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According to research, “Many individuals experiencing problems related to their drinking (e.g., college students) are not interested in changing their drinking behavior and would most likely be characterized in the precontemplative stage of the transtheoretical model. Harm reduction provides a good method for matching these individuals at that stage and providing motivational incentives (e.g., discussing the negative consequences the person is experiencing) to motivate their desire for positive change” (Marlatt & Witkiewitz, 2002). Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful. Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010). These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006).
Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. While many people and treatment centers follow the alcohol abstinence model, there are others that argue that drinking in moderation is effective. One research study on Veterans suggested that both models can decrease alcohol use to a degree, but those striving for abstinence were far more successful than those drinking in moderation.
Controlled Drinking – Alcohol Dependence Treatment Method
A program called Moderation Management advocates this alternative to abstinence as a solution for a substance abuse disorder2. This team of researchers undertook to compare self-identified members of Moderation Management with self-identified members of Alcoholics Anonymous (AA). They looked at demographics—who attends AA versus who attends MM—as well as the relative severity of the controlled drinking vs abstinence drinking problems in the two groups. There is less research examining the extent to which moderation/controlled use goals are feasible for individuals with DUDs. The most recent national survey assessing rates of illicit drug use and SUDs found that among individuals who report illicit drug use in the past year, approximately 15% meet criteria for one or more DUD (SAMHSA, 2019a).
In 1990, Marlatt was introduced to the philosophy of harm reduction during a trip to the Netherlands (Marlatt, 1998). He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994). In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b).
3. Summary of the state of the literature
Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005). The results suggest that the 12-step philosophy, with abstinence as the only possible choice, might mean that people in the AA community who are ambivalent and/or critical regarding parts of the philosophy must “hide” their perceptions on their own process. Experiences of the 12-step programmes and AA meetings were useful for a majority of the clients.
Clearly, for Kishline, controlled drinking was not enough to solve her alcohol problem. For alcoholics like her, alcohol abstinence is the only way to guarantee a healthy life and avoid alcoholic drinking. In fact, MM claims that its program is not a great choice for full-blown alcoholics. They state it’s a “less-threatening first step toward a healthier lifestyle.” MM also claims that programs like theirs fuse moderation, or controlled drinking, with abstinence, are more effective than abstinence-only programs. Moderation Management is a program that seeks to help people identify problems with their drinking patterns before they develop into alcoholism, and to make choices to engage in successful controlled drinking, to moderate intake, or to choose abstinence, based on what they feel they need. Moderation Management offers meetings that function as a support group as well as nine steps of action towards healthier choices.