Abstinence versus Moderation in Addiction Treatment, Which Works Best?

Jan 10, 2024
By Sarah Church, Ph.D.

Should I choose abstinence or moderation?

Traditionally, most of the alcohol and substance use treatment centers in the United States have focused on abstinence-based approaches, many of which follow a 12-step model. Their guiding philosophy reflects a belief in the disease model of addiction. This states that addiction is a progressive disease that can only be managed by stopping the use of all substances and maintaining abstinence, full stop. However, because many, if not most people, are not willing to consider quitting entirely, they avoid treatment. In fact, in 2021, according to SAMHSA, only 6% of people with a substance use disorder received any form of treatment. So, most people who could benefit from treatment are not seeking it out. In a time when so many people are dying from overdoses and alcohol-related diseases (e.g. cancer and cardiovascular disease), it’s important to explore why so few people embrace treatment. Likely, at least part of the reason people don’t come into care more often is that they aren’t interested in the type of treatment that is typically offered. Most of that treatment requires a desire to quit entirely. And that often seems too high a mountain to climb at the beginning of treatment.

Flexibility In Goals Works Best

Allowing patients to flexibly choose their own goals can lead to increased engagement, longer retention, and improved outcomes. During the intake at Wholeview, patients choose a goal of abstinence, moderation, or a mix of both (e.g., quitting cocaine, but having a drink or two occasionally). They also explore if they want to reduce their use, if they want to use more safely (e.g. not having unprotected sex when using, not driving after drinking), or both.

Empowering Patients Leads to Better Care

Empowering patients to set goals that resonate with their needs and that they feel are right for themselves, naturally increases their motivation to work towards those goals. Opening the discussion to talk about what they are willing to change, also encourages patients to deeply reflect on their experiences with substance use. Once they are honestly talking about their use, they are more able to develop helpful coping techniques for managing issues that arise. Based on their experiences using or abstaining, patients may move between moderation and abstinence goals. While they may begin treatment with the idea that they want to moderate, throughout treatment, and through discussion and reflection, they may eventually choose to abstain.

Goals Can Change Over Time

Some patients enter treatment with a firm conviction that they must be abstinent. They have often attempted moderation and have not been successful, they know that their lives are better when they avoid using. We strongly support these decisions. However, forcing an abstinence goal can perpetuate the stigma surrounding substance use because this approach does not fully acknowledge the complexities and challenges faced by individuals who use substances. A nuanced approach to exploring the meaning and reasons for substance use can help a patient clarify why they continue to use despite negative consequences and can allow them to figure out new ways of coping and may eventually help them to decide to give it up for good, but even if it doesn’t, reducing use is helpful and moves them to a safer place.

What Are You Willing To Do?

In the end, the treatment that a patient is willing to participate in is the best place to start. By offering a range of recovery options, patients can take control of their recovery process and tailor their treatment to their unique needs. Ultimately, the choice between abstinence and moderation depends on the individual’s needs and preferences. An approach that focuses on the patient’s needs, wants and desires helps to ensure that the chosen path resonates with the patient’s values and is the most likely to succeed.

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