The Dirty Little Secret of Abstinence Treatment

Abstinence treatment is the norm in alcohol rehab programs, yet research shows many people secretly continue drinking throughout

By Dr. Adi Jaffe

Last week I was standing outside of one of the SMART Recovery meetings we host at Alternatives when a woman approached me to ask about our program. She wanted to know what made us different than her current treatment center, which was an abstinence-only, AA-based, outpatient center that is so common in Los Angeles (and the rest of the country). I asked her how it was going and she said that she “liked it alright” but that she didn’t feel it was the right fit for her. When I asked why, she dropped a bombshell—“I’ve been drinking throughout treatment.”

She mentioned that she wasn’t drinking as much as before, so she felt good about that, but that she had to lie to her therapists at the center because if they knew she was drinking they would either kick her out of the program or come down hard on her. She was looking for a place that could support her progress while she explored whether moderation or abstinence was the right choice for her.

That’s when I told her the secret: most people in treatment for alcohol continue to drink—they just lie about it. She wasn’t the only one.

I first learned of this “hidden truth” of treatment while working in my first clinic. I won’t mention the name because, even though this sort of thing happens everywhere, I like the place and don’t want to tarnish their reputation. The treatment goal for every client was abstinence and clients would get kicked out for relapsing too many times or stating that they weren’t ready to quit. But even though we were randomly testing people and some tests came back positive for alcohol, it was clear to me that a lot of use was slipping by unnoticed. Some clients even trusted me enough to admit they were getting away with drinking. I couldn’t have been the only one to notice this, yet everyone else was pretending that the treatment was strictly abstinence-based!

The numbers don’t lie, and they show that everyone is lying

A number of studies show that this is a very real phenomenon. One recent study, conducted at the University of Connecticut, looked at whether contingency management (CM) improved treatment attendance and outcomes (Alessi, 2016). But the study included one additional element—participants were outfitted with SCRAMx ankle bracelets that, for 24 hours a day, detected their actual alcohol use through their skin. This wasn’t a secret, the participants knew they were being monitored this way. But the results of the SCRAMx showed something completely different than what the participants said. While about 42% of all participants admitted to drinking at least some point in treatment, the monitoring showed that 99% of them actually did.

And the Connecticut study is just one of many. In another study of people in outpatient treatment for alcohol, about 50% of people were positive for at least one of three biomarkers for alcohol during treatment (Helander, 2012). Another study of clients in long-term inpatient treatment looked at their relapse rates during a weekend home (Wetterling, 2013). While only 6% of patients admitted to drinking while away, urine tests that detect the biomarker EtG showed that 38% of them drank.

At this point the message is clear—people in treatment are not strictly sober despite the expectation that they are.

What do we do about this?

It’s not hard to see why clients lie about their drinking when they are told that relapsing might get them kicked out. They want to get better and know that they won’t get the help they need if they are honest. So they lie. In actuality, the blame sits squarely with the treatment industry. Most clinics don’t utilize testing is a way that truly measures substance use but rather test in a punitive manner that punishes patients for having a drug and alcohol problem. They then use this false information (including horribly inaccurate follow-up success rates) to propagate lies about our own outcomes.

What we need to do is be much more transparent about the reality. People with drug and alcohol problems continue to use when they’re in treatment and even when they’re trying to quit. By looking for only abstinence, we can miss substantial progress in our clients. In the end, if a client is persistently using, it is an indication that they need more help (or don’t want to stop), rather than an indication that they should be terminated from treatment. It’s common sense.

The Alternatives approach

At Alternatives we don’t make the false assumption that our clients will stop drinking altogether. We take a harm reduction approach to meet them where they are at, acknowledging that they will slip up along the way. That doesn’t mean we don’t test clients for alcohol. In fact, we use both a mobile breathalyzer to detect more recent drinking and do random drug testing to detect drinking that may have occurred in the past few days. Research has shown that just testing for biomarkers like EtG poses a risk of detecting “false negatives,” meaning if somebody did indeed drink, the test results will say the didn’t. By using both we get a more accurate picture of somebody’s substance use throughout treatment.

But we aren’t just concerned about drinking and drug use. We factor in our clients’ overall well-being and look at how anxiety or depression may be contributing to their substance use, or how their physical health and stress are improving as a result of treatment. Addiction isn’t a black and white problem that can be reduced to a drug test result. It’s way more complex than that. It’s time we start treating it with the same nuance and complexity.

References

Alessi, S.M., Rash, C.J., Barnett, N., Petry, N.M. (2016). 99% of Patients in Outpatient Clinics Continue Drinking During Treatment. Abstracts—Posters. Alcohol Clin Exp Res, 40: 103A. doi:10.1111/acer.13084

Helander, A., Peter, O., & Zheng, Y. (2012). Monitoring of the Alcohol Biomarkers PEth, CDT and EtG/EtS in an Outpatient Treatment Setting. Alcohol and Alcoholism,47(5), 552-557. doi:10.1093/alcalc/ags065

Wetterling, T., Dibbelt, L., Wetterling, G., Göder, R., Wurst, F., Margraf, M & Junghanns, K. (2013). Ethyl glucuronide (EtG): Better than breathalyser or self-reports to detect covert short-term relapses into drinking. Alcohol and Alcoholism, 49(1), 51-54. doi: 10.1093/alcalc/agt155

 

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