September 19th, 2014

Certainly You Can Have Just One Or Two?

Recovery Month is an appropriate time to examine what is meant by the word “recovery” in the context of substance use disorders. For most addiction professionals, abstinence from addictive substances is one of the cornerstones of stable improvement for anyone having met the diagnostic criteria for a substance use disorder.  A return to the moderate, non-problem use of these substances is, however, a wished-for goal for many of our newer patients, who respond eagerly to any suggestions that this may be possible. However, it’s important to know the truth about using in moderation.

I hear the argument for a moderation strategy coming from different directions. I encounter it most often from the family and friends of our patients who do not have a substance use disorder.  Extrapolating from their own experience, they do not understand the difficulty that addicts have with stopping the use on a given occasion after they have started. For this reason, treatment programs such as ours reach out actively to educate the patients’ friends and family.

A recent New York Times article on the issue of moderation attracted much attention. One focus of the article is Center for Motivation and Change. Because their staff see patients more in individual sessions rather than in the context of a structured program, they are able to work through the ambivalence of patients who are not yet ready to commit to long term abstinence.

The article also mentions Moderation Management (MM), which is a support group whose goal is to give people with substance problems a choice between abstinence and moderation. MM points out that there are many more people who have problems with substances than the smaller group who meet diagnostic criteria for a substance use disorder. For the non-diagnosable group, reducing use to a safe level is an accepted goal. The National Institute on Alcoholism and Alcohol Abuse (NIAAA) has created a monograph to help primary care clinicians achieve this.

The strongest evidence for the importance of abstinence comes from an unprecedented 74-year longitudinal study. The most recent summary of this project has been published as a book, The Triumphs of Experience, by George Vaillant. I will go into more detail about this monumental study in an upcoming blog.

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