What does it mean to be in recovery from alcohol or drug use? Research shows that most define it as a commitment to being totally abstinent from the substance as a way of breaking its hold. Abstinence, in fact, is the foundation upon which most 12-step support groups and addiction treatment organizations are built. Even the use of any kind of medication for addiction — to ease cravings or as a substitute for a more dangerous drug, for example — has been seen as incompatible with the concept of abstinence in recovery.
Today, however, a broader definition of recovery is gaining currency, one that puts the focus on improved quality of life and accepts that abstinence may not be the only way to get there.
In its definition of recovery, released in 2011, the Substance Abuse and Mental Health Services Administration (SAMHSA) describes recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” In an accompanying list of guiding principles, it notes that abstinence remains the safest approach for those with substance use disorders, but emphasizes that “recovery occurs via many pathways.”
Among those paths are a growing number of therapeutic medications that can help minimize cravings and reduce use of a substance, as well as mutual support organizations that aim to meet substance users where they’re at rather than insisting abstinence be the starting point — or even the goal.
This more flexible mindset reflects the growing understanding that problems with substances (as well as some compulsive behaviors) occur across a spectrum, so solutions should too. In the past, it was thought that people either had a problem with drugs or alcohol or they didn’t; there was no middle ground. This concept was embraced by Alcoholics Anonymous (AA), founded in the mid-1930s, an era when there were few options, medical or otherwise, for the problem drinker. Abstinence, thus, seemed to provide the only real hope for change.
A Shifting Idea of Abstinence
Starting about 30 years ago, that thinking began to change, says Keith Humphreys, PhD, a professor in the department of psychiatry and behavioral sciences at Stanford University and an authority on addictive disorders and the role of mutual-support organizations like AA. “There has been increasing recognition that people with lower-severity alcohol problems can return to non-problem use, and that some people need medications in order to recover,” explains Dr. Humphreys. He adds, “Funnily enough, AA co-founder Bill Wilson believed both of these things to be true, so they are not actually new ideas.” The AA Big Book, in fact, notes that “our hats are off” to those who can successfully moderate their drinking. AA’s Wilson knew, though, that he wasn’t one of them.
Today, the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), psychiatry’s main diagnostic tool, recognizes that substance use disorders range from mild to severe. That means there may be those at the high end or in the middle of the spectrum for whom abstinence is the answer. Others may benefit from taking therapeutic medications to control cravings. For some at the low end, though, learning to use substances in moderation may be possible.
Recovery Through Moderation
Even the most enthusiastic proponents of expanding the definition of recovery, though, agree that moderation doesn’t work for everyone. “There are people who should never drink even one drink,” says Marc Kern, PhD, chairman of the board of Moderation Management (MM), a support group that teaches strategies to those who want to drink less. “But to overgeneralize and call everyone an alcoholic puts them in a position of shame and embarrassment, and they often go and hide and the problem gets worse rather than putting it out on the table.”
Indeed, 2014 research by the Centers for Disease Control and Prevention found only one out of 10 problem drinkers meets the clinical definition of alcoholism. The other nine still need to drink less but may be turned off by more traditional 12-step approaches that encourage participants to admit they are powerless over alcohol and commit to never touching another drop, Dr. Kern says.
College students are a good example, he notes. They often get in trouble with their drinking, but rarely reach out for help. “To be told immediately you are an alcoholic and you have to stop for the rest of your life — how many college-age students would join … that?” As a result, opportunities to stop a problem before it spirals out of control can be missed, Kern cautions. “The research continues to show that 90% of the people with alcohol problems never seek treatment of any sort — not even a self-help book. Our goal [with Moderation Management] was really to bring them out of hiding and give them solid guidelines, help them determine for themselves whether moderation is a viable goal or isn’t.”
In many cases, Kern acknowledges, it isn’t. Maybe 40% of those who come to the group for help go on to abstinence-based programs, he says. For some of those, abstinence becomes a more appealing option simply because it’s easier than the monitoring of drinks required with moderation. Others come to a better understanding of themselves and the severity of their problem and realize giving up alcohol completely represents their best chance of success.
Allowing people to determine for themselves the extent of their drinking problem can make abstinence easier to accept if it proves necessary. But it’s not without risks. Rare is the problem drinker who doesn’t want to believe they can keep alcohol in their life. Self-determination can easily become self-delusion. “The reality is, this isn’t for everyone,” Kern says.
For proof of this, one need only look at MM’s own history and the tragic story of Audrey Conn, who founded Moderation Management in 1994 as an alternative to AA, creating the first harm reduction mutual support group. (She used her married name, Kishline, at the time.) In 2000, she left the group after coming to realize that she was one of those for whom moderation would not work. A couple of months later, she drove drunk the wrong way down a highway, killing a man and his 12-year-old daughter. The deaths unleashed a firestorm of criticism over the moderation concept, despite the fact that Conn was attending AA and other abstinence-based support groups at the time of the crash. In 2014, struggling with depression, Conn took her life.
Kern calls Conn’s vision for MM “so humanitarian” — a place where a person is provided the tools, structure, guidelines and support to determine how best to recover: whether through moderating the amount they drink, or abstaining altogether. The tragedy of Conn’s life, he says, was that ultimately she could do neither.
For his part, Keith Humphreys sees Conn’s story as a reminder that “all human beings are capable of overestimating their capacities, and there is risk that people will try to become moderate drinkers and fail. But of course, this happens all the time anyway, whether groups like MM exist or not.”
Moderation groups and 12-step organizations are sometimes seen as at cross purposes (if not outright adversaries). But Humphreys and Kern agree that each fills a need and is aiming for the same goal: recovery. AA co-founder Wilson “explicitly acknowledged that some drinkers could return to controlled drinking,” Humphreys says. “Moderation Management acknowledges that some people need to abstain. There is no conflict here. Different strokes for different folks.”
More Ways to Treat Addiction
The growing recovery landscape also includes mutual support organizations that hold out abstinence as the ideal, but keep the focus on reducing harm no matter where someone is. SMART Recovery® for example, was created in 1994 as a science-based, secular alternative to 12-step recovery. Participants are allowed to define recovery and to use the program as they see fit, explains its president, Tom Horvath, PhD. “Rather than focusing on ‘abstinence,’ meetings often focus more on ‘stopping,’” he says. In some cases, he adds, participants stop using some substances but not others. For example, a person might quit heroin but still use marijuana. “Although this idea may seem radical, in fact, in most 12-step groups, participants give up some substances but not caffeine, nicotine or food [overeating]. The last two lead to more premature deaths than the other substances of abuse, so not stopping them is not a trivial matter,” Horvath says. SMART Recovery® also supports members’ use of psychiatric and addiction medication, like naltrexone and acamprosate
Such medications are becoming more widespread as treatment centers and support groups find it increasingly difficult to ignore these drugs’ ability to improve and, in some cases, save lives. The National Institute on Drug Abuse calls medication “an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.” Some of the most commonly used medications for addiction include:
- Naltrexone (brand names: Revia, Vivitrol), which blocks the high from opioids and can help reduce cravings in alcohol-dependent patients. Research shows a link between naltrexone and lower levels of relapse and reduction in heavy drinking. Vivitrol, an injectable version, provides protection for one month.
- Acamprosate (brand name: Campral) appears to balance brain chemicals and minimize alcohol cravings.
- Buprenorphine (brand names: Buprenex, Butrans; and Suboxone, a combination of buprenorphine and naloxone) mimics some of the effects of opioids like heroin and prescription painkillers but has a ceiling to its high, making it a less dangerous, less addictive alternative. It can be used to wean a person off opioids without withdrawal symptoms. In some cases, it’s used long-term or even indefinitely as part of maintenance therapy.
The Controversy of Maintenance Meds
Despite the growing use of medication, not everyone is on board. Some see it as a Band-Aid that prevents a substance user from learning the skills they need for long-term success. Others see it as simply replacing one drug for another. But increasingly, such drugs are being seen as an aid to recovery rather than as a challenge to abstinence. In 2012, the well-known treatment network Hazelden, which has long championed abstinence, shocked the addiction treatment world by announcing it would allow the use of maintenance drugs such as buprenorphine, a move prompted by the national epidemic of prescription painkiller and heroin deaths. Hazelden made clear, however, that following a 12-step lifestyle and abstinence ultimately remain their goals.
There’s also the BRENDA model, which provides a simple framework by which treatment providers can combine the power of medication with psychosocial support, such as is found in 12-step meetings. The BRENDA acronym corresponds to six components: a biopsychosocial evaluation, a report of findings from the evaluation given to the patient, empathy, addressing patient needs, providing direct advice and assessing patient reaction to advice and adjusting the treatment plan as needed.
Even within 12-step groups such as AA, the policy is “not to play doctor and tell other people what to do about any medications they may be on,” according to Humphreys. How this plays out, however, can depend upon the makeup of an individual AA group, observes Laura H., who has been an active AA member for close to 20 years. “It seems to be generational,” she says. “Some of the old-timers don’t like the idea of anyone using medication. But most of the younger people don’t seem bothered by it. The sentiment usually is, whatever helps.”
Even with the options available today and the growing acceptance of a variety of paths to recovery, there is little dispute that total abstinence remains the safest course. Research shows it’s strongly associated with good results in the long-term. The problem is, expecting everyone who wants to get better to be willing or able to commit to abstinence just isn’t realistic, Moderation Management’s Kern says. “Would it be better if no one drank? Absolutely. If we tell everybody to not drink, will they listen? No.” By being flexible about what constitutes recovery and seeing people as individuals with different degrees of need, those who are struggling are more likely to try to change their lives, he believes. “I think we are helping people come out of hiding and get into treatment — whatever form it may take — a lot sooner instead of waiting until they are 50 or 60 years old and their liver is going out.”
Stanford’s Keith Humphreys agrees that a more inclusive view of what constitutes successful recovery for those struggling with drugs or alcohol pays off. “There is a risk in broadening any term that it can become meaningless,” he says. “But in general, the broadening of recovery [beyond abstinence] has been positive and has built community … Millions of people are in recovery, therefore there is hope for everyone facing addiction.”