Psy-Q:  My SUD patient wants to try a “California sober” treatment approach. How should I respond? Collin M. Reiff, MD, answers.

Collin M. Rieff, MD

Collin M. Rieff, MD

Answer: First off, the term “California sober,” which recently made headlines after singer Demi Lovato discussed it in relation to her recovery, doesn’t exactly have a definition. To some, it means only drinking occasionally; to others, it could mean using marijuana but no other drugs – it all boils down to a person deciding to use certain substances in moderation while not committing to abstinence.

“With ‘California sober,’ the danger of it is that it’s a very broad term – it’s ambiguous and it’s easy for it to be misinterpreted,” explains Collin M. Reiff, MD, medical director and clinical psychiatrist for the Steven A. Cohen Military Family Center, and a clinical assistant professor of psychiatry at the New York University Grossman School of Medicine.

“‘California sober’ is essentially a form of moderation management (MM),” Dr. Reiff told Psycom Pro, noting that moderation is not the standard of care and that there is only one study that suggests moderation is effective, and that was in non-dependent problem-drinkers. (More on the Cali sober trend.)

Dr. Reiff says a moderation approach might help a patient with a mild alcohol use disorder (AUD), but if someone has a severe alcohol disorder or dependence, or if they use other substances, “there’s nothing really to support MM other than MM as a form of harm reduction, which is essentially decreasing the risk of substance abuse with abstinence at the far end of the spectrum.”

“The danger of MM is that it can perpetuate the fantasy that MM patients can continue to use substances in life-endangering situations and that they can manage their substance use despite the evidence,” Dr. Reiff says. “And that can delay them getting to a higher level of care, which might be life-changing for some people.”

One positive aspect of moderation management is that it can be used to engage the patient in treatment when they cannot commit to an abstinence model, which can alienate patients who aren’t ready for it, says Dr. Reiff. “You’re going to lose them because oftentimes you have to align with your patient’s goals,” he says.

So, what can clinicians do when patients ask about a moderation approach to AUD or SUD? Dr. Reiff offers several key points:

  • Begin by defining “California sober” with the patient. What does it mean to them in terms of what or how much of a substance they are giving up?
  • Talk to the patient about gathering data about their substance use. Use that data to inform the next step.
  • Review the data weekly with the patient to see how the treatment program is working.

“Keep in mind that you should only do that if it’s safe – meaning the person doesn’t have a severe substance use disorder, they’re not putting themselves in danger on a regular basis, or putting others in danger,” Dr. Reiff clarifies.

The clinical takeaway is that moderation management is not something that Dr. Reiff recommends as a treatment, but that “it can be a way to keep the patient engaged in treatment, and as we gather evidence, they often get to a point where they recognize, ‘Hey, this isn’t working.’”

In this way, a moderation or California sober approach may be viewed as a stepping-stone on the path toward abstinence, which patients may not be ready for when they enter treatment.

“It’s kind of a spectrum,” Dr. Reiff says. “They get there over time.”

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Last Updated: May 7, 2021