The Role of Abstinence
Since the beginning of addiction treatment, abstinence has been heralded as the goal for substance use disorder (SUD) treatment. Yet, while abstinence as the goal, this is inconsistent with the reality that for many programs, abstinence appears to be the requirement for continued treatment rather than the goal. For these programs, drinking or drug use during treatment results in premature, administrative discharge. How does this relate to the treatment of other chronic illnesses? Do we discharge a person with tuberculosis who coughs? How about someone with schizophrenia who hallucinates?
Achieving abstinence is difficult. About 40 percent of people entering treatment are in the precontemplation stage of change with another 40 percent in contemplation (Norcross, Krebs, & Prochaska, 2011). But abstinence neither occurs nor is sustainable until individuals are in the action stage of change. Although we know better, we treat all of our patients as if they are already in action, assuming that they understand and accept that they have a SUD and want to recover. Too often we provide recovery services to patients who really require “discovery” services—services for patients who do not yet consider that they have a substance use problem or are motivated for recovery (D. Mee-Lee, personal communication, March 18, 2007).
Further complicating the issue (although this is thankfully changing) are those providers for whom abstinence is defined as being “drug-free,” which excludes those individuals on an agonist drug like methadone or buprenorphine/Suboxone and even an antagonist drug like Vivitrol. We have finally come out of the dark ages of addiction treatment when the same position was taken in regard to rejecting the use of psychiatric medications.
Please understand that my position is not antiabstinence, but I question if abstinence alone equals recovery. Said another way, it may be a necessary but insufficient state. Another way of conceptualizing this is that abstinence in an intermediate goal on the journey to recovery. This applies to those individuals who meet DSM-5 criteria for a SUD severe, or possibly even of moderate severity. Since addiction is a chronic, relapsing brain disease, abstinence may reflect a step in the process of recovery. But without abstinence, recovery does not proceed. What beyond abstinence may have to occur?
The existence of co-occurring disorders with addiction is no surprise to any of us. Depending on the data you reference, co-occurring disorders exist in the majority of individuals with a SUD, and in some populations (e.g., methadone and criminal justice populations) may be as high as 80 percent (Carpentier et al., 2009). Abstinence may not only not remedy these problems, it may worsen them, particularly for those patients who have been using substances to manage their co-occurring disorder symptoms. As the initiation of drug use and development of addiction has been occurring at younger ages, rehabilitation (returning to an earlier level of successful functioning), may not be possible and instead we must employ “habilitation” strategies, helping patients learn how to function for the first time. This learning must follow the acquisition of abstinence.
For habilitation, recovery management, the development of specific skills needed to cope and maintain abstinence can only take place after abstinence is achieved. Recovery support services (e.g., obtaining a GED or high school diploma; acquiring job skills, even learning how to dress for and interact during a job interview; obtaining employment and housing) are all services that may be required after the achievement of abstinence in order to maintain it.
For some clinicians, abstinence is an “all or nothing” proposition. However, consider a person who has been unable to achieve forty-eight hours of continuous abstinence prior to treatment, but after treatment acquires six months of abstinence, but has one, two-day drinking episode during that time and then promptly returns to abstinence. Consider the person with schizophrenia, who after treatment continues to hear voices, but no longer has to do what the voices command and does not have to be rehospitalized. Are these not treatment successes? Some of the same clinicians who object to agonist drug treatment believe erroneously that people on agonist treatments are “still addicted,” though in reality, if not abusing their agonist or any other drug, rather than being “still addicted,” they remain “physiologically dependent.” Would we similarly object to the diabetic who uses and is dependent on insulin to control blood sugar?
When thinking recovery, think about the concept if locus-of-control. Rotter defined locus-of-control as
. . . the degree to which persons’ expectation that . . . an outcome of their behavior is contingent on their own behavior or personal characteristics versus the degree to which persons expect that outcome is a function of chance, luck, fate, is under the control of others, or is simply unpredictable (1975).
As an example, individuals in active addiction lose all semblance of internal locus-of-control. It is helpful to consider treatment as a process in which there is initially an external locus-of-control (a medical model like withdrawal management services) in which medical staff (externals) interrupt the destructive substance use or behavioral addiction. As treatment continues with declining intensities, the locus-of-control gradually shifts from external to internal, where patients take on more responsibility for their own recovery (think of the shift from inpatient to outpatient treatment) and finally to recovery support groups like AA where locus-of-control is for the most part internal, although external guidance may still be needed in the form of recovery coaches and/or Twelve Step sponsorship. Said another way, people move from counselor to recovery coach to sponsor.
If abstinence is the only goal, then we are back to an acute care model, sometimes seen with an insurer’s unwillingness to reimburse treatment after “stabilization.” Let us use the analogy of the individual who suffers a myocardial infarction. The conclusion of primary treatment and resultant stabilization (akin to abstinence), does not end the process. The patient is likely to be referred for cardiac rehabilitation (for which insurance will reimburse). Neither stabilization of the cardiac problems nor abstinence completes the process of recovery. Is abstinence alone enough?
I would be one of the last clinicians to argue against abstinence. But let us redefine what constitutes abstinence and view it as only a step in the recovery process rather than an end in itself. We must be cognizant that all aberrant behaviors in people who are addicted may not be caused by the addiction. While abstinence changes the using behavior, it may not alone change other behaviors. In fact, it might make the aberrant behavior worse. Think of the person with an antisocial personality disorder (ASPD) who has an extensive criminal history in which the crimes were committed under the influence of a psychoactive substance. If the criminal behavior was the product of the ASPD, abstinence could enable better utilization of the individual’s criminal skills.
There are those people with severe SUD who achieve abstinence but go no further. Far be it from me to criticize them. However, recovery, sometimes referred to as “sobriety,” offers so much beyond abstinence. If abstinence was the goal, AA might be a one-step program, the first step of which would state, “We admitted we were powerless over alcohol and we stopped drinking.”
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143–54.
Carpentier, P. J., Krabbe, P. F., van Gogh, M. T., Knapen, L. J., Buitelaar, J. K., & de Jong, C. A. (2009). Psychiatric comorbidity reduces quality of life in chronic methadone maintained patients. The American Journal on Addictions, 18(6), 470–80.
Rotter, J. B. (1975). Some problems and misconceptions related to the construct of internal versus external control of reinforcement. Journal of Consulting and Clinical Psychology, 43(1), 56–67.