The Changing Role of Abstinence in Addiction Treatment

This is the third article in a series about the complex issues around treatment for substance use disorders, particularly with regard to opioids.

Abstinence is a centuries-old method for treating substance abuse that requires the addict to completely give up all drugs (and alcohol). Abstinence-based treatment (or ABT) uses counseling and behavioral therapy to support addicts in making positive changes in their lives. ABT is available as residential treatment and as outpatient care and is largely covered by insurance, including Medicaid. Most residential programs are a month long, though a few are significantly longer.

Like alcoholics, drug addicts were historically put in jail or mental institutions or abandoned to their addictions. The Narcotic Rehabilitation Act of 1966 changed this practice, allowing judges to use their discretion to send addicts to treatment instead of jail. The largely faith-based 12-step programs that were working with alcoholics in the 1960s and 70s were in the best position to address this need, and over 90% of treatment programs today are modeled on those early programs. In fact, Alcoholics Anonymous was the first group to promote addiction as a disease rather than a choice, a position now supported by medical research.

ABT has long had both critics and supporters. Many who have stayed sober through ABT say that total abstinence is essential to recovery. Supporters also point out that ABT is relatively inexpensive because it does not require a large medical staff. However, critics of ABT argue that addiction is not a “one size fits all” problem and that many people are not comfortable with the focus on spirituality. Other critics argue that complete abstinence is not always necessary or even desirable and that the standard 30-day ABT program is far too short to successfully deal with the long-term brain changes caused by drug addiction. Success rates for ABT range anywhere from 5% to 70%, depending on the source of the data.

In recent years, researchers have begun comparing ABT with medication-assisted treatment (MAT), which combines psychosocial therapy with medication to curb cravings and withdrawal. The studies overwhelmingly show that MAT is more effective in lowering drug use and preventing overdoses than ABT alone. For example, MAT doubles the likelihood that a patient will stay in recovery and avoid relapse for at least a year after seeking treatment. This and evidence like it is the basis for the current groundswell of support for MAT programs.

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