Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Although many researchers and clinicians consider urges and cravings primarily physiological states, the RP model proposes that both urges and cravings are precipitated by psychological or environmental stimuli. The desire for immediate gratification can take many forms, and some people may experience it as a craving or urge to use alcohol. In the absence of other non-drinking pleasurable activities, the person may view drinking as the only means of obtaining pleasure or escaping pain. Moreover, these people often have positive expectations regarding the effects of alcohol (i.e., outcome expectancies). In contrast to the former group of people, the latter group realizes that one needs to “learn from one’s mistakes” and, thus, they may develop more effective ways to cope with similar trigger situations in the future.

AVE thrives on cognitive distortions, especially that black-and-white, “all-or-nothing” thinking. This diagram illustrates that critical fork in the road right after a lapse. It’s full of self-blame and frames the lapse not as a simple mistake you can learn from, but as undeniable proof of some deep, personal failing.

Theoretical and Practical Support for the RP Model

In sum, the RP framework emphasizes high-risk contexts, coping responses, self-efficacy, affect, expectancies and the AVE as primary relapse antecedents. For example, successful navigation of high-risk situations may increase self-efficacy (one’s perceived capacity to cope with an impending situation or task; ), in turn decreasing relapse probability. Although some high-risk situations appear nearly universal across addictive behaviors (e.g., negative affect; ), high-risk situations are likely to vary across behaviors, across individuals, and within the same individual over time . Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal).

The reformulated cognitive-behavioral model of relapse

A 2008 meta-analysis of randomized controlled trials (RCTs) of psychosocial DUD treatment identified five studies testing RP, all of which were conducted in the context of abstinence-based treatment (Dutra et al., 2008). Studies often omit information about whether nonabstinence goals were accepted or goal-aligned treatment offered, making it difficult to parse literature on MI as an abstinence vs. nonabstinence treatment. A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs. Participants with controlled use goals in this center are typically able to achieve less problematic (38%) or non-problematic (32%) use, while a minority achieve abstinence with (8%) or without (6%) incidental relapse (outcomes were not separately assessed for those with AUD vs. DUD; Schippers & Nelissen, 2006).

• Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research.
• Cognitive-behavioral theories also diverged from disease models in rejecting the notion of relapse as a dichotomous outcome.
• The initial trigger is a lapse—breaking a rule you set for your own abstinence.
• Thus, while AUD treatment research can inform research directions for the treatment of other SUDs, it is also important to test the effectiveness of treatments across substance types.
• Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019).

Actionable Strategies to Overcome the Abstinence Violation Effect

In fact, studies show the Abstinence Violation Effect is a what is ayahuasca the recovery village palm beach at baptist health major factor in relapse. One of the most common is the Abstinence Violation Effect (AVE), a powerful cognitive trap that can turn a minor slip-up into a full-blown relapse. For behaviors that carry health risks, like smoking or drug use, abstinence can also be an effective way to improve health outcomes.

• While the overall number of studies examining neural correlates of relapse remains small at present, the coming years will undoubtedly see a significant escalation in the number of studies using fMRI to predict response to psychosocial and pharmacological treatments.
• Stimulus-control techniques are relatively simple but effective strategies that can be used to decrease urges and cravings in response to such stimuli, particularly during the early abstinence period.
• If you’re in the Massachusetts area, a personalized outpatient plan can give you the structure and support you need to build a recovery that lasts.
• Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process.
• Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015).
• Additionally, attitudes or beliefs about the causes and meaning of a lapse may influence whether a full relapse ensues.

One of the key distinctions between CBT and RP in the field is that the term “CBT” is more often used to describe stand-alone primary treatments that are based on the cognitive-behavioral model, whereas RP is more often used to describe aftercare treatment. Interestingly, Miller and Wilbourne’s review of clinical trials, which evaluated the efficacy of 46 different alcohol treatments, ranked “relapse prevention” as 35th out of 46 treatments based on methodological quality and treatment effect sizes. Tonic processes also include cognitive factors that show relative stability over time, such as drug-related outcome expectancies, global self-efficacy, and personal beliefs about abstinence or relapse. A major development in this respect was the reformulation of Marlatt’s cognitive-behavioral relapse model to place greater emphasis on dynamic relapse processes .

Furthermore, individuals with moderate depression in the MBRP group had a significantly lower probability of substance use, fewer drinks per drinking day, and fewer drinks per day than individuals with moderate depression in TAU. This attenuation was related to subsequent decreases in alcohol and other drug use, suggesting MBRP led to decreased craving in response to negative affect, thereby lessening the need to alleviate affective discomfort with alcohol and other drug use. Recent studies have reported genetic associations with alcohol-related cognitions, including alcohol expectancies, drinking refusal self-efficacy, drinking motives, and implicit measures of alcohol-related motivation 51,52, .

This review found consistent support for the superiority of RP over no treatment, inconsistent support for its superiority over discussion control conditions, and consistent support that RP was equally efficacious to other active treatments. The studies reviewed focus primarily on alcohol and tobacco cessation, however, it should be noted that RP principles have been applied to an increasing range of addictive behaviors 10,11. Importantly, this client might not have ever considered such an invitation as a high-risk situation, yet various contextual factors may interact to predict a lapse. For example, one could imagine a situation whereby a client who is relatively committed to abstinence from alcohol encounters a neighbor who invites the client into his home for a drink. A key feature of the dynamic model is its emphasis on the complex interplay between tonic and phasic processes. Thus, whereas tonic processes can determine who is vulnerable for relapse, phasic processes determine when relapse occurs 8,31.

Understanding the Abstinence Violation Effect

It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). These individuals are considered good candidates for harm reduction interventions because of the severity of substance-related negative consequences, and thus the urgency of reducing these harms. Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019). In considering the feasibility of nonabstinence goals for different client populations, some researchers have made a distinction between moderation goals (defining moderation as level of use with no harm) and harm reduction goals (reducing but not necessarily eliminating harm). Together, this highlights that a notable portion of individuals use drugs occasionally (some over long periods of time), and some achieve moderate use after treatment for DUD. For example, there was a series of studies in the 1970s that described small, nonrepresentative samples of “occasional users” of illicit opioids including heroin, suggesting that at least some individuals maintain patterns of infrequent drug use over months or years (Gay, Senay, & Newmeyer, 1974; Powell, 1973; Zinberg, Harding, & Wink-eller, 1977).

Definitions of relapse and relapse prevention

It is inevitable that the next decade will see exponential growth in this area, including greater use of genome-wide analyses of treatment response and efforts to evaluate the clinical utility and cost effectiveness of tailoring treatments based on pharmacogenetics. Consistent with the broader literature, it can be anticipated that most genetic associations with relapse outcomes will be small in magnitude and potentially difficult to replicate. Overall, the body of research on genetic influences on relapse and related processes is nascent and virtually all findings require replication. However, treatment differences emerged in the low-risk genotype group, such that TSF produced the best outcomes, followed by MET . There is also preliminary evidence for the possibility of genetic influences on response to psychosocial interventions, including those incorporating RP strategies.

The Abstinence Violation Effect and Overcoming It

Despite findings like these, many studies of treatment mechanisms have failed to show that theoretical mediators account for salutary effects of CBT-based interventions. One study, in which substance-abusing individuals were randomly assigned to RP or twelve-step (TS) treatments, found that RP participants showed increased self-efficacy, which accounted for unique variance in outcomes . Consistent with the RP model, changes in coping skills, self-efficacy and/or outcome expectancies are the primary putative mechanisms by which CBT-based interventions work . Ecological momentary assessment , either via electronic device or interactive voice response methodology, could provide the data necessary to fully test the dynamic model of relapse. It was noted that in focusing on Marlatt’s relapse taxonomy the RREP did not comprehensive evaluation of the full RP model .

Overall, RP remains an influential cognitive-behavioral framework that can inform both theoretical and clinical approaches to understanding and facilitating behavior change. However, the tendency to subsume RP within other treatment modalities has posed a barrier to systematic evaluation of the RP model. This taxonomy includes both immediate relapse determinants and covert antecedents, which indirectly increase a person’s vulnerability to relapse.

This is that deeply uncomfortable mental static you feel when your actions (like having a drink) don’t line up with your beliefs and goals (your commitment to sobriety). You can find more detail on this model’s role in recovery over at prairieviewpsychology.ca. Your plan must include contacting your support system right away.

An additional concern is that the lack of research supporting the efficacy of established interventions for achieving nonabstinence goals presents a barrier to implementation. In addition to evaluating nonabstinence treatments specifically, researchers could help move the field forward by increased attention to nonabstinence goals more broadly. In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature. Similarly, most studies of MBRP have tested the approach as an adjunct to abstinence-based outpatient and residential treatment (Grant et al., 2017).

Less research has examined the goals of individuals with drug use disorders (DUDs), but the few studies that assessed substance use goals among individuals seeking DUD treatment suggest about 1 in 5 endorse nonabstinence goals (Lozano et al., 2015; McKeganey, Morris, Neale, & Robertson, 2004). As noted earlier, the broad influence of RP is also evidenced by the current clinical vernacular, as “relapse prevention” has evolved into an umbrella term synonymous with most cognitive-behavioral skills-based interventions addressing high-risk situations and coping responses. These two reviews highlighted the increasing difficulty of classifying interventions as specifically constituting RP, given that many treatments for substance use disorders (e.g., cognitive behavioral treatment (CBT)) are based on the cognitive behavioral model of relapse developed for RP . The RP model proposed by Marlatt and Gordon suggests that both immediate determinants (e.g., high-risk situations, coping skills, outcome expectancies, and the abstinence violation effect) and covert antecedents (e.g., lifestyle factors and urges and cravings) can contribute to relapse.

G Alan Marlatt

Ideally, this approach helps clients to recognize high-risk situations as discriminative stimuli signaling relapse risk, as well as to identify cognitive and behavioral strategies to obviate these situations or minimize their impact. The evolution of cognitive-behavioral theories of substance use brought notable changes in the conceptualization of relapse, many of which departed from traditional (e.g., disease-based) models of addiction. Overall, however, research findings support both the overall model of the relapse process and the effectiveness of treatment strategies based on the model.