All the interviewees had attended treatment programmes following the 12-step philosophy and described abstinence as crucial for their recovery process in the initial interview, five years ago. In previous research, several indicators of whether CD is possible are mentioned (Klingemann and Rosenberg, 2009; Klingemann, 2016; Davis et al., 2017; Luquiens et al., 2011; Berglund et al., 2019). Clients reporting CD in the present study only met one of these criteria – an initial period of abstinence (Booth, 2006; Coldwell and Heather, 2006). Polich, Armor, and Braiker found that the most severely dependent alcoholics (11 or more dependence symptoms on admission) were the least likely to achieve nonproblem drinking at 4 years.
After transcribing the interviews, the material was analysed thematically (Braun and Clarke, 2006) by coding the interview passages according to what was brought up both manually and by using NVivo (a software package for qualitative data analysis). After relistening to the interviews and scrutinizing transcripts, the material was controlled drinking vs abstinence categorized and summarized by picking relevant parts from each transcript. By iteratively analysing and compiling these in an increasingly condensed form, themes were created at an aggregated level, following a process of going back and forth between transcripts and the emerging themes as described by Braun and Clarke (op. cit.).
Exclusion criteria were any serious mental illnesses or unstable medical conditions, current abuse or dependence on any drug other than nicotine or marijuana, and taking or requiring any medication that interfered with the study medications, including any current opioid use. Earlier research utilizing drug use goals analogous to goals used in the present study found commitment to absolute abstinence, measured at the end of treatment, to predict days to relapse across nicotine, alcohol, and opiate dependence (Hall & Havassy, 1986; Hall, Havassy, & Wasserman, 1990). These findings were such that participants committed to complete abstinence took longer to slip and longer to relapse, defined as drug use on four or more days in a week. Critically, Hall et al. (1986, 1990) examined participants with an abstinence goal allowing for occasional slips and found that these participants did not fare as well as participants with complete abstinence goals. AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008).
Importantly, one study examined the effects of naltrexone on alcohol non-abstainers and found that participants who drank regularly during the treatment period benefited more from naltrexone relative to placebo (Ray, Krull, & Leggio, 2010). Together, these findings suggest that naltrexone may be better suited to a controlled drinking approach and thus may be more effective among patients with controlled drinking goals. Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992). For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986). Miller, whose seminal work on motivation and readiness for treatment led to multiple widely used measures of SUD treatment readiness and the development of Motivational Interviewing, also argued for the importance of goal choice in treatment (Miller, 1985). Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches.
Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. Drug use behaviors are generally considered the most important outcomes, but there is disagreement about definitions of moderate and controlled drinking and drug use (e.g., Järvinen, 2017; McCrady, 1985) as well as ongoing debate about whether health and quality of life outcomes should be prioritized (Donovan et al., 2012; Kiluk et al., 2019). Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019). While AUD treatment studies commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use.
