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The Efficacy of Abstinence Treatment vs. Harm Reduction

photo of a man with clenched fists sitting at a bar trying to resist the temptation to pick up the glass of alcohol in front of him

In this article, we will review previously published research about the effectiveness of both addiction recovery strategies, analyze data and provide recommendations for recovering addicts and their families. We have included research from nearly two dozen articles from different industries and countries to convey as complete a picture of both strategies as possible.

Two of the primary addiction recovery strategies employed when treating drug addicts and alcoholics are abstinence and harm reduction. While proponents of both strategies tout high success rates, they also attempt to debunk the efficacy of the other through studies, medical research papers and various statistics.

Abstinence Defined

For the purposes of this article, abstinence is defined as the complete cessation of drug or alcohol use. Abstinence has long been heralded as the best and most effective way to defeat addiction. Even dating back centuries, before addictions were treated as medical conditions, the traditional way to break drug or alcohol dependencies was abstinence. 1

Now known as the Minnesota Model, abstinence addiction treatment (which was originally created for alcoholism but is now used to treat all addictions) relies on 10 fundamental tenets. 2

  • Alcoholism is an involuntary, primary disease that is describable and diagnosable.
  • Alcoholism is a chronic and progressive disease.
  • Alcoholism is not curable, but the disease may be arrested.
  • The nature of the alcoholic's initial motivation for treatment, its presence or absence, is not a predictor of treatment outcome.
  • The treatment of alcoholism includes physical, psychological, social and spiritual dimensions.
  • The successful treatment of alcoholism requires an environment in which the alcoholic is treated with dignity and respect.
  • Alcoholics and addicts are vulnerable to the abuse of a wide spectrum of mood altering drugs. This whole cluster of mood altering drugs can be addressed through treatment that defines the problem as one of chemical dependency.
  • Chemical dependency is best treated by a multi-disciplinary team whose members develop close, less formal relationships with their clients and whose activities are integrated within an individualized treatment plan developed for each client.
  • The focal point for implementing the treatment plan is an assigned primary counselor, usually a recovered addict, of the same sex and age group as the client, who promotes an atmosphere that enhances emotional self-disclosure, mutual identification and mutual support.
  • The most effective treatment for alcoholism includes an orientation to Alcoholics Anonymous (AA), an expectation of step work, groups that combine confrontation and support, lectures, one-to-one counseling and creation of a dynamic learning environment.

What Led to the Minnesota Model?

The creation of AA in 1935, followed by the publishing of its primary text, "The Big Book," coupled with several medical advances slowly led to the acceptance of alcoholism as a disease, which was a precursor to the Minnesota Model.3 In the United States, the Minnesota Model or similar abstinence-only programs comprise approximately 96 percent of all addiction treatments.4

Minnesota Model

In the late 1940s, the still fledgling addiction recovery treatment industry was at a loss about what to do with alcoholics. Previously, they were either jailed, put in institutions for the mentally ill or left to the fate of their addictions. At the time, however, AA’s membership had grown to over 90,000, and it had proven to be somewhat successful in reforming alcoholics. 4

This approach assumes that the disease of addiction has grown so strong within an individual that he or she cannot have a single sip of an alcoholic beverage without risking relapse.

Created in 1949, the Minnesota Model first spread to the then small, not-for-profit organization called the Hazelden Foundation (now the Hazelden Betty Ford Foundation) and then quickly reached every corner of the nation.5 This approach (which has since extended beyond just treatment for alcoholism) assumes that the disease of addiction has grown so strong within an individual that he or she cannot have a single sip of an alcoholic beverage without risking complete relapse.

Abstinence is based on AA principles, which use spirituality and family involvement as a foundation of its teachings. The Minnesota Model adapted the first five steps of AA and added medical and psychological components. Patients are generally required to attend AA meetings following treatment in the Minnesota Model, however.

The First Five Steps Translated:6

  1. Admit Powerlessness: We admitted we were powerless over our addiction – that our lives had become unmanageable. In the Minnesota Model, this step serves to make the addict review his or her substance use history and acknowledge the harmful consequences that have ensued as a result.
  2. Find Hope: We came to believe that a power greater than ourselves could restore us to sanity. With the spirituality aspect removed, this translates into “there is help if you want to be helped.”
  3. Surrender: We made a decision to turn our will and our lives over to the care of God as we understood God. Under the Minnesota Model, this means that the addict must stop making decisions in the way he or she has in the past. It means taking advice from others and letting them help you.
  4. Take Inventory: We made a searching and fearless moral inventory of ourselves. This begins the process of self-forgiveness and self-acceptance, even in spite of all the damage substance abuse has caused.
  5. Share Inventory: We admitted to God, to ourselves and to another human being the exact nature of our wrongs. Just as one has to forgive themselves, it’s also important to seek forgiveness from others.

Harm Reduction Defined

The harm reduction approach to addiction treatment refers to two separate ideas. The first is to reduce the health, social and economic harm associated with drug or alcohol use, not reducing actual usage of the abusing substance. This approach has been popularized in European countries since the 1980s, when government officials were searching for ways to combat the growing HIV epidemic. Needle exchange programs and methadone treatments were born from this approach.7

The other form of harm reduction alludes to lessening usage of drugs or alcohol. For the purposes of this article, we will focus solely on this approach. This style of harm reduction controversially came into vogue in mid-90s, with the creation of the Moderation Management organization, founded by Audrey Kishline. A self-identified problem drinker herself, Kishline did not believe in the disease theory or the principles taught by AA. 8

She created Moderation Management as an alternative path to abstinence treatment, allowing drinkers to continue consuming alcohol in moderation. The organization also spurned the need to submit to God or any higher spiritual power, something that was openly welcomed by individuals who were not religious and perhaps put off by the idea of forced spirituality.

Harm reduction focuses on self-accountability and, like AA, utilizes meetings, peer support and online services to self-report alcohol use. In theory, this allows alcoholics to keep track of their drinking.9

Moderation Management as an organization lost a lot of credibility when Kishline admitted in January 2000 that her drinking problems were too severe to be managed by moderation, and she entered AA. Unfortunately, two months after her admission, she drove drunk and killed a mother and her child in a horrific car accident.10

While harm reduction is still practiced in some areas in the nation, it has lost considerable momentum and is not highly utilized. Harm reduction strategy is mainly intended for drinkers who have not yet had their lives significantly damaged by abuse, (meaning they haven’t lost jobs, ruined marriages, destroyed their health or encountered legal problems as a result).

Examining Success Rates

When discussing either abstinence treatment or the harm reduction approach, finding a reliable and accurate success rate is nearly impossible. This is mainly because the collection of this data relies solely on patients self-reporting their alcohol or drug use. With the shame and stigma attached to addiction, especially following often costly treatment, many recovering addicts may not be forthcoming or honest in admitting slips or relapses.

Alcoholics Anonymous has clearly saved countless lives and has unquestionably been successful in changing the lives of many alcohol abusers and their families. But their reported success rates range anywhere from 5 percent to 70 percent, depending on the source of the data.11 The same can be said for most abstinence-only programs.

When it comes to moderation, since the definition of success and failure seems to blurry at best, many of the statistics attached to the method are also unreliable. How does one define success in this model? Going from six drinks per week to five? Reducing down to two drinks per month? This arbitrary nature makes it much easier to claim success in harm reduction than abstinence.

Here are some statistics from previous studies into the efficacies of abstinence and harm reduction.

  • A 2006 Scottish study tracked 695 recovering alcoholics for 33 months following treatment. The results showed that just 5.9 percent of females and 9 percent of males had remained completely abstinent for at least 90 days during the near three-year stretch.12
  • 34 percent of individuals who remain abstinent for one-to-three years will end up relapsing. That number plummets to 14 percent when individuals remain abstinent for five years.13
  • Approximately 30 percent of Moderation Management members move on to abstinence-only programs.14
  • In 2012, 50 percent of counselors interviewed in a study said that it was okay for alcohol abusers to have an occasional drink.15 

 

Criticisms of Harm Reduction

Much of the abstinence-only addiction recovery community attacks the harm reduction theory for enabling addicts to continue drinking. They view this as an excuse for relapse. As was discovered with Kishline (it was later found that she was hiding her drinking the entire time), it’s not uncommon for a person to lie about how much alcohol he or she is consuming. The mission statement of Moderation Management could be viewed as a justification to drink:

MM empowers individuals to accept personal responsibility for choosing and maintaining their own path, whether moderation or abstinence. MM promotes early self-recognition of risky drinking behavior, when moderation is a more easily achievable goal.

Since Moderation Management groups are not intended to be long-term or intensive, membership is predominantly online, and groups do not form easily or last very long. This is in direct contrast to AA, which regularly features meetings with members who have been sober for years or even decades. When a person does attempt to create an MM meeting, they must make the arrangements on their own (space, time, refreshments, recruiting members, etc.) and risk losing anonymity, which may be a problem for high-profile individuals. 8

Perhaps the largest criticism of harm reduction is that it does not hold much weight when dealing with illicit substances, such as heroin or cocaine. How does one recommend doing less heroin, crystal meth or cocaine as a treatment strategy? A single episode of binge drinking can be potentially deadly, but is less likely to be fatal than when using heroin. In 2013, of the 38 million admitted binge drinkers in the U.S., there were only 2,200 deaths due to alcohol poisoning.16 In the same year, 8,260 individuals died from heroin overdoses.17

This same problem extends to painkiller addictions, because harm reduction does not employ therapies that would educate patients how to manage their pain without the use of drugs.

Criticisms of Abstinence Only Treatments

The most common indictment against abstinence-based addiction recovery philosophies is their strict adherence to the 12-steps model, which focuses on spirituality and a higher power. Not all people are comfortable with the idea of praying or focusing on spirituality. Opponents of the strategy also point to low success rates and an unwillingness for many individuals to seek treatment because they do not want to completely cease using.

 

Approximately 10 percent of people who need treatment for a substance abuse problem actually seek and receive it.18 Combined data from 2010 to 2013 shows that 24.5 percent of those who needed addiction treatment but didn’t get it cited not being ready to stop using.19

 

Many addicts struggle with the idea of putting down their substance of choice forever.

Others argue that the abstinence-only strategy unfairly demonizes addicts who relapse and perpetuates the negative stigma associated with addiction.

Another issue non-supporters raise about abstinence-only programs is that they focus solely on alcoholics who have developed a physical dependence. This strategy ignores “problem drinkers” whose usage has not yet reached destructive levels. According to National Institute on Alcohol Abuse and Alcoholism, 16 percent of the adult population are non-dependent problem drinkers.20 A report from the Centers from Disease Control and Prevention showed that nine out of 10 binge drinkers weren’t alcohol dependent.21

Discussion and Recommendations

The argument between harm reduction and abstinence boils down to an individual’s needs. For a person who is a diagnosed alcoholic or a heavy drinker (more than 5 drinks on the same occasion on each of five or more days in a 30-day period),22 harm reduction may not be a realistic option. It relies on a person who previously had difficulty controlling his or her drinking to suddenly develop self-control. As many addiction therapists would attest, this is an unrealistic expectation.

Alcoholics and drug addicts generally require more than just the standard 30-day detox suggested by Moderation Management and other harm reduction organizations. Additionally, they require counseling and other therapeutic services. Much of the medical community classifies addiction as a chronic brain disease. As such, abstinence-treatment is the only way to ensure that the disease remains in remission.

Drinkers who self-identify as needing to curb their drinking may find harm reduction to be a better strategy. It is less intensive, less expensive, less invasive and does not close the door on socially drinking. It does, however, require a level of self-control and accountability that is uncommon in problem drinkers. How many drinkers can even recall how many alcoholic beverages they had the night before? How realistic is it for a drinker to pause in between drinks and mark down in a notebook when he or she has consumed a beverage?

Families attempting to find substance abuse treatment for a loved one must honestly assess the enormity of the problem. If an individual is abusing illicit drugs or prescription drugs, abstinence-only treatment may be advisable. Likewise, if a person has caused significant damage to his or her life, or the lives of others, abstinence-only treatment is the most advisable course of action. However, an individual who is just a “problem drinker” who has not suffered major consequences as a result of drinking, may be successful with a harm reduction approach.

This article was written by addiction care experts at Behavioral Health of the Palm Beaches. We are committed to offering the most comprehensive addiction treatment services in the nation and being thought leaders in the addiction recovery community.