“California Sober” or Abstinence

Michelle Lhooq coined the term “California sober” (Cali sober) in her article on abstaining from the most addicting and dangerous substances (for her), but not all substances. Lhooq’s goal was to avoid alcohol and cocaine, MDMA, and ketamine — not marijuana and psychedelics.

Cali sober describes a lifestyle intent on both using drugs and reducing harm from drug use. We prefer drinking our intoxicants like alcohol or coffee, and now Cali Sober bars are offering cannabis, kava, and kratom drinks. The term, Cali Sober, applied to recovery, has been adopted by those rejecting abstinence as the only path after an addiction overdose or treatment. Advocates believe substituting harmful substances with less dangerous alternatives is a harm-reducing strategy for individuals seeking to control their substance use. However, it’s important to note that we do not really know which drugs are the most dangerous for which people, which people are more vulnerable to drug addictions, or when a person might be more vulnerable to drug addictions or overdose than others. We do know that smoking and injection are the most dangerous routes of drug administration and that overdoses are more likely to happen when fentanyl, opioids, cocaine, and amphetamines are involved. California sober is not medically recognized, lacking scientific evaluation regarding its efficacy or even safety for people with addictions. Many celebrities who successfully battled addictions chose complete sobriety. I reviewed celebrity addictions here.

The term “harm reduction” originated in the 1980s as a pragmatic public health response to rising rates of HIV among people injecting drugs. Instead of insisting on abstinence, British health authorities promoted safer injecting practices to reduce HIV transmission. The term also came to refer to a wide range of services and strategies to deal with the opioid overdose epidemic. Harm reduction generally encompassed clean syringe distribution programs, medically supervised sites where people could use drugs, Naloxone distribution, and other safe use initiatives designed to reduce opioid overdose deaths.

Demi Lovato

The term Cali sober gained widespread global attention when singer Demi Lovato wrote these lyrics: “I’m California sober; It doesn’t have to mean the growin’ part is over; No, it ain’t black or white, it’s all of the colors; That I only just discovered; Now I’m California sober.”

Lovato’s hit song highlighted a new and alternative post-overdose and rehab treatment approach — moderated or California sobriety. However, by December 2021, she completely reversed herself away from the California sober lifestyle, stating, “Sober sober is the only way to be.” This important change was not as widely covered as the suggestion that after a substance use disorder (SUD), you might still be able to use some drugs.

What Experts Think

Nora Volkow, MD, Director of the National Institute on Drug Abuse (NIDA), advocates for recognizing reductions in drug use as meaningful outcomes. “For many people trying to recover from a substance use disorder, perhaps for the majority, abstinence may be the most appropriate treatment objective. But complete abstinence is sometimes not achievable, even in the long-term, and there is a need for new treatment approaches that recognize the clinical value of reduced use,” says Volkow.

The recent shift by the FDA, in collaboration with the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), to accept reduced drug use as a meaningful outcome in pharmaceutical treatment trials for SUDs represents both an acknowledgment that complete abstinence may not be immediately attainable for all individuals and that the FDA would be willing to approve new medicines that reduce drug use and lead to significant health improvements. The FDA currently accepts reduced alcohol consumption, measured as a decrease in heavy drinking days, or reduced tobacco smoking, as valid endpoints in new medication trials. While less-than-ideal, the point is that less vs. none may lead to significant health benefits. They also may be willing to accept less cocaine use, less methamphetamine use, or less fentanyl use as they expand definitions of addiction treatment success beyond abstinence.

Treatment Experts Use Clinical Evidence to Support Abstinence

Many clinical experts and people in recovery think that such changes delay the inevitable realization that sobriety is the only long-term outcome. Certainly, actual randomized and long-term studies are needed to investigate whether using less cocaine, methamphetamine, or other drugs leads to any health improvements or is sustainable.

Scott Teitelbaum, M.D., an academic and treatment expert, with extensive lived experience as well, has treated >15,000+ residential patients with substance use disorders at the Florida Recovery Center (FRC) at the University of Florida College of Medicine (UFCOM). He says: “Addiction means loss of control over drugs and for people who can’t control the use of their mood-altering substances, any drug of abuse can quickly set off the downward spiral.” The rock star Prince died the day before his appointment for an addiction evaluation. Delay in getting treatment, denial of powerlessness, and loss of control over drugs can be fatal.

Scott Teitelbaum, M.D.

Source: University of Florida, with permission

Teitelbaum emphasizes that spiritual and behavioral transformation comes with 12-step abstinence-based treatment, which he has shown and believes is crucial. He says it’s clear from peer-reviewed literature, his own experiences, and as medical director of FRC that 80% success rates are possible for impaired professionals to become clean, sober, and back to work at the 5-year follow-up point.

Teitelbaum believes that for people with an SUD, controlled use is an oxymoron. “I am always careful about abstinence versus this or that drug, because it is often a silent or internal bargaining process for the user that does not generally end well for them or their family,” he says. Teitelbaum says many of his patients tried to cut back or use fewer drugs on their own before a catastrophic event caused them to check into the FRC.

Addiction Essential Reads

The Revolving Door We Call Addiction Treatment

Contingency Management: What It Is and Why It Works

Dr. Robert L. DuPont, the first NIDA director, agrees with Teitelbaum that 12-step abstinence-based treatment, the fellowship, and personal growth are necessary for recovery. He treated substance-abusing patients for 6 decades, wrote books and papers, and performed studies showing that abstinence-based treatment works. DuPont expressed skepticism toward “Cali sober” or strategies focusing on cutting down or reducing drug use without a plan to achieve cessation.

DuPont says, “Millions in AA and NA are clean and sober. Bill Wilson started with alcohol and learned the neurobiology of drugs is such that one drug or another has quite similar effects.” AA’s foundational text, The Big Book, emphasizes that an alcoholic has lost control and moderation. Only total abstinence enables recovery.

Summary

Further advancement in treating addiction requires short and long-term strategies, starting with addicts admitting they’ve lost control and need help. Most come to ask for help after they have lost control over drugs or alcohol and have compromised their family, friends, life, health, or work in the process. The best treatment programs rely on evidence-based protocols for evaluation, treatment of comorbidities, residential treatment, addiction medications, and short-term interventions, which lead to long-term treatment, relapse prevention, recovery support, and follow-up.

Recovering from substance use disorder requires commitment and access to recovery experts, staff, and facilities. Ideally, detox and abstinence or medication-assisted treatment is followed with long-term AA or NA participation. At the same time, complete abstinence sometimes isn’t achievable, and reduced use may lead to sobriety after a while for some.