Abstinence in addiction treatment: definition, role, benefits, types, and process

Drug abstinence is the act of not using drugs and alcohol. The abstinence-based model is the predominant form of addiction treatment today.

The role of abstinence in addiction treatment is to minimize relapse rates and maximize the chances of recovering from a substance use disorder. Additionally, abstinence promotes addiction treatment by improving physical and mental health outcomes in patients and reducing their levels of stress.

The benefits of abstinence in addiction treatment include a reduction in relapse rates; improved health outcomes; enhanced cognitive functioning; and improved mental health. Other benefits are improved interpersonal relationships; increased financial stability; increased inclination to seek formal treatment; and a richer quality of life.

The types of abstinence in addiction treatment are voluntary, forced, continuous, prolonged or sustained, prolonged abstinence with lapses, point-in-time or point-prevalence, and repeated point-prevalence abstinence. Abstinence is most effective when drug interventions are used. Sustained abstinence supports addiction treatment by helping restore those brain functionalities that were impaired by the chronic use of drugs.

What is drug abstinence?

Drug abstinence is the practice of refraining from the use of drugs and alcohol. In the majority of cases, abstinence is the primary goal of substance use treatment. The abstinence-based model is the predominant mode of substance use disorder treatment today and is regarded as the most effective way to prevent relapse.

Drug abstinence is associated with neurobiological changes like an improvement in brain volume deficit that restores brain functionality and enhances the cognitive controls needed to prevent relapse, according to a 2013 article by Garavan et al., published in the journal Current Opinion in Neurobiology, titled “The Neurobiology of Successful Abstinence.” However, the success of abstinence-based addiction treatment is hampered by factors like a shorter duration of treatment, early termination of treatment, and absence of aftercare services after completing formal treatment.

What is the difference between drug abstinence and harm reduction?

The differences between drug abstinence and harm reduction stem from their varied philosophies and the strategies employed by each approach. Abstinence entails that an individual must stop using drugs completely. This approach is grounded in the belief that individuals with substance use disorder are incapable of moderating their drug use in a way that does not progress to addiction or produce negative outcomes.

On the other hand, harm reduction focuses on minimizing the negative physical and social consequences of substance use, such as medical complications including the risk of transmitting diseases, risk of dying, dysfunctional or distressed relationships, and financial and legal troubles. Harm reduction also focuses on promoting safe drug use practices. It is centered on the fact that substance use disorder is complex and by nature, a chronic relapsing disease. So, abstinence is challenging or not realistically achievable by every individual, especially, those with serious mental disorders who tend to use substances to self-medicate psychotic symptoms.

The treatment interventions to promote drug abstinence include detoxification, pharmacotherapy, psychotherapy, and support groups. The components of an addiction harm reduction strategy are needle and syringe exchange programs, medication-assisted treatment programs to manage opioid addiction, Narcan (naloxone) distribution programs targeting those who live in homeless shelters or have just been released from prison, and fentanyl test strip distribution programs. Setting up supervised drug consumption sites and initiating safe disposal programs for unused medications or those that have passed their expiration dates are other common addiction harm reduction strategies.

Harm reduction strategies that address the socio-cultural and economic aspects of addiction include educational workshops that teach people about safe drug-use habits and overdose prevention; public health campaigns to dispel myths and reduce stigma, treatment programs that incorporate counseling and behavioral therapy; and housing assistance programs to help homeless individuals find supportive housing where sobriety is not a prerequisite for acceptance. Harm reduction services also include prevention and treatment of sexually transmitted diseases; condom programs for injecting drug users (IDUs) and their sexual partners; and targeted information, education, and communication for IDUs and their sexual companions.

What is the role of abstinence in addiction treatment?

The role of abstinence in addiction treatment is to reduce the incidence of relapse and increase the chance of long-term recovery from a substance use disorder, according to a 2016 article by Frimpong et al., published in the Journal of Behavioral Health Services & Research, titled “Abstinence at Successful Discharge in Publicly Funded Addiction Health Services.” Although it is suggested that abstinence is not necessary to achieve recovery from substance use disorder, it likely contributes to enhanced well-being and improved functionality in multiple areas of life, according to a 2022 article by Eddie et al., published in the journal Alcoholism: Clinical and Experimental Research, titled “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.”

Sustained abstinence is a powerful predictor of recovery. Abstinence supports addiction treatment by significantly reducing relapse rates. Consuming even a small amount of a drug during abstinence is known to trigger intense cravings that lead to relapse. Abstinence improves an individual’s physical, psychiatric, and emotional health, thereby allowing them to heal and rebuild their relationships, career, and financial stability. Improvements in these pivotal areas of life ease mental stress and induce a sense of well-being by bringing on feelings of personal responsibility, direction, and agency. The feeling of getting one’s life back in order is a powerful motivator that sustains sobriety.

What are the benefits of abstinence in addiction treatment?

The benefits of abstinence in addiction treatment are listed below.

• Reduced risk of relapse: It is challenging to moderate the amount of drug one takes when an individual decides to reduce drug use instead of refraining from consuming the substance entirely. However, exposure to even small quantities of a drug of abuse has the ability to trigger powerful cravings that increase the possibility of a relapse, according to a 2008 article by Fuchs et al., published in the journal Drug Discovery Today: Disease Models, titled “Relapse to drug seeking following prolonged abstinence: the role of environmental stimuli.”
• Improved health outcomes: Abstinence in drug use is associated with improved health outcomes and reduced mortality, according to a 2015 article by Park et al., published in the journal Addiction, titled “Changes in health outcomes as a function of abstinence and reduction in illicit psychoactive drug use: A prospective study in primary care.” For instance, abstinence is associated with reversibility of methamphetamine-related cardiac complications.
• Improved brain functioning: Substance abuse is associated with a decrease in the functioning of cognitive domains like attention, working memory, response inhibition, and decision-making. However, sustained abstinence has been shown to at least partially improve neurocognitive functioning. For instance, extended abstinence improves cognitive functioning in individuals dependent on tramadol, according to a 2021 article by Hassaan et al., published in the journal Neuropsychopharmacology Reports, titled “Effects of extended abstinence on cognitive functions in tramadol‐dependent patients: A cohort study.” Methamphetamine addiction is associated with impaired cognitive functioning. It has been shown that protracted abstinence leads to improvements in neuropsychological performance in tasks involving verbal and motor memory, according to a 2004 article by Wang et al, published in The American Journal of Psychiatry, titled “Partial Recovery of Brain Metabolism in Methamphetamine Abusers After Protracted Abstinence.” There have been reports of a significant decrease in symptoms of attention-deficit/hyperactivity disorder in individuals with polysubstance use disorder after a year of abstinence, according to a 2017 article by Hagen et al., published in the journal Addictive Behaviors Reports, titled “One-year abstinence improves ADHD symptoms among patients with polysubstance use disorder.”
• Increased propensity to seek formal treatment: Individuals who choose to adopt the moderation approach to address a substance use disorder believe that they have control over their drug use and will be able to continue using the substances without triggering a full-blown relapse that necessitates treatment. On the other hand, individuals who choose to go through abstinence usually do so because they realize that their addiction problem is complex and hence, they are not averse to the idea of seeking formal treatment to overcome their issues. These individuals thus undergo treatment that supports their abstinence and promotes sustained sobriety.
• Improved interpersonal relationships: Drug addiction damages interpersonal relationships in multiple ways. The drug user often chooses to isolate themselves from their loved ones to avoid stigma and discrimination or to conceal their addiction. Neglect of childcare responsibilities and domestic chores, emotional and/or physical abuse in relationships, and lying and/or stealing to use drugs cause separation, divorce, and children being taken away by social services. Poor family and social support is a powerful relapse trigger, as noted by authors Yang et al., in their 2015 article titled “From Abstinence to Relapse: A Preliminary Qualitative Study of Drug Users in a Compulsory Drug Rehabilitation Center in Changsha, China” published in the journal PLOS One. Abstinence creates the opportunity to improve strained relationships and build new and supportive ones, thereby supporting and sustaining sobriety.
• Improved financial situation: Spending increasing amounts of money on drugs, being unable to find or retain gainful employment due to drug-use behaviors, and relying on public assistance create financial hardships. Aside from the mental stress that financial woes bring about, the individual using drugs is also likely to lack the money necessary to seek addiction treatment services like therapy or medications to manage a co-morbid psychiatric condition. Abstinence during addiction treatment eases these adverse economic circumstances, thereby relieving mental stress, a known factor that increases vulnerability to addiction relapse.
• Improved mental health: Abstinence from drugs has been shown to improve symptoms of depression. Improvements in interpersonal relationships, physical health, and financial stability too, lead to a sense of well-being. Drug abstinence is also associated with improved psychiatric outcomes (Park et al., 2015).
• Improved quality of life: The enhancement in the quality of life is brought about through the synergistic effect exerted by improvements in physical and emotional health, interpersonal relationships, and financial stability.

What are the types of abstinence in addiction treatment?

The types of abstinence in addiction treatment are listed below.

• Voluntary abstinence: Voluntary abstinence refers to the practice where an individual actively decides to quit using a substance of abuse. The common reasons for choosing to abstain from drugs include concerns about their adverse effects on physical health, negative psychological outcomes, disapproval from family and/or peers, and personal moral standards and beliefs, according to a 2019 publication by Joseph A. Rosansky and Harold Rosenberg published in the journal Substance Use & Misuse, titled “Self-Reported Reasons for Abstinence from Illicit Drugs.”
• Forced abstinence: Forced abstinence refers to the act of refraining from the use of drugs due to a court order or any other form of legal mandate, or from being hospitalized or incarcerated. Compulsory drug treatment, generally mandated by a drug court, is often abstinence-based, particularly if it is delivered at an inpatient rehab facility, according to a 2015 article by Werb et al., published in the International Journal of Drug Policy, titled ”THE EFFECTIVENESS OF COMPULSORY DRUG TREATMENT: A SYSTEMATIC REVIEW.” Abstinence is a prerequisite for obtaining treatment for a mental health disorder, especially in instances where mental health and addiction treatment services are not provided in an integrated manner. During forced abstinence, the individual is removed from the environment that contains drugs so that they are unable to access any substance of abuse. However, there is a belief that forced abstinence, with its element of coercion, is not effective because recovering from an addiction requires intrinsic motivation.
• Continuous abstinence: Continuous abstinence refers to the practice of completely refraining from using drugs for a specific period, usually from the day of quitting to the time when follow-up is conducted, according to a 2003 article by Hughes et al., published in the journal Nicotine & Tobacco Research, titled “Measures of abstinence in clinical trials: issues and Recommendations.”
• Prolonged or sustained abstinence: It is the practice of continuous abstinence after a period of grace during which substance use is permitted, according to a 2020 article by Piper et al., published in the journal Nicotine & Tobacco Research, titled “Defining and Measuring Abstinence in Clinical Trials of Smoking Cessation Interventions: An Updated Review.”
• Prolonged abstinence with lapses: It is prolonged abstinence after allowing for a grace period, but with a specified amount of substance use permitted (Piper et al., 2020).
• Point-in-time abstinence: Point-in-time or point-prevalence abstinence is a common metric to measure treatment progress in recovery programs. It is the practice of not consuming drugs during a specific period, such as the past 30 days, immediately preceding follow-up (Hughes et al., 2003).
• Repeated point-prevalence abstinence: It is point-prevalence abstinence as assessed at two or more follow-ups between which substance use is permitted (Hughes et al., 2003).

How does abstinence in addiction treatment work?

Abstinence in addiction treatment works most effectively when drug interventions are used compared to instances when other methods like psychosocial therapies are employed. It has been found that acamprosate maintains abstinence for up to 12 months in alcohol-dependent patients who have gone through detoxification, according to a 2020 article by Cheng et al., published in the journal The BMJ, titled “Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis.” Similarly, naltrexone maintenance therapy delivered alongside the Community Reinforcement Approach (CRA) yielded abstinence rates of 28% and 32% in a sample of opioid-dependent patients at 10 and 16 months after detoxification, respectively, according to a 2005 article by Jong et al., published in the American Journal on Addictions, titled “High Abstinence Rates in Heroin Addicts by a New Comprehensive Treatment Approach.”

The human brain is plastic and is able to heal and repair itself after the neurotoxic effects of substances of abuse wear off. Substances of abuse cause chemical imbalances in the brain that impair the normal functioning of its various regions. It has been found that after sustained drug abstinence, the brain starts to recover functionalities in the affected regions, such as the reward center, and is able to return to a nearly normal level of functioning. Abstinence has been shown to improve the functioning of the cortical and prefrontal regions of the brain, which are associated with cognitive control, according to a 2013 article by Garavan et al., published in the journal Current Opinion in Neurobiology, titled “The Neurobiology of Successful Abstinence.” Improved cognitive powers support the active process of abstinence, which includes monitoring moods and behaviors and exerting cognitive and emotional control to suppress cravings or the compulsion to acquire drugs.

Can someone overcome an addiction through abstinence alone?

Yes, someone can overcome an addiction through abstinence alone if they are able to fill the void left by their addiction and incorporate regular physical exercise into their lifestyle, according to a post published in the Harvard Health Blog by Christine Junge titled “Natural recoverers kick addiction without help” on 13 February 2012. However, it must be remembered that it is possible to overcome an addiction through abstinence alone only if the individual has a stable, stress- and substance-free environment to live in, robust family and/or social support, a structured daily routine, and does not suffer from co-morbid psychiatric conditions that make sustained sobriety challenging.

In the absence of these sobriety-promoting factors, an individual will likely need to undergo psychotherapy to learn coping skills required to deal with stress, take medications to prevent cravings and manage mental illnesses, participate in self-help recovery groups, and/or stay in transitional sober living houses for an extended time to achieve lasting abstinence.

Boredom is a powerful relapse trigger. Author Christine Junge notes that a large percentage of natural recoverers of addiction take proactive steps to eliminate boredom from their lives. They find hobbies, work, activities, and relationships to fill up the time they earlier used to spend on drug-use activities. These activities also impart structure and routine to their lives and instill a sense of control, direction, and self-mastery. These elements are conducive to abstinence.

Physical exercise has been shown to reduce drug cravings, according to a 2021 article by Zhang et al., published in the International Journal of Environmental Research and Public Health, titled “The Relationship between Different Amounts of Physical Exercise, Internal Inhibition, and Drug Craving in Individuals with Substance-Use Disorders.” Christine Junge observes that physical exercise promotes abstinence by triggering the release of endorphins, which are neurotransmitters that produce feelings of well-being, improve mood, and lower stress. Negative feelings and emotional stress are known to trigger cravings.

Exercise increases the production of dopamine, which dampens withdrawal symptoms during the early phases of abstinence (Zhang et al., 2021). The inability to tolerate the discomfort of withdrawal is known to compel many individuals going through abstinence to resume taking drugs.

How long does abstinence take in addiction recovery?

The duration of abstinence in addiction recovery before an individual is able to break the cycle of addiction depends on the severity of the substance use disorder, their genetic makeup, the personal and social support available to them, and the aftercare treatment they receive. On average, 90% of individuals who are abstinent for two years continue to sustain their abstinence when assessed upto10 years, as noted in the chapter “Specialized Substance Abuse Treatment Programs” from the 1997 Substance Abuse and Mental Health Services Administration (US) publication titled “A Guide to Substance Abuse Services for Primary Care Clinicians.”

It takes about 2-5 years of commitment to abstinence for the majority of individuals to cement change and overcome their addictive habits. A minute percentage of individuals undergoing addiction recovery are able to overcome their compulsive and impulsive drug-use habits after six months of abstinence.

Can abstinence cause relapse in addiction recovery?

Yes, abstinence can cause relapse in addiction recovery by making withdrawal symptoms intolerable and triggering cravings. Environmental stimuli that trigger mental stress, exposure to drug-related cues, and taking even small amounts of the drug are also known to cause relapse after a period of abstinence. Relapse after a period of abstinence in addiction recovery is not uncommon given that substance use disorder is a chronic relapsing condition.

Withdrawal symptoms manifest after a period of abstinence. These symptoms are unpleasant and compel individuals to resume taking drugs to avoid the distress of withdrawal, according to a 2020 article by Fernandez et al., published in the journal Clinical Psychology Review, titled “Short-term abstinence effects across potential behavioral addictions: A systematic review.”

Exposure to drug cues and mental stress during abstinence has the possibility of triggering powerful cravings that eventually lead to an addiction relapse, according to a 2008 article by Fuchs et al., published in the journal Drug Discovery Today: Disease Models, titled “Relapse to drug seeking following prolonged abstinence: the role of environmental stimuli.” This is possible even after a prolonged period of abstinence. Authors Yang et al., in their 2015 article titled “From Abstinence to Relapse: A Preliminary Qualitative Study of Drug Users in a Compulsory Drug Rehabilitation Center in Changsha, China” published in the journal PLOS One observe that situations and environments where an individual lives during abstinence play a key role in triggering relapse. For instance, adverse socioeconomic conditions, poor family or social support, interpersonal conflicts, and stigma and discrimination directed at the individual who is trying to stay sober make it extremely difficult to maintain abstinence.

What are the ways to support someone who is going through abstinence?

The ways to support someone who is going through abstinence are listed below.

• Learning about the drug-use triggers of a newly sober loved one: To support someone who is going through abstinence, it is critical to know about the latter’s drug-use triggers. This knowledge helps the loved ones of an individual in recovery help the latter stay away from people, places, and situations that are likely to trigger cravings and create a living environment that promotes sustained abstinence.
• Creating a drug-free living environment: The lack of a drug-free living environment is a serious impediment to staying sober. To create a drug-free environment, it is necessary to remove all drug-related cues and temptations that have the potential to trigger cravings. These include items that are reminders of earlier drug-taking behaviors and the substance of abuse that the individual is trying to abstain from, such as alcoholic drinks.
• Modeling good behavior: The loved ones of an individual trying to abstain from drugs should model good behavior by not using drugs around them or offering them drugs. They should not take individuals trying to stay sober to places where drugs are likely to be available, such as bars and rave parties, the latter often being associated with the use of illicit drugs.
• Providing companionship and emotional support: Companionship and emotional support inspire an individual going through the challenges of abstinence to keep going and ease their anxieties, fears, and apprehensions about the recovery journey. It is crucial to listen patiently and non-judgmentally as they share their positive and negative feelings without blaming them, doubting if they will be able to sustain sobriety, and labeling them as failures by comparing them to others.
• Encouraging seeking or continuing treatment for co-morbid psychiatric conditions: Abstinence is extremely challenging to practice and maintain for individuals with severe mental health issues who once used to self-medicate their psychotic symptoms with drugs. Psychiatric comorbidities, such as post-traumatic stress disorder and depression, are associated with relapse. So, it is critical that individuals going through abstinence are encouraged to seek or continue treatment for their psychiatric issues even if they have successfully completed detoxification and rehab.
• Encouraging hobbies and/or work: Research shows that keeping oneself busy with activities, such as engaging in a hobby or any productive work, is critical for maintaining abstinence, according to a 2024 article by Pars et al., published in the journal Substance Abuse and Rehabilitation, titled “Not Two Sides of the Same Coin: A Qualitative Comparative Analysis of Post-Treatment Abstinence and Relapse.” It is also important that the loved ones of a newly sober individual find activities to pursue together that do not involve using drugs.
• Helping build supportive social networks: Addiction erodes interpersonal relationships either due to societal stigma or because the individual chooses to isolate themselves from their loved ones to conceal their drug-use activities. During recovery, they distance themselves from their drug-using peers so that they are not exposed to drug-related cues. As a result, individuals in recovery often find themselves alone and without meaningful relationships. However, loneliness is a trigger for relapse. The loved ones of those going through abstinence should help them build social networks comprising sober individuals who understand, respect, and support the latter’s journey. The loved ones of a recovering individual should attempt to repair dysfunctional or unhealthy family dynamics by resolving conflicts and identifying and healing deep-seated traumas. Going through counseling or family therapy helps in this regard.
• Providing support to establish and maintain routine: Having a structured daily routine creates a sense of stability and control over one’s life and is thus, conducive to sustained abstinence. A daily routine looks like exercising, meditating, journaling, planning and eating regular meals, working at a job, and scheduling time for self-care and leisurely activities. The loved ones of an individual going through abstinence should help the latter with practical tasks that allow them to stick to a daily schedule. These tasks include assisting them with shopping for and preparing healthy meals, being their exercise partner who inspires them and holds them accountable to their goals, and accompanying them to doctor visits or self-help group meetings.
• Supporting them after a “lapse”: In the context of addiction recovery, a lapse is an instance when an individual consumes the drug they are abstaining from after being sober for a while. Lapses are common and normal during abstinence. When someone lapses, their loved ones should assure them that a lapse is not a failure. They should continue providing them with the support and encouragement they need to prevent the lapse from progressing to a full relapse.