Harm reduction approaches to alcohol use

Abstract

Harm reduction approaches to alcohol problems have endured a controversial history in both the research literature and the popular media. Although several studies have demonstrated that controlled drinking is possible and that moderation-based treatments may be preferred over abstinence-only approaches, the public and institutional views of alcohol treatment still support zero-tolerance. After describing the problems with zero-tolerance and the benefits of moderate drinking, the research literature describing prevention and intervention approaches consistent with a harm reduction philosophy are presented. Literature is reviewed on universal prevention programs for young adolescents, selective and indicated prevention for college students, moderation-based self-help approaches, prevention and interventions in primary care settings, pharmacological treatments, and psychosocial approaches with moderation goals. Overall, empirical studies have demonstrated that harm reduction approaches to alcohol problems are at least as effective as abstinence-oriented approaches at reducing alcohol consumption and alcohol-related consequences. Based on these findings, we discuss the importance of individualizing alcohol prevention and intervention to accommodate the preferences and needs of the targeted person or population. In recognizing the multifaceted nature of behavior change, harm reduction efforts seek to meet the individual where he or she is at and assist that person in the direction of positive behavior change, whether that change involves abstinence, moderate drinking, or the reduction of alcohol-related harm. The limitations of harm reduction and recommendations for future research are discussed.

Introduction

The moral and disease models of alcoholism have dominated the prevention and treatment of alcohol problems since the early 1930s (Jellinek, 1960). According to these models, abstinence is considered the only alternative to excessive drinking and individuals who drink to excess are viewed as either immoral or diseased. The prevention of excessive drinking within this framework advocates for a zero-tolerance, or “just say no,” approach to alcohol. Conversely, harm reduction offers a pragmatic approach to alcohol consumption and alcohol-related problems based on three core objectives: (1) to reduce harmful consequences associated with alcohol use; (2) to provide an alternative to zero-tolerance approaches by incorporating drinking goals (abstinence or moderation) that are compatible with the needs of the individual; and (3) to promote access to services by offering low-threshold alternatives to traditional alcohol prevention and treatment.