For many years, people who suffered from alcoholism would be pushed to abstinence because it was synonymous with “recovery.” This was intertwined with AA’s view of alcoholics having something of an allergy to alcohol, counting sober days from zero every time there was a slip, and a one-fits-all approach to treatment in the absence of evidence-based approaches. AA dominated the treatment landscape and harm reduction; moderation or controlled drinking were dirty words. Furthermore, research trials (like project MATCH) and medication ‘success’ (like the COMBINE study) were predicated on abstinence: any drinking was a treatment ‘failure’.
What if Recovery from AUD was better conceptualized as a gradual process of change for the individual — one not based purely on one’s drinking practices, but as a heroic journey of flourishing that incorporates wellness, family, spirituality, purpose and emotional regulation (to mention a few). What if there were many paths out of addiction, just as there are many paths into it.
In fact, past research – stretching back decades, to the Sobells – has shown that reducing alcohol consumption for some, rather than just completely abstaining, leads to improvements in health and functioning. So given this background, we know that it is possible to achieve a non-abstinent AUD recovery, but how would that path hold up in the long term, compared to abstaining completely from alcohol?
In a study conducted by Witkiewitz et al. (2020), 146 individuals with alcohol use disorder (AUD) were followed out of treatment 3 years and then 10 years to track their recovery paths with regards to BOTH alcohol consumption and functioning/wellbeing. At 3 years, subjects were placed into one of four profiles: low functioning frequent heavy drinkers, low functioning infrequent heavy drinkers, high functioning heavy drinkers, and high functioning infrequent drinkers. While many of the participants reported practicing abstinence for at least one month prior to hitting that 3 year post-treatment mark, this abstinence failed to predict better functioning 10 years post-treatment. Here was the cool tidbit: people who were functioning well at 3 years had the best functioning outcomes 10 years out, regardless of their drinking intensity (infrequent or frequent – around 8 drinks a day). In fact, even those in the 4th profile (high functioning infrequent drinkers) who returned to some heavy drinking habits had the best overall psychosocial functioning outcomes at year 10. It was the FUNCTIONING level that predicted the outcome — NOT the drinking level!
This finding, together with previous studies, supports the conclusion that abstinence is not the only way to sustain a high level of psychosocial functioning in the years following AUD treatment.
We see this all the time. Certainly drugs and alcohol – well, all addictive behaviors really (sex, gambling, porn, videogames… – can shield us from pain, or at least numb and distract us. But the thing is, addictive substances can deepen their own hole, deepen the pain, knock us off the path of value-based living, ending in a miserable eddy of compulsive escape and avoidance. But, if we can get back onto a track of value-based living, manage painful affects effectively, and moderate our use so that we keep away from the whirlpool of tolerance and withdrawal, then moderation can be effective. It is possible for people with diagnosed AUD to lead high-functioning lives even while they drink quite considerable amounts, and sustain that drinking level over a 10-year period. They are moderating and are ‘recovered’ if your concept of recovery is related to functioning.
I am sure that many people who drink 8 drinks a day are not as healthy or happy as those drinking less. That level of alcohol must cause weight gain, liver problems, driving issues, sleep problems, depression, anxiety, and relationship issues. I can’t see how heavy drinking couldn’t cause these problems and, for sure, we’d be working with people to be curious about what that level of drinking does for them, motivating positive change, and likely seeing reduced drinking. But we no longer have to tell them, in some pessimistic and discouraging way, that their drinking is incompatible with high functioning, and certainly not telling them they are not recovered. To say abstinence is the only way is simply not true and discouraging for many.
So, the definition of AUD recovery should shift beyond the current central defining feature of alcohol consumption; the change that needs to be made within an individual with AUD is deeper, and should be focused on the individual’s functioning and wellbeing, which we now know is as sustainable in the long run as abstinence (or even more so, for some).
We at Psych Garden thought this was a neat article, as it outlined how individuals suffering from AUD can substantially benefit from psychotherapy to identify values-based living, and manage emotions. It is correct to discuss an ideal use-plan with the patient, teach moderation skills and monitor progress with them: it’s supported by the evidence. We recognize that it’s not just about the action of quitting entirely, but rather it’s a deeper and more internal change that we have the resources to help you achieve. Your road doesn’t have to end in abstinence; your path should be individualized to YOU.
Click below for the full PDF of the journal article by Witkiewitz et al. (2020).