Newsletter April 2024

Substance Use Disorder Policy, Strategy and Equity
Dr. Dani Meier, PhD, LMSW, MA
Chief Clinical Officer

Redefining Sobriety

The pairing of sobriety with “abstinence” dominated the substance use disorder (SUD) field through most of the 20th century. The most radical expression of an abstinence approach, of course, was Prohibition which in 1919 banned alcohol sales in the U.S. Prohibition’s failure to curb drinking combined with unintended negative consequences precipitated its repeal in 1933. Two years later, however, the abstinence movement gave rise to Alcoholics Anonymous, a 12-Step model that became integrated into SUD treatment programs in the 1940s and
1950s as part of the emerging Minnesota Model of SUD treatment. This model accelerated the spread of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and established the abstinence-focused 12-Step program as central to mainstream SUD treatment. Today the abstinence model persists in some treatment settings (Volkow, 2020), but treatment practices have been evolving for decades in new and positive directions.

  1. Use of methadone for heroin addiction began in the mid-1960s and as the devastating overdose epidemic exploded starting in the 1990s, a broader array of Medication for Opioid Use Disorder (MOUD)—methadone, buprenorphine and/or naltrexone—became the standard of care for those with an Opioid Use Disorder. Resistance persists to MOUD from some in the medical community and the general public, but
    there’s growing and steady acceptance of MOUD as a best practice.
  2. A more inclusive and expansive view of recovery was also catalyzed by the Acquired Immunodeficiency Syndrome (AIDS) epidemic in the 1980s and 1990s when drug use was identified as having a role in disease transmission. That prompted the adoption of a public health approach to treating SUD (Sobell & Sobell, 1995). The realization that human immunodeficiency virus (HIV) had been spreading among
    people who injected drugs led to the first syringe services programs (SSPs), an early expression of harm reduction in the mid-1980s. Harm reduction has gained increasing traction in recent years at the federal and state level.
  3. The use of cannabis and psychedelics has also expanded as state laws and attitudes have grown more permissive. Fueled by lobbying efforts from combat veterans and others, use of psychedelics to offset or even treat addictions to alcohol, opioids and/or stimulants continues to gain momentum within the medical establishment.

Since 2003, Dr. Nora Volkow has been the director of the National Institute on Drug Abuse. She acknowledges that she was trained to think that “the only way out of an addiction is total and full [abstinence].” Over the years she came to realize that defining recovery as abstinences was unrealistic for some patients. Reduced use and replacing highly addictive drugs like opioids or alcohol with cannabis, can help some patients establish a positive and sustained recovery pathway, Volkow acknowledged.

For more information on expanding the continuum of SUD treatment to include non-abstinence approaches, please see this article in Clinical Psychology Review.

For further information or questions, please contact Dani @