Abstinence-based Recovery

While recovery from mental health challenges and substance use issues have much in common, there are differences. For example, the concept or value of “abstinence.” Just as there are different perspectives on recovery, there are different perspectives on what is and is not “abstinence” and abstinence from what?

Discontinuation of Psychoactive Substances

Historically many have defined “abstinence” as the complete discontinuation of any psychoactive substances. While there are advantages to this definition, there are also disadvantages and questionable exceptions that are often made.

• Advantages: This mental construct of “abstinence” seems simple and clear for many in early recovery to grasp, keeping them safe from relapse while they develop healthy coping mechanisms
• Disadvantage: This definition captures medications that are used to treat substance use or psychiatric disorders. As such, it may marginalize individuals with low recovery capital and high addiction severity and individuals with mental health challenges. Collectively, this is a large percent of the population that deserves recovery. It places them in precarious situations, choosing between taking medication that can improve their quality of life and accessing the support they need to support their recovery.
• Exceptions: Despite caffeine and nicotine being psychoactive and addictive substances, many that hold this definition of “abstinence” make exceptions for these substances. Some question the logic of FDA-approved medications being deemed unacceptable when nicotine products and caffeine are deemed acceptable. This is especially true for nicotine because studies overwhelmingly show that people who quit smoking during addiction treatment have significantly better outcomes.

“Safe” medications are “okay”

In recent years, the concept of what it means to be “abstinent” has evolved, and more effective and safer medications have become available to treat psychiatric disorders. This has led to a definition of “abstinence” that includes the use of medications that are “safe.” This begs the question, who knows best? Who is most qualified to determine what medications are “safe” or “acceptable” for another individual’s recovery?

• Recovery community – Medications that could be habit-forming or used in active addiction are culturally prohibited or frowned upon by many members of mutual aid groups. This can widely vary from fellowship to fellowship and across time. While lived experience is highly valuable, it does not qualify someone to make medical decisions for someone else. Peer pressure to discontinue medication has led to unnecessary shame, relapse, and death.
• Recovery service providers – It is common for addiction recovery and treatment organizations to establish a list of medications they consider safe or unsafe. While this is understandable from a diversion risk management perspective, these policies open them to other risks. When a recovery worker or service provider determines what medications are acceptable for someone else or at what dose and/or for how long, they are “playing doctor.” This has legal and ethical ramifications.
• Doctors – Personal experience, the news, court systems, and pop culture document the existence of “Dr. Feel Good,” which describes prescribers, lured by profits or fame, who knowingly or unknowingly contributed to their patience substance use disorder and/or overdose death. While there are valid concerns around doctors not being adequately trained on substance use issues, medication decisions should be made between individuals and their healthcare professionals.

Reflections: We invite you to reflect and journal on the questions below:

Alcohol and Illicit Drug-Free

Today, many have embraced a definition of “abstinence” as being alcohol and illicit drug-free, but there are some nuances to understand.

• Alcohol-free – Adults can legally consume beer, wine, and spirits in the United States. Some question whether these recovery programs can prohibit using a legal substance on the premise or program. Many argue that we must provide a safe environment for persons with alcohol use risks and disorders. Restrictions can also include over-the-counter products such as alcohol-based mouthwash or fermented products such as Kombucha. It is important to note that the prevalence of alcohol-related deaths is far greater than any other substance.
• Illicit drug-free – “Illicit” means forbidden by law, so illicit drug-free abstinence means not using any prescription or over-the-counter product in a way that is forbidden by law.
  • Prescriptions / controlled substances – This would include taking medication in a way that is not prescribed and selling, sharing, taking, or stealing prescription medication. Recovery residence operators often require a physician’s prescription for psychoactive medications, have a diversion risk, or cause behaviors that impede participation in recovery and/or community activities (e.g., nodding, inability to sustain attention, flat or labile emotions, etc.). Similarly, discontinuation of prescription medications requires the oversight of the prescribing doctor or by another physician, ideally with the prescriber’s knowledge and consent.
  • Over-the-counter / household products – In addition, this includes using household products to achieve a euphoric or altered state.
  • Allows medication as prescribed – The reason many have turned to this definition because it offers a framework that people can easily understand and that supports decisions made between an individual and their health care professional.