Expanding the continuum of substance use disorder treatment: Nonabstinence approaches PMC

Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019). While AUD treatment studies controlled drinking vs abstinence commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity).

controlled drinking vs abstinence

There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment. Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015). In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010).

Take Advantage of “Getting Back to Normal” to Revisit Your Relationship with Alcohol

Social stability at intake was negatively related in Rychtarik et al. to consumption as a result either of abstinence or of limited intake. Apparently, social stability predicts that alcoholics will succeed better whether they choose abstinence or reduced drinking. But other research indicates that the pool of those who achieve remission can be expanded by having broader treatment goals. Vaillant (1983) labeled abstinence as drinking less than once a month and including a binge lasting less than a week each year.

Conversely, beverages with lower alcohol contents can increase gastric emptying rates. Drinks that have an alcohol content greater than 15 percent have an inhibitory effect on peristalsis. This means that alcohol slows down gastrointestinal motility, which can lead to constipation.

Risk of Bias Within Studies

Do I want to give up completely, or do I want to be able to have a few drinks now and then. If the answer is a few now and then, the next question to ask is am I honestly able to do that? The majority of people I ask this question to will say no, it is never one or two, it always leads onto more.

Additionally, the system is punitive to those who do not achieve abstinence, as exemplified by the widespread practice of involuntary treatment discharge for those who return to use (White, Scott, Dennis, & Boyle, 2005). Despite the reported relationship between severity and CD outcomes, many diagnosed alcoholics do control their drinking. The Rand study quantified the relationship between severity of alcohol dependence and controlled-drinking outcomes, although, overall, the Rand population was a severely alcoholic one in which “virtually all subjects reported symptoms of alcohol dependence” (Polich, Armor, and Braiker, 1981). Alcoholic remission many years after treatment may depend less on treatment than on posttreatment experiences, and in some long-term studies, CD outcomes become more prominent the longer subjects are out of the treatment milieu, because patients unlearn the abstinence prescription that prevails there (Peele, 1987).

Moderate Drinking is About Having More Control Over Your Drinking

Previous studies suggests that these strict views might prevent people from seeking treatment (Keyes et al., 2010; Wallhed Finn et al., 2014). The present study indicates that the strict views in AA also might prevent clients in AA to seek help and support elsewhere, since they percieve that this conflicts with the AA philosophy (Klingemann and Klingemann, 2017). Initially, AA was not intended to offer a professional programme model for treatment (Alcoholics Anonymous, 2011). When the premise of AA was transformed into the 12-step treatment programme, it was performed in a professional setting. Many clients in the study described that the 12-step programme was the only treatment that they were offered.

  • Here we found that a number of factors distinguish non-abstainers from abstainers
    in recovery from AUD, including younger age and lower problem severity.
  • Many clients in the study described that the 12-step programme was the only treatment that they were offered.
  • Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985).
  • Successful moderation involves understanding yourself (what factors trigger excessive drinking), planning (how much you are going to drink and how you are going to stop), and taking concrete steps to exit or avoid situations where you won’t be able to moderate.
  • According to an article in The Journal of the National Institute on Alcohol and Abuse and Alcoholism, a small study found daily consumption of red wine resulted in increases in compounds that could cause a IBD flare-up.
  • By quitting drinking completely, your body can begin to repair the damage caused by alcohol.

When they are offered 12-step treatment, they get exposed to these strict views in a different setting than what was initially intended within AA, namely a self-help group that people join voluntarily. Williams and Mee-Lee (2019) have discussed this shift in the 12-step programme and argue that current 12-step-based treatment settings promote practices that run contrary to the spirit of AA. For example, they point out that the original AA teaching endorses abstinence only for people with severe addiction disorders, which in the 12-step approach has been changed to abstinence for all members. Williams and Mee-Lee (op. cit.) also claim that AA originally taught that it was not the responsibility of group members or counsellors to give medical advice to others while there is a widespread opposition to using medically assisted treatment in the 12-step approach. Further, that the original focus on support has been replaced by a focus on denial and resistance as personality flaws. This pinpoints the conflicting issues experienced by some clients during the recovery process.

1 Non-abstinent recovery from alcohol use disorders

Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation. Consistent with previous research, behavioral self-control training continues to be the most empirically validated controlled-drinking intervention. Recent research has focused on increasing both the accessibility/availability and efficacy of behavioral self-control training. Moderation-oriented cue exposure is a recent development in behaviorally oriented controlled drinking that yields treatment outcomes comparable to behavioral self-control training.

  • Additionally, the preferred interventions are different for improving PDA and change in DDD.
  • Finally, the WIR survey did not ask about preferential beverage (e.g., beer, wine,
    spirits), usual quantities of ethanol and other drugs consumed per day, or specifics
    regarding AA involvement; because these factors could impact the recovery process, we will
    include these measures in future studies.
  • It’s hard to measure how effectively different programs are treating a condition when the two different programs are entirely different.
  • For example, they point out that the original AA teaching endorses abstinence only for people with severe addiction disorders, which in the 12-step approach has been changed to abstinence for all members.

The only way to ascertain for certain whether you are capable of having just one or two drinks is to try it over a period of time, say 6 months. If during that time, you only ever drink the amount you intend to, and no problems arise as a result of the drinking, then you have found the way that works for you. It is important to know when seeking treatment for substance use that there are options.

Abstinence or controlled drinking a five-year follow-up on Swedish clients reporting positive change after treatment for substance use disorders

Potential correlates of non-abstinent recovery, such as demographics and
treatment history, were based on NESARC results. Additionally, the survey asked about current quality of
life using a 4-point scale as administered by the World Health Organization (The WHOQOL Group 1998). Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success.

This effect may be worse if the alcohol beverages you drink are high in sugar or mixed with sugary juices or sodas. While doctors have connected a person’s diet and smoking to making IBD worse, there aren’t as many studies about alcohol and IBD. The study was funded by the National Institute on Drug Abuse and the National Institute of Health.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Thus, brain CRF systems appear to remain hyperactive during protracted abstinence, and this hyperactivity is motivationally relevant to excessive alcohol drinking. Results such as these suggest that the emotional substrates of the brain that are dysregulated in the binge/intoxication and withdrawal/negative affect stages remain dysregulated and contribute to craving and relapse (see Chapters 1 and 2Chapter 1Chapter 2). They state it’s a “less-threatening first step toward a healthier lifestyle.” MM also claims that programs like theirs fuse moderation, or controlled drinking, with abstinence, are more effective than abstinence-only programs.

  • Even total abstinence from alcohol may achieve pain relief in only 50% of patients with moderate to mild chronic pancreatitis (Gullo et al, 1988).
  • While harm reduction can be effective and successful in helping a person be more cognizant of their drinking behaviors and therefore decreasing them, it is not for everyone.
  • First, some therapies included had few clinical studies and insufficient sample sizes for pooling or looping analyses.43 Second, the small number of included studies and the lack of severity stratification of results in some of the studies did not facilitate the exploration of the association between severity and outcomes.

This could include the number of days they drink per week, the number of drinks they have at a time, specific types of drinks they allow themselves to drink, as well as building awareness behind the types of emotional drinking they may engage in. Most importantly, this treatment model provides accountability, where clients are working weekly and sometimes more with their providers to monitor their progress. We often find that clients seeking alcohol treatment are interested in a harm reduction model. Imagine, as a young adult, you are aware that you drink too much and want to seek help.

Take Our Substance Use Self-Assessment

If you want to resolve problem drinking without medication, abstinence may be a better choice for you. However, the extent of their problems according to ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th edition) or DSM 5 (Diagnostic and Statistical Manual of mental disorders, 5th edition) was not measured. Thus, there might be individuals in the sample who do not consider SUD as their main problem. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied. It often depends upon how much you drink, what you drink, and your overall intestinal response.

controlled drinking vs abstinence

Severity of alcoholism is the most generally accepted clinical indicator of the appropriateness of CD therapy (Rosenberg, 1993). Untreated alcohol abusers probably have less severe drinking problems than clinical populations of alcoholics, which may explain their higher levels of controlled drinking. But the less severe problem drinkers uncovered in nonclinical studies are more typical, outnumbering those who “show major symptoms of alcohol dependence” by about four to one (Skinner, 1990). In addition, Helzer et al. identified a sizable group (12%) of former alcoholics who drank a threshold of 7 drinks 4 times in a single month over the previous 3 years but who reported no adverse consequences or symptoms of alcohol dependence and for whom no such problems were uncovered from collateral records.

Fear of an Inability to Cope Without Alcohol Can Deter You From Trying

Traditional alcohol use disorder (AUD) treatment programs most often prescribe
abstinence as clients’ ultimate goal. In the broadest sense, harm reduction seeks to reduce
problems related to drinking behaviors and supports any step in the right direction
without requiring abstinence (Marlatt and Witkiewitz
2010). Witkiewitz (2013) has suggested
that abstinence may be less important than psychiatric, family, social, economic, and
health outcomes, controlled drinking vs abstinence and that non-consumption measures like psychosocial functioning and
quality of life should be goals for AUD research (Witkiewitz 2013). These goals are highly consistent with the growing
conceptualization of `recovery’ as a guiding vision of AUD services (The Betty Ford Institute Consensus Panel 2007). Witkiewitz also argued
that the commonly held belief that abstinence is the only solution may deter some
individuals from seeking help.

Likely, the concept of abstinence would be overwhelming, as alcohol is a major part of our culture. Expecting someone to potentially cut those events out of their lives to reduce the exposure to alcohol is not always realistic. According to research, “Many individuals experiencing problems related to their drinking (e.g., college students) are not interested in changing their drinking behavior and would most likely be characterized in the precontemplative stage of the transtheoretical model. Harm reduction provides a good method for matching these individuals at that stage and providing motivational incentives (e.g., discussing the negative consequences the person is experiencing) to motivate their desire for positive change” (Marlatt & Witkiewitz, 2002). We do not know what factors relate to non-abstinent vs. abstinent recovery among
individuals who define themselves as in recovery.

Moderated Drinking: A Creative Strategy to Treat Alcoholism?

Important features common to these groups include low program barriers (e.g., drop-in groups, few rules) and inclusiveness of clients with difficult presentations (Little & Franskoviak, 2010). Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) controlled drinking vs abstinence may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). To date, however, there has been little empirical research directly testing this hypothesis.

However, there were no significant differences between groups on the Addiction Severity Index (ASI) psychiatric problems subscale and cravings for secondary drugs. Most participants had no change in the level of use or increased their use through the trial (68%) or transitioned from low (1-4 days a month) to high (5 or more days a month) frequency use. According to the predefined inclusion criteria, two authors (H.C.and S.W.) separately reviewed the list of papers retrieved through preliminarily screening titles and abstracts and full text with Endnote X7 to decide which could be included. Any controversial points were resolved with discussion after an independent review of the list of papers by another author (P.Z.). It’s not an easy road to lasting recovery, but with the right support and resources, it can definitely be a journey worth taking.

How to Get Help for Drug or Alcohol Misuse

Multivariable stepwise regressions estimating the probability of non-abstinent
recovery and average quality of life. Some of the abstainers reported experience of professional contacts, such as therapists or psychologists. These contacts had often complemented the support from AA but in some cases also complicated it as the IPs found that their previous SUD was related to other things that were not in line with the approach to addiction as a disease (e.g. IP19). While people metabolize alcohol differently, alcohol does have the potential to cause constipation.

  • About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b).
  • Moderated drinking could give you the space to address those issues you’ve been pushing aside.
  • The protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and was registered on the International Prospective Register of Systematic Reviews (PROSPERO).
  • In previous research, several indicators of whether CD is possible are mentioned (Klingemann and Rosenberg, 2009; Klingemann, 2016; Davis et al., 2017; Luquiens et al., 2011; Berglund et al., 2019).

For some, attending was just a routine, whereas others stressed that meetings were crucial to them for remaining abstinent and maintaining their recovery process. After transcribing the interviews, the material was analysed thematically (Braun and Clarke, 2006) by coding the interview passages according to what was brought up both manually and by using NVivo (a software package for qualitative data analysis). After relistening to the interviews and scrutinizing transcripts, the material was categorized and summarized by picking relevant parts from each transcript.

Alcohol Moderation Management Steps and Process

Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008). Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013). In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008).

Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020). Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches. Indeed, a prominent harm reduction psychotherapist and researcher, Rothschild, argues that the harm reduction approach represents a “third wave of addiction treatment” which follows, and is replacing, the moral and disease models (Rothschild, 2015a).

Does drinking alcohol cause constipation?

For example, someone might want to cut back on the amount they drink, or maybe slow down their rate of drinking. Another possible option is using medications such as naltrexone or disulfiram along with psychotherapy. You may be able to gradually decrease the amount you drink without needing to go for full abstinence from alcohol. 12-step programs alone do not usually address the underlying need that’s been suppressed through alcohol.

  • No treatment showed a significantly better effect than TAU or TAU plus PLC (Figure S11C and Table S12B).
  • Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008).
  • Every patient requires an individualized type and dose of analgesic drug, starting with the lowest dose necessary to control pain.
  • This study supplemented a network comparison of intervention compliance to assess the patient’s ability to adhere to a specific intervention, using the risk ratio (RR) as the ES.
  • For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment.
  • Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically.
  • They state it’s a “less-threatening first step toward a healthier lifestyle.” MM also claims that programs like theirs fuse moderation, or controlled drinking, with abstinence, are more effective than abstinence-only programs.

Alcohol Moderation Management: Programs and Steps to Control Drinking

Take our free, 5-minute substance use self-assessment below if you think you or someone you love might be struggling with substance use. The evaluation consists of 11 yes or no questions that are intended to be used as an informational tool to assess the severity and probability of a substance use disorder. The test is free, confidential, and no personal information is needed to receive the result. If you are struggling with some of the following signs above, be sure to contact your physician or seek help at a substance abuse treatment facility. Take our short alcohol quiz to learn where you fall on the drinking spectrum and if you might benefit from quitting or cutting back on alcohol.

We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders.

1 What Is Recovery? study

The relative efficacy of moderation-oriented cue exposure versus behavioral self-control training may vary depending on the format of treatment delivery (group versus individual) and level of drinking severity. In general, the efficacy of both techniques does not appear to vary as a function of drinking severity but may vary as a function of drinking-related self-efficacy. Guided-self change is a relatively new and brief cognitive-behavioral intervention that has demonstrated efficacy with problem drinkers.

  • If one drink still leads to several more, attempting moderation isn’t the safest choice.
  • Given data demonstrating a clear link between abstinence goals and treatment engagement in a primarily abstinence-based SUD treatment system, it is reasonable to hypothesize that offering nonabstinence treatment would increase overall engagement by appealing to those with nonabstinence goals.
  • If you believe that harm reduction therapy may help, you may be interested in our alcohol addiction program.
  • At the first interview all IPs were abstinent and had a positive view on the 12-step treatment, although a few described a cherry-picking attitude.
  • This can lead to symptoms like bloating and constipation, according to an article in the journal Alcohol Research.
  • Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013).
  • Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment.

The effectiveness of these programmes can greatly vary depending on several factors such as treatment duration, individual factors, and programme challenges. Learning to drink in moderation can be the goal, or it can be a way station on the way to abstinence. Once you are able to allow yourself some alcohol in controlled circumstances, you may ultimately choose to give up drinking entirely. And even if you don’t plan to quit, you may find that you lose interest in alcohol after practicing moderation. Some people aren’t ready to quit alcohol completely, and are more likely to succeed if they cut back instead.

Moderated Drinking May Empower You to Give Up Drinking Entirely

Even moderate drinking can lead to long-term health problems such as liver disease, heart disease, and increased risk of certain cancers. Besides, alcohol affects your sleep quality and mental health too; it’s not uncommon for people who drink regularly to struggle with anxiety or depression. Alcohol moderation management isn’t just about cutting back and reducing your blood alcohol concentration, it’s a deeply personal journey that can empower you to regain controlled drinking vs abstinence control of your life and reconnect with those who matter most. This strategy is not about total abstinence but involves setting moderate drinking goals that are safe and sensible for you, paying attention to social influences that may sway your decisions, and developing self-awareness around your triggers. Moderation techniques such as pacing yourself, choosing lower-alcohol options, or having alcohol-free days can be practical tools in this journey.

controlled drinking vs abstinence

By the same token, controlled drinking may be the more common outcome for untreated remission, since many alcohol abusers may reject treatment because they are unwilling to abstain. In Britain and other European and Commonwealth countries, controlled-drinking therapy is widely available (Rosenberg et al., 1992). The following six questions explore the value, prevalence, and clinical impact of controlled drinking vs. abstinence outcomes in alcoholism treatment; they are intended to argue the case for controlled drinking as a reasonable and realistic goal. The ability to control drinking varies significantly from person to person and is influenced by a range of factors including genetics, environment, emotional state, and individual psychology.

5. Feasibility of nonabstinence goals

Psychologically, you might be dealing with a range of emotions from guilt over past incidents to anxiety about future relapses. Also, consider your health – excessive drinking can lead to serious conditions like liver disease or heart problems. The path towards moderation management comes with its unique set of challenges which can include social pressure or dealing with underlying emotional issues that contribute towards excessive drinking habits. Individual factors like personal motivation, mental health status, and support system also play a key role in determining how well someone will fare within a programme. It’s heartbreaking to see loved ones caught in the grip of addiction, but there’s hope – research shows that many people find success with programmes aimed at reducing consumption. Alcohol moderation management programmes are often successful when tailored to an individual’s specific needs and circumstances.

  • Even moderate drinking can lead to long-term health problems such as liver disease, heart disease, and increased risk of certain cancers.
  • Abstinence benefits extend beyond just physical improvements though; they also encompass mental health improvements.
  • Consistent with the philosophy of harm reduction as described by Marlatt et al. (2001), harm reduction psychotherapy is accepting of a wide range of client goals, including risk reduction, moderation, and abstinence (of note, abstinence is conceptualized as consistent with harm reduction when it is a goal chosen by the client).
  • In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985).
  • AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008).

Alcohol Moderation Management: Steps To Control Drinking

Though programs like Alcoholics Anonymous and other well-known programs meant to aid in the recovery from alcohol use disorders and alcohol misuse require or encourage full abstinence, these are not the only solutions known to help people quit or control drinking. Different people may be drawn to trying a moderation approach for a variety of reasons. But if they have a problem with alcohol, taking a harm reduction approach could be a constructive way to help them take a look at the negative consequences of their behavior and motivate them to make positive changes. Most people who seek out moderation management (MM) have already tried and been unsuccessful at stopping drinking or cutting down on their use.

Alcohol affects the digestive tract in many ways, depending upon what types of alcohol, and how much of it, you’re drinking. Participants using methamphetamine were more likely to be in the abstinence vs reduced use category (21.3% vs 13.9%, respectively), whereas participants using cocaine were less likely to be in the abstinence vs reduced use category (9.1% vs 20.9%). Among the participants, 1196 sought treatment for cocaine use disorder and 866 for methamphetamine use disorder. In addition, the compliance of the active controlled drinking vs abstinence interventions also did not show better evidence than TAU in Figure 3 (12 articles included). Briefly, as the Supplementary File presents, 14.71% of the included trials were considered low risk, 66.67% were considered unclear risk, and 20.59% were considered high risk (Figure S6A). The unclear ROBs were mainly concentrated in the randomization, allocation concealment, and blinding to therapists and patients, while the high ROBs existed from the implementation to the reporting stage (Figure S6B, details listed in Table S6).

Moderate Drinking is About Having More Control Over Your Drinking

We know that in the majority of cases where addiction is present, abstinence is the only option that works, but for us to insist on this route for others means they are unlikely to try and get help. The idea of never drinking again is extremely daunting, even to those not affected by addiction, and so our advice is to take it one day at a time. If a person tells themselves this every day, the number of days without a drink will soon add up. The negative effects of your drinking may have turned you off of alcohol entirely, and that’s completely okay.

Finally, the WIR survey did not ask about preferential beverage (e.g., beer, wine,
spirits), usual quantities of ethanol and other drugs consumed per day, or specifics
regarding AA involvement; because these factors could impact the recovery process, we will
include these measures in future studies. The dearth of data regarding individuals in long-term recovery highlights the
need to examine a sample that includes individuals with several years of recovery
experience. Moreover, although previous studies have examined treated, non-treated and
general population samples, none has focused on individuals who identify
themselves as “in recovery” from alcohol problems. Importantly, the only published study that asked individuals in recovery (from
crack or heroin dependence in this particular study) how they defined the term revealed
that less than half responded in terms of substance use; the other definitions were more
general, such as a process of working on oneself (Laudet

How to prevent constipation while drinking

In 1990, Marlatt was introduced to the philosophy of harm reduction during a trip to the Netherlands (Marlatt, 1998). He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994).

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Игровое заведение принимает местные валюты из определённых разных регионов. Гости способны использовать EUR, USD, швейцарские кроны, австралийские и канадские доллары. Пополнить счет не трудно, так как доступно несколько различных вариантов оплаты, среди которых:

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– Skrill,


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Все это честные варианты, в которых используются современные технологии шифрования, исходя из этого их есть шанс использовать без опасений.

Если из-за чего-то вам нужна помощь департамента поддержки, казино Вавада сформировало исчерпывающий раздел часто задаваемых вопросов, где размещены ответы на самые распространенные вопросы. Если это не помогает, игроки могут связаться с представителем службы поддержки, кликнув кнопку «Живой чат» или заполнив контактную форму. С казино предусмотрена возможность связаться круглосуточно каждый день, а представители приветливы, компетентны и помогут найти ответ на любой вопрос очень быстро.

Иначе говоря, каждый, кто решит ставить в онлайн-казино Вавада попадает в захватывающее королевство азартных интриг, необычных миссий и премиальных бонусных начислений! Казино имеет обильное число с высоким RTP вендеров, безукоризненно функционирует на ваших мобильных устройствах и позволяет совершать платежи при помощи определённых вариантов оплат. Веб-сайт в целом удобен и обычный в использовании, и вы сможете пользоваться VIP-привилегиями, где бы вы ни играли! Готовы ли вы осознать, что может предложить азартное заведение Вавада с точки зрения приключений и веселья? Тогда скорее создавайте аккаунт, и не забудьте забрать свой бонусный набор, который состоит из 3 частей!

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Джой Казино – игры для всех!

В ассортименте интересных видеослотов сегодня предоставляется около 700 позиций, которые поставляются более чем 25 востребованными разработчиками игр.

Джой Казино на протяжении длительного периода есть одним из известных веб-казино в стране. В то же время основное внимание уделялось не количеству. Вместо этого хозяева JoyCasino стараются добавлять исключительно те игры, которые уже известны или могут стать востребованными. Игровой сервис работает, используя специальную лицензию Кюрасао, предлагая тем самым, безопасное и надежное место для игрового процесса.

Азартный с играми список Джой Казино

В 2022 году в списке JoyCasino не менее 700 вендеров. Что можно отметить еще более впечатляющим, так это то, что реально быстро прокрутить насыщенный список. Всего в JoyCasino работает чуть более 30 провайдеров слотов. Здесь вам доступны следующие разработчики:

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В меню «JoyCasino слоты» доступны не менее 500+ наименований. Когда дело доходит до настольных игр, в Джой Казино есть опция принять участие в 22 виртуальных игровых столах для Roulette и Blackjack, в том числе от Red Tiger и Play’n GO.

Джой Казино также предоставляет широкий набор вендеров для живых казино. Самые известные вендеры среди них – это игры от Evolution Gaming. Яркой особенностью есть то, что JoyCasino имеет право похвастаться эксклюзивными азартными столами, поставляемыми Evolution.

Игры с джекпотом также предлагаются в большом объёме. В целом список развлечений с фиксированным или прогрессивным джекпотом приблизительно 15. Red Tiger, Microgaming, NetEnt, Blueprint и Play’n GO — достаточно популярные среди востребованных операторов для этой категории игр.

Первая страница игрового лобби обеспечивает умный и приемлемый доступ к самым передовым играм на сайте. Здесь вам доступны следующие категории:

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– в целом известные развлечения;

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Чарты, как и большой % второстепенных лицензированных ресурсов, заполнены этими вендерами, как Bonanza, Jammin’ Jars, Book of Dead, Starburst и Reactoonz.

Множество интересных слотов доступно на сайте JoyCasino

Для мобильного игры Джой Казино

Немногие азартные клубы имеют традицию советовать качественные игры для мобильных устройств и таблетов, как JoyCasino. По сути, веб-ресурс был адаптирован для мобильных устройств с самого первого момента запуска. Сегодня в Джой Казино можно вести игру в слоты, классические игры, живое казино на мобильном телефоне и iPad. По факту, если вы запускаете веб-сервис в браузере, неважно, используете ли вы Айос или Андроид.

Несмотря на то, как вы пожелаете получить доступ к ресурсу, вы получите одно и то же предложение. Вы можете делать ставки в более чем 600 вендерах и, конечно же, реально зарегестрироваться и внести депозит сразу на ваш смартфон / таблет.

Благодаря большому разделу часто задаваемых вопросов и регулярно работающим администраторам служба помощи клиентов Джой Казино в целом безупречна. Ресурс также несколько раз получал награды за обслуживание клиентов. Вам предлагаются эти каналы связи:

– электронная почта;

– live чат;

Ответственность за игровые автоматы — это вопрос, к которому JoyCasino относится очень серьезно в течение многих лет. Казино разместил ряд инструментов для лимитов. Как пользователь в этом игровом сервисе, вы можете использовать инструменты, чтобы поставить лимиты на депозит и вход в сервис. Вы также имеете шанс заблокировать учетную запись и закрыть профиль самостоятельно.