In the final episode of Demi Lovato’s docuseries, “Dancing with the Devil,” the singer reveals she isn’t completely sober following her near-fatal 2018 overdose. Lovato said she still drinks alcohol and uses marijuana in moderation, referring to herself as “California Sober,” a controversial and somewhat fluid colloquialism to describe people who abstain from most substances.
“I know I’m done with the stuff that’s going to kill me,” she said, but swearing off alcohol and marijuana entirely is just “setting myself up for failure.”
The dominant narrative around addiction is that using substances in moderation is incompatible with long-term recovery. But some experts argue the field’s understanding of addiction is evolving to make room for less rigid, didactic approaches.
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“Recovery is a process of change through which people improve their health and wellness, live self-directed lives and strive to reach their full potential,” according to the Substance Abuse and Mental Health Services Administration.
Elizabeth Burden, senior advisor at the National Council for Behavioral Health, notes that nowhere does the definition mention abstinence.
“Many experts would agree that there are many pathways to recovery and that there are many elements or components of it,” she said. “In some frameworks, such as in 12 Step fellowship traditions, abstinence is one of the core components, but that’s not the only definition of recovery.”
‘Recovery isn’t a one-size-fits-all solution’
Lovato said she was reluctant to share her use of substances for fear she’d be criticized and because of concern someone would make a decision about their own recovery based on hers.
“I also don’t want people to hear that and think that they can go out and try having a drink or smoking a joint, you know?” she said. “Because it isn’t for everybody. Recovery isn’t a one-size-fits-all solution.”
In the docuseries, some people in Lovato’s support system said they understood her desire to explore boundaries, while others worried about her approach.
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Singer Elton John, an outspoken proponent of the AA model that stresses abstinence, has been in recovery for more than three decades. He was direct in his disapproval.
“Moderation doesn’t work,” he said. “Sorry. If you drink you’re going to drink more. If you take a pill you’re going to take another one. You either do it or you don’t.”
But some experts say what’s true for John may not be true for others.
“If we believe that recovery is a self-directed process … then one person’s definition may not fit for someone else,” Burden said.
Carly Larson is an opioid response coordinator at Rocky Mountain Crisis Partners in Colorado and identifies as a “non-abstinent person in recovery.”
Larson said John’s perspective is the prevailing one, though it may reflect bias.
“He’s probably not seeing any success stories because if people are successfully moderating their use, they’re not going to be in AA anymore,” she said.
A 2010 meta-analysis published in the journal “Addiction” on the efficacy of abstinence versus controlled drinking concluded that “available evidence does not support abstinence as the only approach in the treatment of alcohol use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence-oriented approach is not applicable.”
Larson said there is little formalized support for people who want to try moderation, which often means people exploring it are managing alone.
“Recovery is about moving towards a better, fuller, more meaningful life,” she said. “That, to me, can be with or without substances. And if you are making choices and progress in building connection, in stabilizing your life, in kind of just making your life worth living, then you’re not going to want to escape that as much. You’re not going to need to fill whatever kind of void is there with substances.”
Harm reduction as a way to save lives
Harm reduction is a strategy that helps people who use drugs stay healthy and alive. It often gets talked about in terms of overdoses, or in preventing things such as HIV infection and Hepatitis C among intravenous drug users.
Harm reduction is typically thought of in the context of formalized programs – methadone clinics and syringe service programs – but experts say the way Lovato speaks about her own moderation could fall under the umbrella of harm reduction. Lovato says she no longer uses heroin, which qualifies as a harm reduction strategy.
Collin Reiff, an addiction psychiatrist at NYU Langone Health who specializes in substance abuse treatment, said harm reduction is a broad term that can be thought of as a spectrum, with the far end being abstinence.
“I kind of think of it as the longterm goal when the patient’s ready for it. But if I told every patient I met, ‘Hey, we’re going to go for abstinence longterm,’ they would say, ‘That’s not what I want. You’re not aligning with my goals. So I don’t want to engage in this treatment,'” he said.
Reiff said his work is to meet a patient where they are. Individuals in recovery, he said, often learn what works and what doesn’t in small steps. But he is skeptical of moderation as a long-term strategy, noting that moderation management may work for a small sub-group of people who struggle with only alcohol use disorder, but a lot more research is needed to make any claim that it is effective or safe for people who have a severe alcohol use disorder, a history of alcohol dependence or other substance use disorders including opiate use disorder or dependence.
“There’s a fantasy that, ‘Hey, I can get this under control.’ And so those individuals are often … reasonably so, I get it, they’re eager to try moderation management. ‘Let me see if I can control how much I drink or how much cocaine or how much heroin I use.’ And for most people that doesn’t work,” he said. “But if you’re doing that it’s important to really keep track of it and to be honest with yourself and with whoever you’re working with about your substance use. “
Lovato’s recovery still full of unknowns
Lovato’s disclosure has been lauded by mental health professionals, even if they don’t all agree with her publicly-stated approach.
“She’s very brave and courageous for opening up about her substance use disorder and being public about it,” Reiff said. “I give her a lot of credit.”
But much about Lovato’s recovery journey is unknown, Reiff said. Viewers only see what she disclosed, including her use of Vivitrol, which he says reduces the euphoria of alcohol. Her experience may not be comparable to someone who is attempting to regulate alcohol use without it.
“This is her life, these are her experiences,” he said. “We do not know all the ins and outs of her substance use disorder. We don’t know all the details of her recovery. She is at a specific point in time and my guess is that she is going to continue to evolve in one direction or the other. Where she’s at right now isn’t going to be where she stays.”