On Abstinence

Twelve step programs begun in 1935 by Alcoholics Anonymous and later adopted by Narcotics Anonymous, Gamblers Anonymous, Sex Addicts Anonymous and more are recognized as the most effective approach to treatment for addicting conditions to date. In common they encourage abstinence. They recognize “slips” where a member attempts to use or participate in the addictive behavior, but they recognize those as a part of the journey to recovery usually defined as one year of continuous abstinence. Smoking cessation is also abstinence based.

Abstinence has been considered by many too difficult a threshold for the person with a substance use disorder. The evidence is that while AA et al are effective for those who achieve abstinence, no more than 10% of the people that suffer from the disease achieve that marker. A recent study published by the National Center for Biomedical Information in the NIH in 2023 found that 4 million people with the disease achieved that definition of recovery where more than 40 million are estimated to suffer from SUD. As a result, there are many that now suggest that approaches other than strict adherence to abstinence from “day one” may prove more effective or, at least, effective for a broader segment of the population. This is a part of the core argument for “harm reduction”. It is also a part of the increased focus on substance use disorder as a chronic medical condition.

The study referenced above “Abstinence versus moderation recovery pathways following resolution of a substance use problem: Prevalence, predictors, and relationship to psychosocial well-being in a U.S. national sample” started with approximately 40,000 Americans who considered themselves “in recovery” and eventually studied 2,300 for in depth assessment. Based on their findings they project that 22 million Americans consider themselves to be “in recovery”. That would be approximately one-half of those with a SUD (being a bit loose with data management here). Among the study participants, 20% are always abstinent, 34% have occasional use (per week, per month, per year), 21% abstain from their drug of choice (the primary substance they identify as the most used and causing the most issues) but use another mind altering substance, and 25% use both their drug of choice and another mind altering substance. Again, all of these individuals consider themselves to be in recovery.

The researchers measured dimensions of recovery success including self-esteem, psychological distress,  happiness, quality of life, and recovery capital. They found that any use of the primary drug or other drugs, or in combination, resulted in lower measures on every scale. The greater use, the less success of recovery on these measures. They also found that as longevity “in recovery” increased, the proportion of survey participants using abstinence as a technique increased. The longer one is “in recovery” the less likely they are to use alcohol and/or other drugs.

There were many in the study population who considered themselves to be in recovery that used their primary substance on an occasional basis, who used another but not their primary drug of abuse, and those who used their primary drug and another drug. The researchers suggested that this behavior, as opposed to abstinence,  may be correlated with the depth of abuse and addiction or the identification with the problem. The transition in the Diagnostics and Statistical Manual V5 (started in previous versions) to the term substance use disorder, as opposed to addiction, was, in part, a recognition of abusive behavior that may not be addiction in the biochemical or behavioral health sense. It stands to reason, then, that those who recognized a problem before “hitting bottom” (the usual point of entry to twelve step membership) might yet be able to use that drug in moderation and, possibly, other drugs as well. Similarly, it may also be a correlation between the strength of problem identification and abstinence. The greater one perceives this to be a problem the more likely they are to abstain.

This kind of research is an important contribution to the national effort to answering our drug abuse problem. Clearly, abstinence is a high bar or more people with a drug issue would be abstinent through twelve step means. More and different treatment approaches will need to be informed by individual reactions to how they manage their issue and those other approaches based in pharmaceutical, behavioral therapies and their combination.

There remains in our mind the question of why abstinence is such a high bar. Certainly, alcohol and increasingly cannabis in the form of marijuana are not only socially acceptable drugs but are engrained in our culture and reinforced daily. We associate alcohol with food (wine with dinner), and we enhance recreational activities (beer with golf), and sporting events (beer again). Alcohol lowers inhibitions and in moderation is often a social lubricant. The comparison to the reduction of smokers in America from 43% in the 1950s to 11% today, a much greater success rate, is certainly associated with the very negative attitudes in America toward smoking that emerged in that timeframe. Alcohol and cannabis do not have those prevalent, negative connotations on their own merit.

There is also a well associated use of alcohol and drugs as self-medication for transient emotional difficulty (disappointment) and for behavioral health conditions (depression and more) especially when self-diagnosed. It is well studied and reported that self-medication often leads to substance use disorder while binge drinking that is not (perhaps yet) addictive behavior is a hazard for those who drink for fun.

It is also the case that at some point in the progression of abuse and addiction transitioning to abstinence is very difficult. Alcohol and other drugs affect the brain involving production of pleasurable feelings and dulling negative ones. Not surprisingly then, people who evidence abusive and addicted behavior may continue to drink despite its various risks. Additionally, long-term alcohol consumption can change the structure and function of the brain and compromise brain function, making it more difficult to quit drinking and maintain abstinence. In some cases, or at some point in most cases, people are no longer able to make a rational choice.

Further, withdrawal is a difficult physical and mental event with symptoms ranging from mild effects (anxiety, headache, stomach upset, palpitations, constipation) to hallucinations, seizures, delirium tremens, and more. Given the potential severity of withdrawal symptoms it is highly recommended that some form of medical supervision be involved during alcohol withdrawal. In some cases people prefer the issues associated with continued abuse as opposed to withdrawal despite the consequences. In some cases they are no longer capable of the focus and attention that quitting requires.

We know why people start to use alcohol and other drugs. We know why quitting is difficult for those who have left social use for abusive drinking and drugging. There is also the negative, cultural connotation surrounding abstinence. In Christianity, Islam and Judaism abstinence is practiced in certain holy times such as Lent, Ramadan and Yom Kippur. In these cases abstaining is a “task” or “sacrifice” performed as recognition to a religious commitment. It is also common in religious and other settings to abstain from sex outside of marriage.

In our dictionaries we also see the definitions of abstinence as denying oneself. The Cambridge Dictionary, for example, notes that abstinence usually involves not participating in something pleasurable but that has harmful effects. They cite alcohol and nicotine. Miriam Webster has similar definitions and implication.

For too many newcomers in twelve step circles abstinence is perceived as penance for the “fallen”. In those meetings outsiders are a threat to those inside who are struggling to avoid continued use. They are actively, sometimes manically avoiding continued use or participation in something they presumably enjoyed at one time though the consequences have become too steep to countenance.

Yet, we know from a recent Gallup poll that a substantial portion of American adults do not use alcohol. That poll has been conducted for over 90 years. The recent high point of consumption was 70% in 1975 and has been steadily declining to a remarkable low point of 54% in 2025.

Another Gallop Poll from 2024 tells us that only 15% of American adults use marijuana. It is true from other polls we have previously reported that 88% of Americans believe that there are appropriate uses of marijuana and that about 65% believe that it is appropriate for recreational use. The general approval by the American populace has not resulted in popular use. As more States approve recreational cannabis we might expect to see that percentage increase.

The data similarly tells us that use of drugs other than alcohol and marijuana is not prevalent. A 2025 report from SAMHSA tells us that Americans 12 years of age and older used cocaine in the past year at a rate of 1.7%, prescription opioids at 3% and hallucinogens at 2.7%

Of course, it is not our purpose to suggest that drug abuse is not a serious problem in America, nor do we mean to minimize the pain suffered by those who abuse alcohol and other drugs as well as the pain for their families. Rather, we do intend to turn the view of abstinence as a penance for immoral or irresolute behavior into the understanding that abstinence is the norm not the exception.

Attention to increasing the numbers of people who are able to treat and recover from their substance and behavioral addictions is important and long overdue. It would appear from early efforts that there are those on the scale from use to abuse to addiction who can continue to use substances or participate in behaviors while reducing or eliminating the negative consequences. All good.

At the same time, we wonder if the approach to recovery that involves continued use is wrong headed or worse an excuse. This is especially worth asking given that the long held views of abstinence as unusual, at least in the case of substances and likely gambling, is simply incorrect. Abstaining from alcohol and other drugs is quite normal behavior in American society.

Gene Gilchrist

January 2026