How long did it take for the government to recognize reduced substance use as a successful outcome? The answer: about 50 years. Nevertheless, it is great that the time has come. For the many who were not around when reduced use first became an issue for the field in the early 1970s, my wife, Linda, and I, quite literally as youngsters (26 and 22 when the study was conducted) evaluated the utility of a reduced drinking alcohol treatment goal for persons with a severe alcohol use disorder in a randomized controlled trial. What for years has struck me as the most important, but ignored, finding was that the group told they could drink but at a reduced level had more than twice as many abstinent days over two years of follow up as their control group told that they should not drink at all. It is profoundly curious that severely dependent patients who were told they could drink a little ended up having many more non-drinking days than their randomized control group who were told to never drink again. This study posed a serious threat to the developing and research averse grass roots alcohol treatment field, and a decade after its publication the study endured a well-publicized attack claiming it was fraudulent. Fortunately, we had retained voluminous records for the follow up. Investigations by a blue-ribbon committee appointed by the Addiction Research Foundation of Ontario (Canada), a Congressional committee, the National Institutes of Health, and the APA all vindicated us, but it was clear that reports of reduced drinking were not welcome. This led to curious anomalies. For example, in 2006 when results were reported for the COMBINE study, a large scale RCT funded by the NIAAA testing medications combined with psychosocial treatment, a category of “good clinical outcome” was used. What did that mean? It meant “abstinent or moderate drinking without problems.”
Jump ahead to today and there are statements by both the NIAAA and NIDA that reduced use should, using FDA terminology, be considered a successful “end point” of substance use disorder treatment. At least for NIDA this seems prompted by the opiate epidemic and the thousands of deaths that could have been prevented had harm reduction strategies been in place.
Of course, just because the government has adopted a harm reduction policy does not mean it will spread to community treatment programs, referred to as specialty programs by the NIAAA. It seems likely, however, that over time things will change. As Dr. Nora Volkow, Director of the NIDA has written: “Healthcare and society must move beyond this dichotomous, moralistic view of drug use and abstinence and the judgmental attitudes and practices that go with it.”
This state of affairs in the practice community needs to be addressed, and the NIAAA and NIDA, which provide substantial treatment funding, are in a good place to promote what the Institute of Medicine in 1990 called Broadening the Base of Treatment for Alcohol Problems, but now addressing all substance use disorders. A paradigm shift is needed and seems to have occurred at the level of science. The shift needs to be broadened to practice, however, in order to benefit the diverse population of persons with substance use problems in this country by making evidence-based services readily available to them. Paradigm shift, full speed ahead!