Abstinence vs. harm reduction

By Josh Thompson,

Alcohol addiction is a complex problem with no easy answers.  Is alcohol abuse a mental illness?  Experts don’t agree. Even when it comes to peer-reviewed research on how to treat alcohol addiction, the studies are often conflicting. Yet the recovery community in the U.S. so often takes an “us against them” approach when it comes to discussing treatment methodologies.  So, what role should alcohol harm reduction techniques play in addiction recovery?  Perhaps no one should be claiming that a given methodology (abstinence) is the only path to recovery.  We review why here, and invite your comments at the end.

Abstinence vs Harm Reduction – Why There’s No “Right” Answer

When it comes to 12 step programs, the accepted orthodoxy is that abstinence is the only way; the mere mention of harm reduction or moderation will often draw attacks from 12 step proponents. Some treatment providers believe in the abstinence philosophy so strongly that they will actually expel addicts who relapse.

There certainly is a logic to the notion that abstinence is the only way. After all, if you’re a recovering alcoholic, alcohol is your enemy. And periods of abstinence can repair brain and central nervous system functions that were formally impaired. But having an alcoholic self-moderate their alcohol intake is like having the fox guard the hen house – it just seems like a really bad idea. The temptation of having “just one (1) drink” is a classic precursor to relapse.

In a study performed by the APA, addiction counselors who rejected moderation – even as an intermediate goal – cited 3 primary reasons for their beliefs:

1. They believed that moderation didn’t work.

2. They believed moderate drinking sent the wrong message.

3. Decreased drinking was incompatible with their overall treatment philosophy.

Why Abstinence Isn’t The Only Answer

There are certainly many people dependent on alcohol for whom abstinence is the only realistic solution. The truth is that even in Moderation Management – a program dedicated to harm reduction –their own website states that 30% of their members go onto abstinence based programs. But just because abstinence may be the best approach for many alcoholics and drug addicts doesn’t mean that it’s the best approach in every situation.

Why are such vague notions like “it sends the wrong message” or “it’s incompatible with my overall treatment philosophy” sufficient to dismiss an entire treatment approach that has proven to work in some circumstances, for some people? Moderation as a treatment option for problem drinkers has certainly proven to be effective – perhaps even more effective than abstinence – in multiple peer reviewed studies. And while there are conflicting studies on the effectiveness of alcohol moderation (as there are in many aspects of addiction research) for full-fledged alcohol dependents, there are many countries where moderation and harm reduction – even for alcoholics – is widely accepted amongst addiction professionals.

Is The Abstinence vs Harm Reduction Argument A False Dichotomy?

Perhaps we need to ask ourselves, “Why is an affliction/behavior as incredibly complex as alcoholism being distilled down to a one-size-fits-all answer?” Even for professionals who have had tremendous success with a given methodology, does anyone really have the authority to claim that there is only one correct method in dealing with such a complex, multi-facetted issue?

The truth is that there should be room for both approaches. For some problem drinkers and many alcoholics, moderation simply doesn’t work. At the same time, moderation may benefit individuals who otherwise might not seek treatment. As an intermediate goal, it might help those who are unable to psychologically cope with the idea of attending/returning to an abstinence oriented recovery program. Closing our minds to moderation means that many individuals who may be ambivalent about quitting alcohol will be pushed away from seeking any form of treatment.

In sum, whether it’s used as an intermediate goal for alcoholics who need to ultimately work towards complete abstinence, or as an end goal for those who simply aren’t benefiting from an abstinence only approach, there needs to be room for moderation and harm reduction in the addiction treatment arsenal.