The substance use disorder (SUD) treatment industry is beginning to move away from an abstinence-only approach to care toward harm-reduction and medication-assisted treatment approaches. Research demonstrates that abstinence-based SUD treatment is deadlier than no treatment at all.
Despite shifts in the industry away from a concept of recovery that involves strict abstinence, providers say that more traditional approaches will remain an essential part of the treatment spectrum.
The abstinence-only treatment industry is heavily influenced by the 12-step program model popularized by Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).
AA involves group meetings and 12 “spiritual principles” designed to lead participants to sobriety.
The 12-step model is still widely used today, with 65% of SUD facilities reporting using it in 2020, according to SAMHSA’s National Survey of Substance Abuse Treatment Services.
Methods of recovery besides the 12-step model are becoming more popular, however.
“There used to be this very strict abstinence-only rule where if you weren’t completely abstinent from substance use, the treatment programs wouldn’t keep you,” Jessica Fear, senior vice president of behavioral health at VNS Health, told Behavioral Health Business. “Everybody is moving towards harm reduction.”
VNS Health is a nonprofit home and community health care provider headquartered in New York that provides behavioral health and SUD treatment as well as home, hospice and palliative care, among other services.
Alternatives to abstinence-only
Harm reduction approaches involve mitigating adverse consequences of drugs or alcohol. They can include syringe services programs, the distribution of the opioid overdose reversal drug naloxone, or providing education about overdoses and infectious diseases, among other techniques.
Harm reduction can also involve a titration process, reducing the amount or frequency of drug or alcohol utilization over time.
Personal bias may impact the popularity of harm reduction approaches, according to Cooper Zelnick, chief revenue officer at Groups Recover Together.
“I think that if you take someone who was using heroin five times a day and you can figure out how to help that person use heroin once every three days, that is a really good outcome,” Zelnick said. “So I think it’s really important for us to check our biases.”
Groups Recover Together provides treatment through Suboxone, a brand name of buprenorphine, along with group therapy to promote members’ recovery through in-person or virtual care models.
Abstinence-only approaches are increasingly being replaced or augmented with harm reduction and medication-assisted treatment (MAT) approaches, which Zelnick said is beneficial for population health and from a cost perspective.
Telehealth SUD treatment provider Lionrock is among the providers augmenting abstinence-based treatment approaches with harm reduction models.
Lionrock provides virtual intensive outpatient (IOP) and outpatient treatment for SUD. The company launched a specialized treatment program for nurses in July 2023 to address high rates of SUD within the profession.
While around 90% of Lionrock’s patients are in abstinence-based programs, the company has a harm reduction program that offers patients medication and leverages a version of the Sinclair method.
The Sinclair Method allows people seeking treatment to continue drinking alcohol at the beginning of the program, along with taking prescription medication Naltrexone. Over time, the drug blocks endorphins and teaches the brain to de-associate alcohol with pleasure.
The drug alone does not address the underlying problems associated with SUD, according to co-founder and CEO Peter Loeb.
“Our program is not in the Sinclair method in its pure form,” Loeb told Behavioral Health Business. “We also provide [a lighter version of] the resources, structure and counseling that you would find in our IOP program. Because if you don’t get at the root cause of a substance problem, which is not the substance, … it recurs.”
Harm reduction is not necessarily becoming more popular, Loeb said, but it is becoming accepted as a serious modality.
“I don’t think that harm reduction will become more popular in the sense that more people will want it,” he said. “Because I think everybody wants it. I think that the starting perspective is I have a substance problem, I’d like to get it under control.”
Why abstinence-based treatment persists
Abstinence-based treatment persists, partly because of governments’ and payers’ interests. Payers are specifically interested in abstinence-only methods, Loeb said.
SUDs cost employer-sponsored insurance plans $45.3 billion each year, according to a study led by CDC researchers. Outpatient drug-free treatment is the least costly modality for treatment.
State messaging also led providers to focus on abstinence-based treatment, Fear said.
“A lot of the reason that Article 32 providers were espousing abstinence-only is because that was the message that was coming from the state,” Fear said. “The substance use provider community has always known that [harm reduction] is a better way to approach it, but they faced an uphill battle.”
Abstinence-based treatment is widespread, even though it may cause more deaths than no treatment at all, because the people for whom it works become passionate advocates for abstinence, according to Robert Heimer, professor of epidemiology and pharmacology at Yale University.
“The ones for whom medication works don’t talk about it because medications remain stigmatized,” Heimer told BHB. “The loudest voices in the field of people who talk about their management of their chronic disease of opiate use disorder are the people who’ve recovered through abstinence.”
Abstinence-based care as part of a continuum
Abstinence-only treatment will not be going away any time soon, providers told BHB, but harm reduction is now a serious alternative to complete sobriety.
Having received abstinence-based care himself, Zelnick said such treatment should still be an option within a continuum of addiction treatment approaches.
“Saying that, statistically, MAT is the right answer for everyone can be misleading,” Zelnick said. “Because there are a lot of different types of people. I think, as treatment providers, we need to be responsive to the ways in which people are different, and use patient-centered approaches to solve this problem.”
Loeb said that, while MAT prevents overdoses, improving the mental health conditions he considers to be at the root of SUD is key. He calls drugs like Suboxone “maintenance drugs.”
“If you look at the data, it says that using Suboxone prevents overdoses,” he said. “But it doesn’t say that you’re getting people healthy. … If you’re switching from one really harmful medication, which is the one that you’re not supposed to use, to the Suboxone, which is prescribed, what are you doing? You’re finding a better medication that you use.”
There is a genuine need for detox units, Fear said, but without supportive networks in their communities, people with SUD can end up in a regular cycle of admissions and readmissions.
“If you can get someone in consistent treatment, going regularly to their appointments, they get the therapy they need, they get the substance use support that they need,” Fear said. “They have all the tools in their toolkit to be able to resist falling back into the same habits and patterns.”
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