“The research evidence clearly demonstrates that a one-size-fits-all approach to addiction treatment typically is a recipe for failure.”
~ National Center on Addiction and Substance Abuse
Is abstinence the ONLY way to recover from alcohol or drug addiction?
Can problem drinkers and drug users learn to manage their addictions through moderate use?
Or is there a middle ground?
And despite massive public awareness campaigns, constant headlines and new stories, new legislation, changes to prescribing guidelines, and even expanded access to lifesaving overdose-reversal drugs, the problem is getting worse.
There is an ongoing controversy about what the most effective type of addiction treatment is. The debate is whether we should continue using an abstinence-only model or overhaul the general philosophy and instead focus on harm reduction efforts.
Here, we’re going to look at the pros and cons of each to determine what might be the best course.
The 12-Step Model of Recovery
“…I realized this was the best thing that could have ever happened to a person like me…The most amazing education I’ve ever had…But it is like the kingdom, I guess, we’ve all been looking for, in peace, in spirit. I don’t understand it, because what I’ve put into this program and into this life is nothing compared to what I’ve got back.”
~ Sir Anthony Hopkins, actor, talking about how the Twelve Steps have helped him
Ever since Alcoholics Anonymous was founded in 1935, the Twelve Steps have guided millions of alcoholics and addicts as they regained their sobriety and successfully recovered. The Steps were originally written for people struggling with alcohol, but over the years, they have been modified to be applicable to nearly every kind of addiction and compulsive behavior, from substance abuse to gambling to disordered eating.
Today, the majority of drugs and alcohol rehab programs incorporate some version of the Steps. It’s rather ironic that these guidelines from a completely non-professional mutual support fellowship now shape professional treatment programs around the world.
But one thing has NEVER changed—the Twelve Steps espouse an abstinence-only recovery philosophy. Members of Alcoholics Anonymous, Narcotics Anonymous, and other associated fellowships believe that addiction in any form is, by definition, beyond any individual’s ability to control.
And without that control, one drink or pill or toke or shot leads to another…and another…and another, until they are stopped by “insanity, institutionalization, or death”. Realizing this, members focus on making those personal changes that support a completely substance-free life.
When a member is overwhelmed by temptation or cravings, they are supposed to find strength and support from the group.
The Disease Model of Addiction
“The emerging science shows this is a brain disease. It’s got the same genetic transmutability as a lot of chronic illnesses. And the organ that it affects is the brain, and within the brain it is motivation, inhibition, cognition, all those things that produce the aberrant, unpleasant behaviors that are associated with addiction.”
~ Dr. A. Thomas McLellan, Ph.D., Co-founder, Treatment Research Institute, former Deputy Director, White House Office of National Drug Control Policy
But much has changed in the past almost-85 years.
Medical science has advanced to the point where addiction—now properly called Substance Use Disorder—is recognized as a disease of the brain. Substance abuse causes neurochemical changes to the brain in the areas responsible for reward, pleasure, memory, learning, and impulse control, and motivation. These changes drive compulsive drug-seeking behaviors.
SUD is not a character defect, a moral weakness, a personal choice, or a lack of willpower. SUD in any form is a legitimate medical condition, with identifiable symptoms.
But this also means that there are no approved medical treatments, therapies, and medications for SUD, just as there are with any other chronic illness. This has led to a significant paradigm shift in how SUD is perceived and treated.
FIRST, because there is no cure for SUD, successful treatment focuses on teaching recovering substance abusers how to best manage their disease, reduce symptoms, and prevent relapse, so they can live as healthy and full a life as possible.
SECOND, the most effective treatment strategies are based on empirical evidence—peer-reviewed, measurable, and provable scientific data. Some of these evidence-based treatment protocols are quite a bit different from those utilized in the past.
THIRD, the use of FDA-approved medications to ease withdrawal reduce cravings has expanded. Right now, there are nearly three dozen anti-addiction medications in use in rehab programs around the country. Medication support has proven to be more effective than peer support.
FOURTH, many treatment programs are moving away from the total abstinence required of followers of the Twelve Steps, instead focusing on reducing consumption and therefore, the harm.
What are the 12 Steps?
“The 12 Step program, which has saved my life, will change the life of anyone who embraces it. I have seen it work many times with people with addiction issues of every hue: drugs, sex, relationships, food, work, smoking, alcohol, technology, pornography, hoarding, gambling, everything. Because the instinct that drives the compulsion is universal…We are all on the addiction scale.”
~ Russell Brand, Entertainer and recovering addict
Here are the Twelve Steps of Recovery, worded so as to be applicable to any SUD:
- We admitted that we were powerless over our addiction, that our lives had become unmanageable.
- We came to believe that a Power greater than ourselves could restore us to sanity.
- We made a decision to turn our will and our lives over to the care of God as we understood Him.
- We made a searching and fearless moral inventory of ourselves.
- We admitted to God, to ourselves and to another human being the exact nature of our wrongs.
- We were entirely ready to have God remove all these defects of character.
- We humbly asked Him to remove our shortcomings.
- We made a list of all persons we had harmed and became willing to make amends to them all.
- We made direct amends to such people wherever possible, except when to do so would injure them or others.
- We continued to take personal inventory and when we were wrong promptly admitted it.
- We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
- Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts and to practice these principles in all our affairs.
Criticism of the 12 Steps
“It’s open only to those who are willing to publicly declare themselves to be alcoholics or addicts and who are willing to give up their inherent right of independence by declaring themselves powerless over addictive drugs and alcohol, as stated in Step One, “We admitted we are powerless over alcohol- that our lives had become unmanageable.”
~ Chris Prentiss, The Alcoholism and Addiction Cure: A Holistic Approach to Total Recovery
It is important to understand that, despite their long history, programs like AA and NA are NOT medically-approved treatment plans. The Steps are not based on scientific evidence or clinical experience, and this leads to criticism from some sectors within the modern addiction treatment industry.
In their book, The Sober Truth, Lance and Zachary Dodes claim that the AA model has the worst success rate among all recovery options, between five and ten percent.
The Dodes claim that AA only earned its reputation because the small percentage of people who did succeed with the program spoke and wrote about it regularly, as the Twelfth Step directs. In other words, we never hear from those people who weren’t helped by AA.
They also take issue with AA’s statement that “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves.”
The Dodes say that this is AA’s way of placing the blame for failure solely on the alcoholic/addict, rather than the program.
That particular criticism, say the Dodes, is even worse when it comes to AA’s chip system. Members can earn differently-colored chips marking their length of sobriety – 24 hours, 30 days, 90 days, etc. But, if the person “slips”—taking even ONE drink—the counter is reset back to zero. For some, this can be a source of shame when all of their progress is lost and they have to start all over again.
After all, the majority of people in recovery relapse at least once.
The Abstinence Approach
“The idea that somehow, someday, he will control and enjoy his drinking is the great obsession of every abnormal drinker…We alcoholics are men and women who have lost the ability to control our drinking. We know that no real alcoholic ever regains control.”
~ Alcoholics Anonymous, The Big Book
Abstinence—complete freedom from alcohol or drugs—is ALWAYS the most-desired goal of recovery. If a person is not drinking or using, the progressive physical and emotional damage stops. To put it bluntly, a person cannot overdose if they are not using.
And just as important, when the person has successfully detoxified and is no longer under physical compulsion, their brain’s chemistry will slowly return to normal. Then, they will be better able to fully grasp the lessons and concepts of recovery and practice them in their daily lives.
Although it can be difficult to achieve, sustained abstinence supports successful recovery more than any other treatment philosophy. For example:
- Among people who have abstained from alcohol or drugs for one to three years, just 34% will relapse.
- But among those who have remained abstinent for five years, the relapse rate drops to only 14%.
Long-term abstinence is most likely when the person has sought professional treatment at some point. According to a recent analysis:
- Among individuals who started abusing alcohol 20 or more years ago, over 56% of those who received rehab services at some point are currently abstinent.
- Less than 25% of those who were never treated were able to remain alcohol-free.
A similar study did a 20-year follow-up on abusers on amphetamines, cocaine, and heroin. And among the 27% who had died during the interim, 73% had never been able to remain abstinent from illicit drugs or methadone for even as long as four months.
Why Some Philosophies Disagree with Abstinence
“We’ve defined “success” as abstinence—forever! And we define “failure” as anything else. This message is 100 percent wrong. We need to throw away the silly (and unsupported by research) notion that anyone who needs help must commit to lifelong abstinence from alcohol and drugs before they can begin their journey.”
~ Dr. Adi Jaffe, Ph.D., The Abstinence Myth: A New Approach for Overcoming Addiction Without Shame, Judgement, or Rules
Despite these positive statistics, there are critics of the recovery model that requires total abstinence from alcohol and drugs. They believe that the abstinence model is far too rigid, creating an “all-or-nothing” scenario where anything less than perfection is a failure.
This is significant, because only about 1 out of every 3 people in treatment for alcoholism are able to remain completely abstinent for the first year after rehab.
These critics are of the opinion that because it requires perfection from someone who is already struggling, the 12 Step is unworkable for a large percentage of problem drinkers and drug users.
The supposition is that early-stage alcoholics should be able to go from excessive drinking to moderate, controlled drinking if they have sufficient support and motivation.
At a bare minimum, they reason, cutting back should reduce many of the harms associated with alcohol abuse, such as DUIs, drunken driving fatalities, alcohol poisoning, accidents, and violence.
This is why 50% of counselors who were interviewed in 2012 believe that it is sometimes okay for alcohol abusers to have an occasional drink. In these cases, the appropriate treatment goal is for the person to cut back on their drinking, rather than give up alcohol entirely.
But this argument carries much less weight when it comes to drug abuse.
Although alcohol poisoning is a possibility when the person binge drinks, drug overdoses are far more common. For example, while there are currently over 38 million Americans who admit to binge-drinking, there are only about 2200 alcohol poisoning deaths annually, compared to more than 72,000 fatal drug overdoses.
To put that dichotomy into even greater perspective, a heroin user is 203 times more likely to fatally overdose than a binge drinker is to guide of alcohol poisoning.
And when you also factor in the growing number of overdose cases where the drug has been cut with or replaced by the super-powerful illicit synthetic opioid fentanyl, it highlights the fact that there is no safe level of drug use.
What is Moderation Management?
“…Moderation Management is a program for beginning-stage problem drinkers who want to cut back OR quit drinking. MM provides moderate drinking limits based on research, and a fellowship of members who work the program’s steps together. Some of our members have been able to stay within healthy limits, some have not.”
~ Audrey Kishline, Founder of Moderation Management
Founded in 1994 by Audrey Kishline, Moderation Management is for problem drinkers who believe that with the right support, they can control their drinking. Members say there are far more problem drinkers in America than there are true alcoholics.
MM has positioned itself as an alternative to AA, especially for those people who have trouble admitting that they are “powerless” over alcohol. In fact, the idea that they may be able to control their drinking can be attractive to women, minorities[AF1] , or anyone who already feels disenfranchised.
There are several important differences between MM and AA.
- MM members don’t want to give up alcohol
- Weekly limits: 9 drinks/week for women and 14 drinks/week for men
- Members should refrain from drinking three or four days a week.
- Members are encouraged—but not required—to drink within these limits.
- MM members do not accept the disease concept of addiction. They consider problem drinking to be merely a bad habit that can be corrected and controlled.
- The majority of MM fellowship meetings are held online.
- Most MM members do not believe that they had a substance abuse problem prior to joining. As a rule, they shun the label “alcoholic”.
- There is no spiritual component of MM.
On average, regular users of the MM website cut their blood alcohol content levels in half, even on days that they drink.
Moderation is really only an option for people who are not physically dependent on alcohol. In fact, this is one of the tests that help determine if the program is appropriate. If a drinker is either unsuccessful at sticking to the MM program or they experience alcohol withdrawal symptoms when they try to cut back, that is a strong sign that they need medically-supervised alcohol detox and an abstinence-based treatment plan.
Approximately 30% of MM program members eventually end up in an abstinence program.
This included Moderation Management’s founder. In 2000, six years after she started the movement, Kishline publicly admitted that moderate drinking, was, at least for her, not working. She sent out an e-mail to all the official program members that said, “I have made the decision recently to change my recovery goal to one of abstinence, rather than moderation…. For many, including myself, MM is a gateway to abstinence. Seven years ago, I would not have accepted abstinence. Today, because of MM, I do.”
Unfortunately, that was not the end of her story.
Does Controlled Drinking or Drug Use Work?
“…patients whose goal was total abstinence were more successful than those who had chosen to control their drinking.”
~ Dr. Kristina Berglund, Associate Professor, Department of Psychology, University of Gothenburg
According to the disease concept of addiction, trying to bargain with or set limits on your drinking or drug use is one of the major signs of a severe problem.
Why is this?
The average drinker or recreational drug user doesn’t start a program like MM, AA, or NA without cause. Rather, they attend meetings because they KNOW they have a problem. Most likely, that problem has somehow negatively impacted their life in some fashion—DUI charges, relationship issues, blackouts, health concerns, etc.
But despite such problems directly attributable to their substance use, a person in a MM program is looking for a way to keep drinking.
In a 2006 interview for Dateline, Kishline admitted as much.
Dateline: “As you look back on it, was MM something you devised to give yourself license to drink because you didn’t want to abstain?”
Kishline: “I do think that deep down as an addict that was the purpose.”
Dateline: “All the good research that you did and the presentation of it to a national audience, it was really to justify it for you as a drinker.”
Kishline: “It would legitimize my drinking.”
In 2000, while extremely drunk with a BAC that triple the legal limit, Kishline drove the wrong way down a Washington State interstate. She later confessed to “driving a hundred miles an hour in a total blackout”.
She had a head-on collision with another vehicle and killed a 38-year-old father and his 12-year-old daughter. For her crime, Kishline went to prison. When she was paroled 3 ½ years later, she relapsed several times. At one point, was even sent back for violating her parole by drinking.
For many years, Kishline continued to struggle, not only with her alcoholism but also with overwhelming guilt. Her drinking worsened and her disease progressed, resulting from the end of her marriage. In 2015, just a few days before Christmas, Audrey Kishline Conn committed suicide in her mother’s home in Happy Valley, Oregon.
The Philosophy behind Harm Reduction
“Harm reduction works on the premise that it is easier to get people to make small changes than to get them to make big changes. Because of this, it is possible to have a far greater positive impact on society by getting a large number of people to make small positive changes than by getting only a few people to make big changes.”
~ Kenneth Anderson, How to Change Your Drinking: A Harm Reduction Guide to Alcohol
Moderation Management and controlled use are considered to be forms of “harm reduction”. This is the idea that if a drug addict or alcoholic can learn to drink/use in a controlled or supervised way, many of the dangers to both the individual and two society will be reduced or eliminated, including:
- Worsening addiction
- Drunken or drugged driving
- Criminal behavior
- Overcrowded jails and prisons
- Lost workplace productivity
- Law enforcement allocation
- An overburdened judicial system
- Hepatitis C
According to the National Institute on Drug Abuse, substance abuse negatively impacts the American economy to the tune of $700 billion a year.
Other examples of harm reduction programs include:
- Needle exchange programs
- Supervised injection sites
- Opioid Substitution Therapy—methadone or buprenorphine
- Distribution of anti-overdose kits
Although these programs expressly do not attempt to stop addicts from using, supporters of harm reduction efforts to say that these programs save lives and provide another way to connect addicts and alcoholics with treatment services.
The Downside of Harm Reduction
“With Narcan readily available and over the counter now, they are having group gatherings called ‘Narcan parties’.”
~ Chris Richardson, Battalion Chief, Emergency Services, Rowan County, North Carolina
Critics say that these harm reduction programs normalize and give tacit approval of drug use. For example, there are reports that some opioid addicts are recklessly using even more drugs because they know they can be revived if they overdose.
This dangerous new trend sees abusers of heroin and prescription painkillers intentional taking huge amounts of drugs, either in the presence of others or in public places. They no longer feel the need to be cautious, because either someone in the group or first responders can revive them by administering Narcan.
It is important to note that harm reduction IS IN NO WAY drug rehab. That is not the goal. Addicts who use the services are not required to seek treatment, although anyone who wants help will be connected to available resources.
What is Medication-Assisted Rehab?
“With the current trend in national eye on addiction, more professionals are specializing in this type of care, called Medication-Assisted Treatment (MAT). MAT embraces behavioral therapy in conjunction with medicines for cravings, relapse prevention, and overdose production.”
~ Dr. Arwen Podesta, M.D.
But there is one option that reduces harm and treats the addiction—Medication-Assisted Therapy. MAT uses FDA-approved prescription drugs to augment and support the psychosocial counseling that traditionally has comprised addiction treatment.
Right now, there are nearly three dozen medications that are used to:
- Reduce cravings
- Ease withdrawal symptoms
- Treat co-occurring mental disorders
- Prevent relapse
Generally, the use of methadone or buprenorphine is considered to be OST, a harm reduction technique where these less-addictive opioids replace more dangerous ones like heroin. This manages the addiction until such as the time as the person is ready to participate in the treatment program that includes counseling, group therapy, and other recovery strategies.
However, when the methadone/buprenorphine patient is also receiving drug treatment aimed at eliminating illicit use, then it can be considered MAT.
It’s important to understand that MAT isn’t an option for ALL forms of SUD. While there are medications that can ease cravings for alcohol, opioids, benzodiazepine tranquilizers, and cocaine, there are no such specific medications to help with methamphetamine cravings.
Is MAT Effective?
“With Medication-Assisted Treatment (MAT), which is using a medicine to treat a disease, success rates are over 70 percent—70 percent of people will be abstinent in one year.”
~ Raj Masih, the Potomac Highland Guild’s Substance Abuse Anti-Stigma Initiative
The combination of anti-craving medications and evidence-based behavioral counseling is considered to be the “gold standard” of addiction treatment. This is because it addresses addiction the right way:
As a disease of the brain—Many of the medications used in MAT specifically target the areas of the brain involved in addiction. Some reduce cravings by taking the place of other, more dangerous substances. Others completely block the effects of specific drugs, thereby taking away their “positive” effects. And still, others cause the person to suffer an extremely painful adverse reaction if they use even a small amount of drugs.
As a behavioral issue – True recovery is more than just physical sobriety. It also requires the person to make significant and positive lifestyle changes that support good mental health and continued sobriety. For example, a person and successful recovery must learn to communicate better, reduce stress, avoid triggers, and improve their coping skills.
As a result, MAT patients realize the benefits of their sobriety. long Numerous studies have determined that patients receiving MAT:
- Remain in treatment longer
- Are more likely to successfully complete treatment
- Are less likely to drink or during treatment
- Have better sobriety rates at three-month, six-month, and one-year benchmarks
- Experience fewer arrests
- Have lower divorce and unemployment rates
As Chrissy Smith of the Human Service Center says, “The majority of opioid users would not stop using opioids without medication-assisted treatment. Could people go cold turkey and stop? Maybe, but their long-term success is better with the medications. Medication-assisted treatment (MAT) helps people get through the cravings and withdrawal so they can manage some of the other things that are essential to recovery.”
Incorporating Both Approaches
“The Twelve Step program advises that you must be willing to go to any lengths to get sober and stay that way. And “any lengths” often means getting additional help from doctors, psychologists, and/or counselors. Most recovering people can benefit from both the Twelve Steps and professional therapy.”
~ Terence T. Gorski, Understanding the Twelve Steps: An Interpretation and Guide for Recovering
The 12 Steps are a wonderful framework that offers support and encouragement to people who often have neither. But because fellowship meetings are by nature nonprofessional, participants can miss out on evidence-based treatment strategies that could be beneficial.
For example, AA/NA meetings don’t help with cravings or address co-occurring mental illness.
Likewise, MAT is incomplete on its own, because it doesn’t provide the patient with the ongoing social support they need and to achieve a successful, long-term recovery.
Both options have complete abstinence from alcohol and drugs as the primary goal, with additional benefits to social, mental, and physical health. In other words, they are completely compatible.
This means that the most effective treatment programs should incorporate medication, behavioral counseling, and some version of the 12 Steps.
The Bottom Line
“People are able to stop illicit use. Their risk for overdose goes down, their risk of health-associated complications from their substance use goes down. They’re much more likely to return to work, to return to normal life and have less criminal activity. So there’s a number of benefits to the medications.”
~ Dr. Carla Marienfeld, Associate Professor of Psychiatry, University of California San Diego
Addiction is a complicated disease with many contributing factors. As a result, SUD manifests differently in every individual. No person’s addiction is exactly like others. This is precisely why no single approach is successful 100% of the time with 100% of patients.
An evidence-based, wellness-focused, Step-supported, and medication-assisted treatment has the flexibility to help anyone whose life has been impacted by problematic alcohol or drug abuse. This is the best way to move forward on a successful sober journey.