Is Abstinence Necessary for Recovery?

In Emeryville, there is something called the Alcohol Research Group, and it’s essentially a think tank, one of 18 centers around the country funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The ARG engages in high-quality research that seeks to understand our relationship to alcohol, including why some of us drink too much and the harm that alcohol can cause to individuals and society.

One of its senior researchers is Lee Ann Kaskutas, and one of her specialities is studying the extent to which non-professional, mutual aid and self-help alcohol treatment programs -- such as Alcoholics Anonymous  -- help people recover from alcoholism.

Like other researchers across the board, she has found mixed results on whether AA and other 12-step programs are effective for many of the people who have drinking problems. Various studies have shown that other kinds of self-help programs or cognitive behavioral therapy can be equally effective, and that AA success stories constitute a fraction of the estimated millions of people who have alcohol problems. In her 2009 study, "Alcoholics Anonymous Effectivess: Faith Meets Science," Kakustas found that, yes, AA can help people dedicated to the program: rates of abstinence are higher among people who attend AA than those who don't and the more that people go to meetings, the more likely they are to stay abstinent. 

On the other hand, AA doesn't have a strong record of keeping people in its program. AA itself reports that, in a 1990 summary of five different membership surveys, that 81 percent of alcoholics who engaged in the program stopped attending within a year, and only 5 percent kept going for more than a year. And, as reported by Kenneth Anderson, founder and CEO of The HAMS Harm Reduction Network, a 2009 landmark study of 43,000 US adults, conducted by the NIAAA, found that about half of all people who recovered from alcohol dependence did so by quitting completely and the other half by reducing their drinking. 

Despite the mixed results on AA's effectiveness, the 12-step model of recovery, which includes regular meetings, fellowship, the recommendation that people turn their will over to a higher power, and the goal of lifelong abstinence, dominates the public consciousness about recovery. Most medical rehab centers across the United States, including those locally, incorporate the 12 step model into their alcohol and drug treatment programs.  

I first came across Kaskutas and her the Alcohol Research Group when researching a story for Diablo magazine, called "Am I an Alcoholic?" In that article, I questioned my own relationship to alcohol.  

Now Kaskutas  is wrapping up an new project, another landmark study which seeks to ask a broad swath of the American public how they define recovery from drug or alcohol addiction. Do they see recovery as being part of a 12-step program? 

But an even bigger question Kakustas asks is whether abstinence is necessary for recovery. Is, for example, it possible for an alcoholic to cut back, as some studies have asserted? Does recovery involve more than one's relationship to a substance? 

According to the website for the project, "What is Recovery?," Kakutas and her colleagues introduce the project by saying "We hear the term recovery often, yet it is difficult to define." 

• Does recovery require abstinence?

• Can someone be “in recovery” if they are still drinking or using?

• Is recovery more than just being clean and sober? If so, how is that defined?"

The idea is that addicts will continue to use until they decide, for whatever reason, that it's time to quit. In the meantime, harm reduction adherents say, let’s “meet them where they are at” and give them tools so that at least they will be safe while they continue to use or decide to stop using altogether. 
Harm reduction, not surprisingly is controversial, with abstinent and recovering alcoholics and addicts saying that harm reduction just gives people an excuse to stay in denial and keep using. 

"Many former problem drinkers and other substance users who are now trying to pursue an improved way of living, say that they are 'in recovery.' Yet with its frequent use, there is no agreed-upon definition of the term recovery. For instance: 

Between July 16 and October 31, 2012, a “What is Recovery” survey was on online, and 9,432 people responded -- "the largest and most diverse research group of people in various pathways to recovery," the website says. 

The definitions came from all kinds of indiviuals, including those in 12-step programs and those who are not, as well as people who are adherants to “harm reduction."

I’ve been hearing more and more about the theories and practices of  harm reduction. 

Actually, harm reduction probably first gained notice in the late 1980s and 1990s in regards to needle-exchange programs for IV drug users to reduce the spread of HIV. 

This past year, I interviewed a UCSF assistant psychology professor, Adam Carrico, who advocates a harm-reduction approach in helping meth-using HIV-positive men adopt safer habits around their drug use and sexual behavior.  The interventions this professor uses with these men do not require them to quit using meth or stop having sex; rather it creates various strategies for them to reduce their use of meth and reduce high-risk sexual behaviors. 

“People come to treatment with various goals,” Carrico told me in the story, "Zeroing in on HIV" on the UCSF School of Nursing's Science of Caring website. “We work with them with their stated goals, and then move them through stages of change. I was really excited about [this model] because they are meeting people where they are at and helping them make the changes they are motivated to make.”

Harm reduction is gaining attention as an alternative approach to the traditional alcohol and drug treatment programs that require abstinence, judging by this story on the recovery-related website The Fix about a rehab that "teaches you to drink safely." 

The "HAMS" Harm Reduction website said their approach offers "a set of practical strategies intended to reduce the negative consequences of high-risk behaviors.

“Harm reduction works on the premise that it is easier to get people to make small changes than to get them to make big changes. Because of this it is possible to have a far greater positive impact on society by getting a large number of people to make small positive changes than by getting only a few people to make big changes. It is easier and far more effective to get people to use seat belts than to eliminate the automobile and driving entirely. ...  Prohibition and coerced abstinence do not work. Harm reduction does.”

Harm reduction adherents say this approach is needed for some problem alcohol and drug users because "traditional approaches to alcohol problems which are based on AA and the 12-step model are wonderful resources for the people that they work for." It's just that these programs don't work for everyone, or even a majority of the people who need help, they say. 

Well, it will be interesting to see what the Alcohol Research Group's survey reveals, to see whether the study's more than 9,000 respondents believe that their idea of recovery means membership in a 12-step program or abstinence, or if there is another definition that "meets people where they are" and allows them to make small changes towards improving their lives.

In my view, people should do what works for them to make their lives better and healthier -- whether that involves abstinence or not. I can't believe that there is a one-sized-fits-all approach when it comes to addiction, a horrible monster that ruins lives. I say let's develop as many effective options as possible to help people pull themselves out of misery and find their own path to serenity.