Incorporating Harm Reduction Into Alcohol Use Disorder Treatment and Recovery

For many years, complete abstinence from alcohol consumption was viewed as the most effective way to recover from alcohol use disorder (AUD) and was a primary outcome of AUD treatment. A large body of evidence, however, suggests that treatment and recovery strategies that reduce heavy alcohol consumption and alcohol-related consequences without complete abstinence can be effective for mitigating the harms associated with alcohol misuse for many individuals. Today, although abstinence is the safest course for certain subgroups, harm reduction strategies that are non-abstinence based have become an important part of the discussion around AUD treatment and the recovery process.

“Indeed, the NIAAA research definition of recovery, released in September 2020, defines recovery as a process through which a person achieves remission from AUD as well as cessation from heavy alcohol consumption, which is a non-abstinent recovery outcome,” noted National Institute on Alcohol Abuse and Alcoholism (NIAAA) Director George F. Koob, Ph.D. The definition also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing recovery outcomes. “This definition was developed to help standardize how we view and measure recovery for research studies and, in turn, advance recovery research and the treatment of AUD,” said Dr. Koob.

Katie Witkiewitz, Ph.D., Distinguished Professor of Psychology and Director of the Center on Alcohol, Substance Use, and Addictions at the University of New Mexico and member of the NIAAA Advisory Council, reviewed the history of harm reduction in alcohol research at the Council’s May 2023 meeting . In her presentation, Dr. Witkiewitz argued that expanding the scope of treatment and research to include non-abstinent drinking reductions as a treatment target could substantially lessen the public health burden of AUD.

“An expanding body of research demonstrates that reductions in drinking lead to reductions in risk and has established that individuals can reduce their drinking and/or their experience of harm associated with alcohol use without achieving abstinence,” said Dr. Witkiewitz. Dr. Witkiewitz and colleagues recently reviewed this work in NIAAA’s Alcohol Research: Current Reviews.1

She added that the need to allow for other ways to define “success” for AUD treatment is driven by observations that:

  • Few individuals achieve continuous abstinence after undergoing AUD treatment.
  • Many who do seek treatment do not want to abstain.
  • Many with AUD do not seek treatment because they do not want to abstain.
  • Non-abstinent goals for treatment and recovery may encourage more people to seek treatment or reduce drinking on their own.
  • Reductions in heavy alcohol use by more people will result in a greater public health benefit.
  • Drinking reductions may be more desirable for certain people and may help people seek treatment.

Finding the Right Drinking Levels To Measure Harm Reduction

In clinical trials for AUD, abstinence and no heavy-drinking days are currently the only endpoints approved by the U.S. Food and Drug Administration (FDA). However, many individuals who do not achieve these endpoints may still reduce their drinking to less harmful levels during treatment. Dr. Witkiewitz and other investigators have examined associations between reductions in drinking risk levels established by the World Health Organization (WHO) and improvements in physical health and quality of life.

WHO defines four levels of drinking risk: low, medium, high, and very high.

World Health Organization Alcohol Risk Levels (For Males)
Low Risk Medium Risk High Risk Very High Risk
Drinks per day (in grams)
Drinks per day (in standard drinks)

1 to 40 g
0 to 2.9 drinks

41 to 60 g
3.0 to 4.3 drinks

61 to 100 g
4.4 to 7.1 drinks

101+ g
7.2+ drinks

World Health Organization Alcohol Risk Levels (For Females)
Low Risk Medium Risk High Risk Very High Risk
Drinks per day (in grams)
Drinks per day (in standard drinks)

1 to 20 g
0 to 1.4 drinks

21 to 40 g
1.5 to 2.8 drinks

41 to 60 g
2.9 to 4.3 drinks

61+ g
4.4+ drinks

Witkiewitz K, Kranzler HR, Hallgren KA, O’Malley SS. Drinking risk level reductions associated with improvements in physical health and quality of life among individuals with alcohol use disorder. Alcohol Clin Exp Res. 2018 Dec;42(12):2453-65. PubMed PMID: 30395350

In a variety of AUD treatment studies, researchers have found that reductions of one and two levels of WHO-defined drinking risk (e.g., reducing alcohol consumption from high risk to medium or low risk) were associated with:

  • Reduced risk of AUD1
  • Fewer drinking consequences and better mental health2
  • Improvements in quality of life, blood pressure, and liver function3
  • Reduced risk of liver disease, depression, and anxiety disorders4,5
  • Positive medication treatment effects6
  • Reductions in health care costs7

“These findings suggest a reduction in WHO drinking risk levels could be a meaningful surrogate marker of improvement in how a person feels and functions after AUD treatment and that extending treatment options to target reductions in drinking, rather than complete abstinence, could expand the reach of alcohol treatment and have an important impact on public health,” said Dr. Witkiewitz.

Contingency Management as a Means of Harm Reduction?

In a presentation to the NIAAA Advisory Council in early 2022, Council Member H. Westley Clark, M.D., J.D., Dean’s Executive Professor at Santa Clara University in Santa Clara, California, provided an overview of contingency management (CM). CM is a behavioral treatment based on the systematic delivery of positive reinforcement, such as incentives, for desired behaviors. Subsequent discussion addressed the possibility that CM could be part of an overall harm reduction treatment strategy.

Dr. Clark’s presentation focused on the use of CM for treating people with methamphetamine and other stimulant use disorders. Currently, there are no FDA-approved medications for treating individuals with stimulant use disorder, and CM is one of three behavioral treatments with robust empirical evidence of effectiveness.

Dr. Clark explained that, in most CM protocols, the value of the incentive increases as patients demonstrate the target behavior, such as attendance at treatment sessions. If a missed session occurs, for example, then the value of the incentive returns to the original value. He noted that incentives have been used successfully in other fields and could be studied more broadly in AUD treatment. In general, Dr. Clark said that CM incentives should advance goals, as determined by the individual’s health care provider. Such goals might include:

  • Adherence to a treatment regimen, medication regimen, and/or follow-up care plan.
  • Management of a disease or condition, improvement in measurable evidence-based health outcomes for the patient or the target patient population.
  • Ensuring patient safety.

Dr. Witkiewitz added that most prior studies of CM have focused on incentivizing abstinence and as a consequence have often focused on abstinence as the benchmark for treatment success. “In the context of AUD treatment, I suspect that contingency management may actually be even more effective than previously tested given that it may be the case that contingency management interventions are also very effective in reducing drinking or harms associated with drinking. It might be especially important and effective to use incentives that are aligned with the patient’s own goals, including harm reduction goals.”


1 Witkiewitz K, Montes KS, Schwebel FJ, Tucker JA. What is recovery? Alcohol Res. 2020 Sep 24;40(3):1-12. PubMed PMID: 32983748

2 Witkiewitz K, Hallgren KA, Kranzler HR, Mann KF, Hasin DS, Falk DE, Litten RZ, O’Malley SS, Anton RF. Clinical validation of reduced alcohol consumption after treatment for alcohol dependence using the World Health Organization risk drinking levels. Alcohol Clin Exp Res. 2017 Jan;41(1):179-86. PubMed PMID: 28019652

3 Witkiewitz K, Kranzler HR, Hallgren KA, O’Malley SS, Falk DE, Litten RZ, Hasin DS, Mann KF, Anton RF. Drinking risk level reductions associated with improvements in physical health and quality of life among individuals with alcohol use disorder. Alcohol Clin Exp Res. 2018 Dec;42(12):2453-65. PubMed PMID: 30395350

4 Knox J, Wall M, Witkiewitz K, Kranzler HR, Falk D, Litten R, Mann K, O’Malley SS, Scodes J, Anton R, Hasin DS; Alcohol Clinical Trials (ACTIVE) Workgroup. Reduction in nonabstinent WHO drinking risk levels and change in risk for liver disease and positive AUDIT-C scores: prospective 3-year follow-up results in the U.S. general population. Alcohol Clin Exp Res. 2018 Nov;42(11):2256-65. PubMed PMID: 30204248

5 Knox J, Scodes J, Wall M, Witkiewitz K, Kranzler HR, Falk D, Litten R, Mann K, O’Malley SS, Anton R, Hasin DS; Alcohol Clinical Trials (ACTIVE) Workgroup. Reduction in non-abstinent WHO drinking risk levels and depression/anxiety disorders: 3-year follow-up results in the US general population. Drug Alcohol Depend. 2019 Apr 1;197:228-35. PubMed PMID: 30852375

6 Falk DE, O’Malley SS, Witkiewitz K, Anton RF, Litten RZ, Slater M, Kranzler HR, Mann KF, Hasin DS, Johnson B, Meulien D, Ryan M, Fertig J; Alcohol Clinical Trials Initiative (ACTIVE) Workgroup. Evaluation of drinking risk levels as outcomes in alcohol pharmacotherapy trials: a secondary analysis of 3 randomized clinical trials. JAMA Psychiatry. 2019 Apr 1;76(4):374-81. PubMed PMID: 30865232

7 Aldridge AP, Zarkin GA, Dowd WN, Witkiewitz K, Hasin DS, O’Malley SS, Isenberg K, Anton RF. The relationship between reductions in WHO risk drinking levels during treatment and subsequent healthcare costs for the ACTIVE Workgroup. J Addict Med. 2022 Jul-Aug;16(4):425-32. PubMed PMID: 34864785


This article first appeared in NIAAA Spectrum.

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