Moderation vs. Abstinence

Probably no debate has generated more passion, smoke, and confusion as opposed to clarity and understanding than the question of whether those who are addicted, or dependent, on a substance (moderate to severe substance use disorder) should have a goal of abstinence or moderation. The debate has been going on for more than 50 years and continues to this day to some extent.

Much of the controversy is maintained by confounding of terminology, lack of diagnostic clarity, and attempting to championing a single model for all concerned. These factors combined with muddled thinking yields controversy without benefit to those afflicted.

Let’s begin with terminology before getting to the core of the matter. Harm reduction and moderation have often been confused or comingled as synonymous terms. Any reduction in symptoms or harms is really harm reduction, which makes abstinence part of a harm reduction complex. Others have sought to resolve the issue by introducing new words, such as gradualism, to signify a continuum of approaches. Semantics and terminology are not really the issue.

The more important factor is that a large proportion of prior research on this topic, and substance use disorders in general, has used rather sloppy methodology in defining the conditions under consideration. I cringe when a study purports to study “problem drinkers” for which a Canadian counselor had the definition “someone who spills more than he swallows.” A similar problem is mixing abuse and dependence or all levels of the DSM-5. Lack of precision and clarity in the diagnosis is a persistent issue in research. In oncology, this would be analogous to studying all lumps as equal whether they were cysts, benign growths, or malignancies.

In my opinion, the crux of the matter is that advocates of moderation and abstinence are both correct in that their approach is appropriate – just not for the same people or conditions. In the previous blog on “The Devil is in the Details,” we discussed how individuals with the same diagnosis based on the DSM-5 can have substantially different expectations as to whether abstinence or moderation is a logical option. The key is in identifying which of the eleven diagnostic criteria are positive as opposed to which are not.

In our research we have identified what we term the “Big Five” criteria. These are the five DSM-5 criteria that are most strongly associated with a severe diagnosis and suggest a loss of control over use. They include: persistent desire or unsuccessful effort to cut down or control use; craving or strong compulsion to use; recurrent role obligation failures; sacrificing social or other activities to use or because of use; and withdrawal syndrome (Hoffmann & Kopak, 2015 in Alcoholism: Clinical and Experimental Research). This pattern has been found among adults for alcohol, cocaine, and cannabis. The expectation is that if none of the five are positive, moderation is likely to be a viable option. If one or more of the five are positive, abstinence may be to be the more logical goal of treatment.

The Big Five Criteria
  • Persistent desire
  • Craving or strong compulsion
  • Role obligation failures
  • Sacrificing social or other activities
  • Withdrawal syndrome

There have been those who purport that chronic cases can moderate use. There is no question that an individual could have a chronic course of misuse without necessarily being positive on multiple criteria in the Big Five or manifesting a loss of control. The question is whether two or more of these criteria or any other pattern of positive findings will distinguish whether abstinence is the more logical goal for treatment.

To achieve progress in the treatment of substance use disorders, we need to pay more attention to the exact nature of the conditions involved instead of just championing one program, strategy, or model. Determining what works for whom with what exact condition is more likely to help more people.