Updated July 2021

Two of the primary addiction recovery strategies employed when treating drug addicts and alcoholics are abstinence and harm reduction. While proponents of both strategies peddle high success rates, they also attempt to debunk the efficacy of the other through studies, medical research papers, and various statistics. To get to the truth, it is important to compare the harm reduction model vs the abstinence model. At Behavioral Health of the Palm Beaches, we are doing just that. Our rehab in Lake Worth, Florida, is looking into the efficacy of harm reduction vs abstinence treatment and giving you both sides of the story.

What Is the Definition of Abstinence?

When comparing harm reduction versus abstinence, you need to first look at each individually to start. The alcohol or drug definition of abstinence is the complete cessation of drug or alcohol use. Drug and alcohol abstinence has long been heralded as the best and most effective treatment for alcoholism and drug addiction. Even dating back centuries, before addictions were treated as medical conditions, the traditional way to break drug or alcohol dependencies was through abstinence.²

Now known as the Minnesota Model, the total abstinence principle for treating addiction (which was originally created as a supplement to alcohol detox programs but is now used to treat all addictions) relies on 10 fundamental tenets.²

• The first tenet is that alcohol addiction is an involuntary and primary disease. It is also considered describable and diagnosable.
• Alcoholism should also be considered a progressive and chronic disease.
• While this disease cannot be fully cured, it can be managed.
• While some people are more or less motivated to get residential alcohol treatment, this does not define the success of the treatment outcome.
• Holistic addiction treatment for alcoholism should be used. This method will address physical, mental, social, and spiritual dimensions.
• A successful alcoholic treatment plan should include the alcoholic being treated with respect and dignity.
• Alcoholics and addicts are vulnerable to the abuse of a wide spectrum of mood-altering drugs and all of these problems should also be addressed during treatment.
• Addiction should be treated by a team of multi-disciplinary professionals. The best treatment will also involve more informal, closer relationships between the professionals and the patients.
• The primary counselor will be one of the most important factors of the treatment. He or she should be a similar demographic to the patient and perhaps a former addict as well. This should promote an environment of self-disclosure, mutual identification, and mutual support.
• The most effective treatment for alcoholism includes an orientation to Alcoholics Anonymous (AA). These principles include group support, set expectations, and individual counseling.

History of the 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

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 drug abstinence programs comprise approximately 96 percent of all addiction treatments.⁴

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 inpatient and outpatient alcohol treatment) 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.

 

Alcoholics Anonymous Treatment Model

When comparing harm reduction vs abstinence, it is also important to bring up the AA Model. The abstinence method is based on AA principles, which use spirituality and family involvement as a foundation of its teachings. The Minnesota Model of addiction adapted the first five steps of AA and added medical and psychological components. Patients are generally required to attend AA meetings following treatment that follow the Minnesota Model tenants.

The First Five Steps of the AA Model 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 decided 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 despite 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.

 

What Is Harm Reduction Therapy?

When comparing harm reduction vs abstinence treatment, you will quickly notice that the harm reduction approach for alcohol and drugs are very different from abstinence. The harm reduction approach to drug abuse and alcoholism refers to two separate ideas. The first is to reduce the health, social, and economic harm associated with drug or alcohol use, without reducing the actual use of certain substances. 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 kind of harm reduction alludes to decreased use of drugs or alcohol. Of the two main harm reduction strategies, this one is the most controversial. This style of harm reduction came into vogue in the mid-90s with the creation of the Moderation Management (MM) 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. This program allows 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. Additionally, 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

Some common harm reduction program examples and services include: 

• Impaired driving prevention programs (increase awareness of the risks of driving under the influence)
• Outreach and support programs
• Information and resources on safer ways to use substances
• Supply distribution and needle recovery programs
• Options for opioid substitution therapies such as methadone, suboxone, or Vivitrol (naltrexone)
• Take-home naloxone kits
• Supervised consumption/injection services and overdose prevention services (mainly to help prevent drug overdose death)
• Mental health programs
• Peer support programs are run and attended by people with experience using substances

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.¹⁰

The disadvantages of harm reduction have reduced its momentum in the United States. The 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 of Harm Reduction vs Abstinence Treatment

When discussing either abstinence treatment or the harm reduction approach to alcohol and drug use, 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. Due to ties between stigma and addiction, especially following often costly treatment, some 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’ statistics.

When it comes to moderation, since the definition of success and failure seems blurry at best, many of the statistics attached to the harm reduction 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 the harm reduction model vs abstinence model.

Here are some statistics from previous studies into the efficacy of harm reduction vs abstinence treatment.

• 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

Harm Reduction Criticism

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 in 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 a direct contrast to AA, which regularly features meetings with members who have been sober for years or even decades. Alcoholics Anonymous (AA) has more than 120,000 groups in more than 175 countries around the world, with more than 2 million members.¹⁶ 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.¹⁷ In the same year, 8,260 individuals died from heroin overdoses.¹⁸

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

 

Criticisms of Abstinence-Only Treatments

The most common indictment against addiction abstinence recovery philosophies is their strict adherence to the 12-steps model, which focuses on faith-based addiction treatment. 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.

• 19.7 million American adults (aged 12 and older) battled a substance use disorder in 2017.¹⁹
• In 2017, an estimated 20.7 million people aged 12 and older needed drug or alcohol addiction treatment. Only 4 million people received treatment (around 19%).¹⁹
• Approximately 10 percent of people who need treatment for a substance abuse problem actually seek and receive it.²⁰
• 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.²¹

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 physical dependence. This strategy ignores “problem drinkers” whose usage has not yet reached destructive levels. According to the National Institute on Alcohol Abuse and Alcoholism, 16 percent of the adult population are non-dependent problem drinkers.²² A report from the Centers for Disease Control and Prevention showed that 9 out of 10 binge drinkers weren’t alcohol dependent.²³

 

Discussion and Recommendations of Harm Reduction vs Abstinence Treatment

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 five drinks on the same occasion on each of five or more days in a 30 day period), 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 long-term alcohol and drug rehab that includes 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 to 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 markdown in a notebook when he or she has consumed a beverage?

Families who want 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’s drug addiction or alcoholism 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.

If you’re searching for drug treatment programs for yourself or a loved one, look no further. Behavioral Health of the Palm Beaches offers various forms of addiction treatment in Palm Beach. Our treatment experts teach patients how to maintain abstinence to ensure they achieve long-term sobriety from alcohol and drugs. For more information about the addictions we treat and the mental health services we offer, contact us today.

Sources:

1. William White Papers – Significant Events in the History of Addiction Treatment and Recovery in America
2. Centre de Consultations FAS – Minnesota Model for Alcohol Réhabilitation and Treatment
3. CQ Press – Treating Addiction
4. International Network on Personal Meaning – Abstinence approaches to addiction treatment
5. NCBI – The origins of the Minnesota model of addiction treatment–a first person account.
6. NCBI – Treatment of Adolescents with Substance Use Disorders.
7. DFAF – STATEMENT ON SO-CALLED `HARM REDUCTION´ POLICIES
8. The Fix – Moderation vs. Abstinence: What’s More Effective?
9. Moderation Management™ – Moderation vs. Abstinence: What’s More Effective?
10. NBC News – Road to Recovery
11. A-1 Associates – A. A. Recovery Outcome Rates
12. Taylor & Francis Online – Abstinence and drug abuse treatment: Results from the Drug Outcome Research in Scotland study
13. DualDiagnosis.org – Recovery: Abstinence vs. Moderation
14. Moderation Management – What is Moderation Management?
15. American Psychological Association – Study: Alcohol, Drug Abuse Counselors Don’t Always Require Total Abstinence
16. Springer Link – Attending Substance Abuse Groups and Identifying as Spiritual but not Religious
17. Alcohol.org – The Consequences of Alcohol
18. CNN – Heroin deaths up for 3rd year in a row
19. SAMHSA – Key Substance Use and Mental Health Indicators in the United States: Results from the 2017 National Survey on Drug Use and Health
20. U.S. News & World Report – A Blind Eye to Addiction
21. SAMHSA – State Grant Program
22. NIH – Alcohol Facts and Statistics
23. CDC – Prevalence of Alcohol Dependence Among US Adult Drinkers, 2009–2011
24. CDC – Fact Sheets – Binge Drinking