Addiction Treatment – Abstinence or Improvement?

Improvement is also known as risk reduction. In addiction treatment, the question between abstinence and improvement doesn’t have to be resolved by absolutely choosing one or the other. Historically, those who advance risk reduction have clashed with those who advance abstinence. A lot depends on definitions and emphasis. Are we talking about clients who misuse drugs and aren’t addicted or is the subject addiction? Is medically assisted treatment under consideration?

I think this controversy relies too much on the expectations of the addiction professionals. In reality, there are clients who choose abstinence, and there are those who go through treatment and continue to drink alcohol or smoke pot or use some other drug. The problem with determining the validity of all this is the reliability of self reporting post treatment– however, such things as legal problems or job loses or divorce, etc., can be corroborated.

So, if a person who has experienced several DUIs, several job losses and a divorce due to drinking alcohol then goes into treatment and a few years after treatment is still drinking alcohol but has had no legal problems, no job losses and is now married reporting a healthy relationship, you can say that the person’s life has improved during this period of time post-treatment. The treatment professional can claim success if the measurement is improvement in the quality of life. If the measurement for success is abstinence, then the treatment professional might say that treatment didn’t work. This is all from the perspective of the professional’s expectations and measurements. The ex-treatment client might see it all from a different perspective. Perhaps the client was not an addict and went through treatment during a time of emotional stress and was simply misusing alcohol or some other drug. When addiction treatment professionals perform assessments, they should be sure that the signs and symptoms of addiction are prevalent, but assessments are not 100% valid. Abstinence is never a bad choice, but if someone chooses to drink or use some drug post-treatment, and if that person doesn’t experience the same problems as pre-treatment, then it is what it is. The most likely explanation is that the person was never an addict, just someone who misused drugs and was misdiagnosed. Another explanation is that when addicts return to drugs, they don’t always lose complete control right away — it can take awhile before the addiction causes major problems. If ex-client is taking a prescribed mood-altering medication to deal with co-existing problems such as depression or anxiety, then this is another situation that requires knowledge and careful decision making, but it’s not necessarily a failure of treatment just because the ex-client is not maintaining total abstinence.

Some treatment professionals who insist on abstinence, regard the use of Suboxone to treat opiate addiction as a failure of treatment and recovery. The evidence of successful long term recovery using Suboxone suggests that the abstinence model is too rigid for the evolving field of addiction treatment. For those of us who were in the treatment field in the 80s and before and who saw opiate addicts consistently leave treatment a few days after entering treatment, we see Suboxone as a life saver.

Treatment professionals should present the client with the facts about addiction and substance abuse. Once the client knows the risks of continuing drinking or using drugs, it’s the client’s decision. The danger of the improvement/risk reduction expectation, on the other hand, is that if the professional translates to the client that it’s reasonable to expect a return to alcohol or drugs can produce marked improvement, if the client takes proper actions to avoid severe consequences, this flies in the face of what’s known about addiction. On the other hand, the professional who insists that total abstinence is the only way does not respect the client’s free choice, and misses the fact some improvement in quality of life is possible without complete abstinence. It also misses the fact that some recovering addicts require mood altering medicine to maintain recovery and improve quality of life.

The best the professional can do is offer knowledge, understanding, compassion and expertise with honesty regarding addiction, based on what’s known about addiction, substance abuse, psychology, behavior, etc., then leave the client to the client’s free will to make his/her own choice. If the treatment team has provided knowledgeable, competent treatment and has educated the client on Recovery Management, then that’s success. There are different paths to recovery. Addiction and substance misuse are complicated — it takes a great deal of understanding to provide a nuanced approach that makes sense and helps the recovering addict make better choices.