then many have jumped on board and made successful turnarounds in their lives with the MM program.

In the program, accountability is high on the list of must-haves, and an online, interactive calendar where MM members can report their drinking or drug use keeps them on track with their pattern of substance use and holds them responsible for it. Members can take advantage of in-person meetings, just like AA offers, or opt for online encounters that serve the same purpose while providing more flexibility. The program’s website offers detailed guides on how much alcohol use is permissible and message boards where members can discuss their struggles and find praise for their achievements.

The program encourages you to focus on your substance abuse patterns. When do you use? Why? Those are important questions, because their answers reveal wounds that need fixing and a general lack of coping skills. When these issues are repaired, the urge to drink when upset or as a way to avoid emotions may be managed.


Other Methods

The program operates virtually so that members remain truly anonymous, and lifetime membership isn’t a requirement. Labels of addiction aren’t a part of this program, because there is no shame involved. Absent of religious affiliation, SMART Recovery teaches members the tools they need to practically handle their substance abuse problems without a commitment to a higher power, but more so with a commitment to themselves. The program is most popular with alcohol abusers, but isn’t solely aligned with them.

A UK review of participants tallied 67 percent of surveyed members sought out the program for their drinking, while 36 percent did for an opiate addiction, 10 percent for a marijuana or stimulant dependency, and seven percent for other drugs, with 19 percent of respondents reporting poly-substance abuse.[13]
smart recovery

Abstinence and MM aren’t the only remedies for alcohol abuse. Self-Management and Recovery Training (SMART Recovery) is another treatment option that concentrates on four main principles, which are:

  • Creating and sustaining motivation
  • Managing urges to use
  • Controlling thoughts, emotions, and actions
  • Living a well-rounded life

Rational Recovery, which centers on a singular approach to recovery with no support groups or regular meetings to attend, utilizes the Addictive Voice Recognition Technique. In other words, the idea is that you are constantly battling a beast inside yourself that wants to lure you back to substance abuse. The program allows participants to consider themselves fully recovered on day one and to operate with that mindset moving forward.

Today, there is a strong push for help on the pharmaceutical front that can assist some problem drinkers in curbing their alcohol abuse. Naltrexone has aided in inhibiting the desired high many drinkers receive from alcohol abuse, and thus, it makes many lose the desire to seek it. Others have benefitted from Antabuse, a commonly prescribed drug that induces vomiting when mixed with alcohol.

Opioid antagonist nalmefene has been approved for opioid overdose treatment in the US, but not yet for alcohol abuse as it has elsewhere. Still, it may be a promising movement in the future. A manufacturer study touted impressive results among 604 participants that decreased the number of days they drank heavily from 19 to eight over six months’ time and lowered their overall rate of alcohol use by about two-thirds.[14] Essentially, the drug curbs the drinker’s craving to go beyond the consumption of a couple drinks at happy hour.

One program known as Harm Reduction, Abstinence, and Moderation Support (HAMS) focuses more on the lifestyle-related causes of drug and alcohol abuse. It recognizes the frequency with which these behaviors are tied to social activities and aims to assist members in reaching self-set goals. Some of these individuals may seek to stop drinking altogether. Others might just want to scale things back, while some may be seeking ways to continue engaging in the substance abuse habits they choose while learning how to make those practices safer and less likely to cause harmful side effects.

HAMS strongly urges members to pay attention to how they feel before, during, and after drinking or using drugs. These revelations can come in handy afterward. For example, a problem drinker may feel great after two or three drinks, thus encouraging him to keep going, but he finds through the HAMS program that after four or five, he begins to feel sad and depressed. Those negative emotions then drive him to keep drinking, and he may learn through this experience that two or three drinks needs to be his limit.


Criticism

Critics of Alcoholics Anonymous — the largest abstinence-based program in existence — continue to say that AA boasts poor success rates, just five to 10 percent among some sources, though the organization states that success rates can’t be measured correctly due to the anonymous nature of the group.[15] There are also drawbacks to moderation management, and those who are against it have concerns that aren’t unfounded.

Some people aren’t fans of the modernized method and tout moderation as nothing more than an excuse to relapse. The biggest risk involved in moderation management is staying accountable. It isn’t uncommon for those practicing the MM method to hide their excess drinking or use their participation in the program as an excuse to drink more than they should be. It often aids in staving off concerns from others in their life, too. Of course, while critics of MM are quick to point out the potential for falsely subscribing to program practices, the same can be said of abstainers. Personal accountability is a big part of MM, just as it is with AA.

moderation to abstinenceSome worry that moderation practices may encourage alcohol use among abusers, seeing drinking in moderation as a free pass to continue abusing alcohol when it has been an obvious problem in the abuser’s life. Proponents of the MM program feel this is not true. Those individuals who cannot maintain moderation habits in the MM program generally end up moving on to abstinence programs, something a reported 30 percent of MM participants do.[16]

Other critics have concerns that the MM program will give abstinent substance abusers the idea that they can return to using and keep it under control. Supporters say that the program doesn’t entice relapse, and those who have such ideas about MM generally would have relapsed anyway.

The focus of moderation management is not to deter substance abusers from abstinence or draw them away from an already present commitment to such. Rather, there is more concern in the substance abuse treatment community over the number of addicts who never even attempt to seek treatment — a figure that accounts for around 90 percent of the substance-abusing population.[17] The moderation management protocol may serve as a feasible way for many of those individuals to seek help or at least be more inclined to. Likewise, MM acts as a gateway to abstinence later on for a large number of participants.

Still, many who are in favor of abstinence will tell you that problem drinkers generally have one thing in common — they drink too much and cannot control it. So they pose the question: How then will they learn to do just that — control their drinking habits? Whether the outcome of a childhood experiences or causing a ruckus in college, binge drinking and drug experimentation are often part of the young American’s culture. As of 2005, 68 percent of a sample of American college students were drinkers and 40 percent of them admitted to binge drinking.[18]

In a study of 90 heavy drinkers that participated in MM and were monitored at three, six and 12 month intervals following such, those who utilized the MM website were able to increase their rate of monthly alcohol management from 16 percent to 20 percent — results that persisted throughout the entire study period.[19] In addition, they decreased their blood alcohol content levels by half, even on days they were drinking.[20] Those who utilized the MM interactive site were able to reach a 40 percent rate of abstinence throughout the month.[21]

Citations

[1] McKeganey, N., Bloor, M., Robertson, M., Neale, J. & MacDougall, J. (2006). “Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study.” Informa Healthcare. Accessed May 14, 2015.
[2]Extended abstinence is predictive of sustained recovery.” (July 2008). National Institute on Drug Abuse. Accessed May 14, 2015.
[3]Substance Recovery Rates: With and Without Treatment.” (2012). The Clean Slate. Accessed May 14, 2015.
[4] Termorshuizen, F., Krol, A., Prins, M. & Van Ameijden, E.J.C. (2005). “Long-term Outcome of Chronic Drug Use.” American Journal of Epidemiology. Accessed May 14, 2015.
[5]DrugFacts: Nationwide Trends.” (January 2014). National Institute on Drug Abuse. Accessed May 14, 2015.
[6]Alcohol Poisoning Deaths” (2015). Centers for Disease Control and Prevention. Accessed May 14, 2015.
[7] Kounang, N. (2015 January 14). “Heroin deaths up for 3rd year in a row.” CNN News. Accessed May 14, 2015.
[8]DrugFacts: Nationwide Trends.” (January 2014). National Institute on Drug Abuse. Accessed May 14, 2015.
[9]Substance Use and Mental Health Estimates from the 2013 National Survey on Drug Use and Health: Overview of Findings.” (2014 September 4). Substance Abuse and Mental Health Services Administration. Accessed May 14, 2015.
[10]Why is a Moderation Program Needed?” (n.d.). Moderation.org. Accessed May 14, 2015.
[11] Davis, A. & Rosenberg, H. (2012 November 2). “Study: Alcohol, Drug Abuse Counselors Don’t Always Require Total Abstinence.” American Psychological Association. Accessed May 14, 2015.
[12] Scott, C.K., Dennis, M.L., Laudet, A., Funk, R.R. & Simeone, R.S. (April 2011). “Surviving Drug Addiction: The Effect of Treatment and Abstinence on Mortality.” American Journal of Public Health. Accessed May 14, 2015.
[13] Bitel, M. (January 2014). “The evaluation of SMART Recovery in the Lothians.” SMART Recovery UK. Accessed May 14, 2015.
[14] Andrey-Smith, P. (2014 October 19). “A Pill Could Help Alcoholics, and Let Them Drink in Moderation.” Newsweek. Accessed May 14, 2015.
[15] Dodes, L. & Dodes, Z. (2014 March 23). “The pseudo-science of Alcoholics Anonymous: There’s a better way to treat addiction.” Salon. Accessed May 14, 2015.
[16] Fowler, R. (2011 July 13). “Moderation vs. Abstinence: What’s More Effective?” The Fix. Accessed May 14, 2015.
[17] Shallow, P. (2014 October 9). “#14 Days: Moderation, a radical option in treating addiction.” CBS News. Accessed May 14, 2015.
[18]Wasting the Best and the Brightest: Substance Abuse at America’s Colleges and Universities.” (March 2007). CASA Columbia. Accessed May 14, 2015.
[19] Jaffe, A. (2011 March 9). “Abstinence Is Not the Only Option.” Psychology Today. Accessed May 14, 2015.
[20] Ibid.
[21] Ibid.
[22]Annual Causes of Death, By Cause 2013

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