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Substance Use Treatment

Is an abstinence-only approach sufficient?

Substance abuse has globally been a scientific, political, and public concern, due to the far-reaching adverse consequences attached to it (Tshitangano & Tosin, 2016).  In South Africa, more than 15% of the population suffers from drug-related issues, and an 123% increase in drug-related crimes has been observed (Tshitangano & Tosin, 2016).  It thus constitutes an alarming national problem, and appropriate treatment measures are required to address this challenge.

An abstinence-only approach has extensively been applied within the field of substance abuse treatment and previously formed the foundation of the legal and policy framework concerning drug use (MacMaster, Holleran & Chaffin, 2005).  Abstinence is defined as the complete cessation of drug or alcohol use and has for centuries been deemed to be the best and most effective way to defeat addiction.  Abstinence models include the Traditional Prevention Model, the Minnesota Model, and the well-known 12-step programme (Thompson, 2010).  These treatment approaches are based on principles such as the criminal justice principle of prohibition; the perceived power of education; and the notion that addiction is a disease (MacMaster, 2004).

Despite its obvious advantages, abstinence is not a suitable intervention for all substance users.  The desire to abstain is naturally not uncomplicated, and individuals who do not readily seek complete abstinence are viewed as “resistant or unservable” (MacMaster, 2004, p.357).  Furthermore, a high number of individuals involved with an abstinence form of treatment fail to comply with this objective and do not complete the relevant programmes MacMaster, 2004).  It thus appears implausible to demand immediate abstinence without exception (Diana, 2002).

Due to a global change in understanding substance use and related issues as well as the manner in which change could be effected, it was progressively proposed that drug users are rather to receive treatment than to be incarcerated (Tatarsky & Marlatt, 2010).  It has also been acknowledged that substance abuse frequently comorbidly occurs with psychiatric, physical, and social issues (Tatarsky & Marlatt, 2010).  In certain instances, it is not feasible to begin considering abstinence or even reduced use, until more pertinent issues, such as trauma or psychiatric disorders, have been attended to (Tatarsky, 2003).  Consequently, the Harm Reduction Model was introduced in the 1980s as an alternative treatment option.  This was deemed to be a paradigm shift as it provided new perspectives and innovative ideas in relation to the traditional substance abuse interventions (Tatarsky, 2003).

The Harm Reduction Model aims to reduce the health, social, and economic harm associated with drug and alcohol use, instead of only focusing on eradicating substance use (Diana, 2002).  The reduction model thus aims to inter alia decrease the use of drugs and alcohol, and combat the growing HIV epidemic associated with drug use (Tatarsky, 2003).  The Harm Reduction Model, which is client-centered, consequently does not deem these users to be in denial, but deals with resistance to abstinence in a healthier way (Diana, 2002).  The possible advantages of the Harm Reduction Model cannot be denied as it has the power to include more people in treatment; lessen stigmatisation; and focus on the person to address the issues, rather than being prescriptive from the top down (MacMaster et al., 2005; Tatarsky & Marlatt, 2010).

Despite the above, it is not always possible to make room for reduced use as the physical and/or mental health of an individual could be adversely affected by continued substance use.

A possible solution could be to integrate the abstinence and harm reduction models and to adjust the intervention programme based on the needs of the patient (Finney & Moos, 2006; Kellogg, 2003; MacMaster et al., 2005).  When the models are integrated, harm reduction can be understood as an ‘abstinence-eventually’§ model that provides optimal care to the individual (Cheung, 2000).

* The above overview is provided for informational purposes only.  All healthcare decisions are to be made in consultation with the treating practitioner/s in order to review all pertinent factors and determine the most beneficial course of action.

References & Further Reading

Cheung, Y. W. (2000). Substance abuse and developments in harm reduction. Canadian Medical Association Journal, 162(12), 1697-1700.

Diana, D. A. (2002). Harm reductio: From substance abuse to healthy choices. In S. E. Cooper, J. Archer & L. C. Whitaker (Eds.). Case Book of Brief Psychotherapy with College Students (pp. 255-268). Philadelphia: Haworth Press.

Finney, J. W., & Moos, R. H. (2006). Matching clients’ treatment goals with treatment oriented towards abstinence, moderation or harm reduction. Addiction, 101(11), 1540-1542.

Gleghorn, A., Rosenbaum, M., & Garcia, B. A. (2001), Bridging the gap in San Francisco: The process of integrating harm reduction and traditional substance abuse services. Journal of Psychoactive Drugs, 33(1), 1-7.

Kellogg, S. H. (2003). On ‘‘Gradualism’’ and the building of the harm reduction-abstinence continuum. Journal of Substance Abuse Treatment 25, 241-247.

Lee, H. S., & Zerai, A.. (2010). “Everyone Deserves Services No Matter What”: Defining Success in Harm-Reduction-Based Substance User Treatment. Substance Use and Misuse, 45, 2411-2427.

MacMaster, S. A. (2004). Harm reduction: A new perceptive on substance abuse services. Social Work, 49(3), 356-363.

MacMaster, S. A., Holleran, L. K., & Chaffin, K. (2005). Empirical and theoretical support for the inclusion of non-abstinence-based perspectives in prevention services for substance using adolescents. Journal of Evidence – Based Social Work, 2(1&2), 91-111.

McKeganey, N. (2011a). Abstinence and harm reduction: Can they work together? International Journal of Drug Policy, 22, 194-195.

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