Matching clients' treatment goals with treatment oriented towards abstinence, moderation or harm reduction
Year: 2006
Type: editorial
Abstract: Harry Reasoner, a correspondent on the television program 60 Minutes, in the United States, began a 1983 segment from a cemetery. He was reporting on an alcohol treatment trial [1] that included a condition with a moderate drinking goal. The camera showed him next to the headstone of a participant who had received behavioral treatment aimed towards moderate alcohol use and had died some time later. Thus began a highly biased ‘exposé’ of the alleged deleterious effects of moderate drinking as an alcohol treatment goal. The story was based on information from a long-term follow-up by Pendery et al. [2] of only the group of participants in the Sobells' trial (there were four treatment type X treatment goal conditions) that had received behavioral treatment directed toward a moderate drinking goal. The simplistic storyline failed to mention the inconvenient fact that more people who had been assigned randomly to behavioral treatment with an abstinence goal had died during the same period [3]. The Sobells were precluded by their involvement in litigation from participating in the 60 Minutes segment and no outside treatment researcher was asked to provide an objective perspective. This episode exemplifies the passion and bias that characterized some of the discussion of research on moderate drinking goals in alcohol treatment in the United States at that time. Hopefully, reactions to research, such as that by Lozano et al. [4], this issue, on reduced use goals in relation to marijuana dependence treatment, and to new research on moderate use or harm reduction goals in the broader substance misuse treatment field, will be less heated and more objective. Before proceeding, it is appropriate to define terms and distinguish between ‘moderate use’ and ‘harm reduction’ goals in the addictions field. We use the term ‘moderate use’ here to refer to a level of psychoactive substance use that is associated with no harm. Indeed, some research suggests that moderate use of alcohol not only may cause no harm, it may be beneficial [5,6]. It is more difficult to think of moderate or non-problem levels of use of other substances (e.g. nicotine, marijuana, cocaine, heroin). For some substances, problems derive from the fact that their use is illegal in some countries. When discussing treatment goals from a treatment, as opposed to a client, perspective for the use of substances other than alcohol (which is legal in most countries and, again, may be beneficial in moderate amounts), it seems more appropriate to consider an abstinence orientation versus a harm reduction orientation, rather than an abstinence orientation versus a moderate use orientation. Most treatment providers would not want to openly espouse a moderation goal for use of an illegal substance; however, they would probably believe it to be clinically appropriate to promote reduced harm from substance use, when harm reduction is deemed an attainable goal for a client and abstinence is not. The distinction between harm reduction and moderation goals, coupled with an absence of harm or even benefit from ‘moderate use’ of alcohol, may explain why the preponderance of research on abstinence-oriented versus moderation-oriented addiction treatment has been conducted in the alcohol field. In the study by Lozano et al. [4], it was not determined whether ‘moderation goals’ and ‘moderate use’ referred to levels of use that were associated with no problems. Thus, we use the term ‘reduced use’ rather than ‘moderation’ or ‘harm reduction’ in discussing this study. Some of the findings presented by Lozano et al. [4] on the personal goals (abstinence or reduced use) of people entering treatment for marijuana dependence parallel findings in other addiction fields. Individuals who had an initial reduced use goal were more likely to have fewer dependence symptoms and fewer problems associated with marijuana use, a finding that Lozano et al. note is similar to results from research on moderate drinking in the alcohol treatment field. In addition, some participants were able to achieve their reduced marijuana use goal. As the authors note, similar findings have emerged in research in the alcohol field with respect to moderate drinking; other research (e.g. Polich et al.[7]) suggests that people with fewer dependence systems are more successful in achieving moderate drinking. With respect to tobacco use, research has demonstrated that smokers can reduce their use with treatment [8], an example of harm reduction rather than moderate use, as defined above. Additional ethical complexity for treatment providers and researchers is raised by findings such as those presented by Lozano and colleagues that a reduced use goal is a more slippery slope than an abstinence goal. At every assessment point in their study, individuals with a reduced use goal were more likely to be engaged in ‘non-moderate’ marijuana use (more frequent use than that meeting the threshold for ‘reduced use’) by thesubsequent assessment point than was the case for people with an abstinence goal. Admittedly, reduced use was a more tenuous goal in the context of a trial in which the treatments offered were largely abstinence-oriented. However, this finding, coupled with findings on the relationship between dependence symptoms/problems and reduced use goal orientations by Lozano et al. and in studies of moderate drinking, suggest that research to compare treatments with abstinence versus moderate use is best limited to people who have strong non-abstinence goals and mild–moderate dependence symptoms and problems. Research on treatments with abstinence versus harm reduction goal orientations is best limited to people with strong non-abstinence goals for whom abstinence is not an attainable goal (a high level of dependence may be a key indicator, along with prior failures to achieve abstinence or moderate use). Depending on the substance being used, studies could randomly assign appropriate individuals to receive abstinence-oriented versus moderation-oriented treatment; as Lozano et al. note, some studies of this type in the alcohol field have found comparable ‘success’ rates across the two treatment orientations. In other studies in which non-problem substance use is not possible, appropriate participants could be randomly assigned to receive abstinence-oriented versus harm reduction-oriented treatment. In studies of either type, it would be interesting to determine if there were high refusal rates among people with strong preferences for non-abstinence goals because of the possibility that they might be randomly assigned to receive abstinence-oriented treatment. In addition, it would be illuminating to evaluate the effects of ‘stepped-down’ and ‘stepped-up’ treatment goal orientations, paralleling work on stepped care with respect to addiction treatment intensity. The treatment provided in the trial by Lozano et al. [4], although described as ‘abstinence-oriented’, seems to have employed somewhat of a stepped-down approach. No attempt was made to dissuade clients who mentioned their interest in a reduced use goal from trying to achieve that goal. Rather, such clients were told that it would be better to have a period of abstinence before attempting to use marijuana less frequently than they did prior to treatment initiation. In studies of ‘stepped down’ goals, some people with initial strong non-abstinence goals would be randomly assigned to a condition in which treatment was initially oriented toward abstinence. However, participants would be told that either moderation-oriented or harm reduction-oriented treatment, depending on the study population, would be offered to those who were not successful in abstaining and wanted to pursue an alternative goal. In the same or other studies, individuals with strong non-abstinence goals could be randomly assigned to a ‘stepped-up’ approach in which participants were told that moderation- or harm reduction-oriented treatment, again depending on the population, would be provided initially, but those participants who were unable to achieve moderation or a level of use associated with reduced harm would be stepped-up to abstinence-oriented treatment. It would be important to determine if responses to abstinence- versus moderation-oriented, or abstinence- versus harm reduction-oriented treatment, as well as to stepped-down and stepped-up approaches involving a moderate use or a harm reduction goal, varied depending on individuals' confidence (self-efficacy) for achieving moderate use or less harmful use, dependence symptoms and substance use-related problems, and features of individuals' social contexts (e.g. how supportive they were of a moderation or reduced harm goal). Research on matching individuals' personal treatment goals to treatment goal orientations might inject life into the somewhat dormant area of patient–treatment matching research in the addictions field. Again, one can only hope that research examining carefully selected individuals' treatment goals in relation to different goal orientations of treatment would foster rational discussion and debate, rather than the firestorm that the Sobells' study elicited. The opinions expressed in this editorial are those of the authors and do not necessarily reflect those of the Department of Veterans Affairs. We thank Keith Humphreys for his comments on an earlier version of this editorial.
Source: Addiction
Authors: JOHN W. FINNEY, RUDOLF H. MOOS
Institution: VA Palo Alto Health Care System
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2126409726