Rethinking Treatment Goals, “Successful” Outcomes and Reduced Alcohol Use
By John de Miranda
Innovation does not come quickly or easily to the addiction treatment sector. For example, harm reduction strategies had been employed in the public health sector for decades before their recent adoption by the federal government as a latecomer to fighting our nation’s opioid epidemic. Similarly, the Minnesota Model of addiction treatment, which emerged in the 1950s, still accounts for the model preferred by the majority of treatment programs. At its core, this approach draws heavily from 12-step ideology and requires a commitment to abstinence as the key focus of treatment goals.
“If you have had enough and are ready to quit, then we can help you,” is the metamessage sent to potential clients by most addiction treatment programs.
The problem with this approach is that it will only resonate with a small percentage of individuals in need of assistance. A more effective message that acknowledges the power and ubiquity of ambivalence is, “If you are interested in doing something about your drug/alcohol use, we can help”.
A Change in the Language of Treatment Goals
For this reason, recent guidance from both the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) is significant. In 2020 NIAAA released a definition of recovery “as a process through which a person achieves remission from Alcohol Use Disorder as well as cessation from heavy alcohol consumption, which is a non-abstinent recovery outcome.” An NIAAA advisory in October 2023 stated:
“A large body of evidence…suggests that treatment and recovery strategies that reduce heavy alcohol consumption and alcohol-related consequences without complete abstinence can be effective for mitigating the harms associated with alcohol misuse for many individuals. Today, although abstinence is the safest course for certain subgroups, harm reduction strategies that are non-abstinence based have become an important part of the discussion around AUD treatment and the recovery process.” https://www.niaaa.nih.gov/news-events/research-update/incorporating-harm-reduction-alcohol-use-disorder-treatment-and-recovery
Similarly, a January 2024 news release from NIDA begins:
“Reducing stimulant use was associated with significant improvement in measures of health and recovery among people with stimulant use disorder, even if they did not achieve total abstinence. This finding is according to an analysis of data from 13 randomized clinical trials of treatments for stimulant use disorders involving methamphetamine and cocaine. Historically, total abstinence has been the standard goal of treatment for substance use disorders, however, these findings support the growing recognition that a more nuanced perspective on measuring treatment success may be beneficial.” https://nida.nih.gov/news-events/news-releases/2024/01/reduced-drug-use-is-a-meaningful-treatment-outcome-for-people-with-stimulant-use-disorders
These challenges to the long-held beliefs among a preponderance of treatment professionals coincide with growing public sentiment that simply reducing alcohol consumption leads to health benefits. An example, from the Harvard Health Publishing arm of Harvard Medical School provides an example:
“…cutting out alcohol for even a month can make a noticeable difference in your health. Regular drinkers who abstained from alcohol for 30 days slept better, had more energy, and lost weight, according to a study in BMJ Open. They also lowered their blood pressure and cholesterol levels and reduced cancer-related proteins in their blood.” https://www.health.harvard.edu/blog/thinking-of-trying-dry-january-steps-for-success-202201032662
These benefits from even short periods of abstinence would seem to belie the popular belief that some wine consumption is actually good for health.
Early in my career I worked at a “halfway house” in Boston’s Combat Zone. The men we served were the clients that most treatment programs did not want. Homeless, disabled, homosexual, with chronic addiction-related health problems. They came to us and we served them but not with the expectation that they would remain abstinent after their treatment episode. For many a stay at Victory House was simply respite from the streets. We were helping our clients stay alive. We tried to practice the Minnesota Model but found that our clients primarily needed a drug-free environment, rest, good food and caring helpers.
What This Means for Core Principles and Treatment Goals
In today’s environment, traditional treatment organizations and mutual aid programs will have to reexamine core principles and practices in order to embrace these kinds of research findings. Similarly, current 12-step approaches are incompatible with recovery objectives other than abstinence.
Treatment goals of abstinence were foundational to the development of the modern addiction and recovery sectors. Embracing the growing body of evidence that incorporates “outcome flexibility” into our thinking will be a major challenge for treatment professionals and members of mutual aid organizations.
If you or a loved one are interested in exploring an approach where treatment goals fit the individual, our outpatient services may be a great fit. Please don’t hesitate to reach out – we’re here for you.