Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

A smaller placebo controlled study has also found evidence for better responses to NTX among Asp40 carriers 94. One study found that the Asp40 allele predicted cue-elicited craving among individuals low in baseline craving but not those high in initial craving, suggesting that tonic craving could interact with genotype to predict phasic responses to drug cues 97. The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. Despite compatibility with harm reduction in established SUD treatment models such as MI Halfway house and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD). 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.

Ark Behavioral Health

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 16. 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. Given that CBT is often used as a stand-alone treatment it may include additional components that are not always provided in RP.

Abstinence Violation Effect (AVE)

Instead of continuing with recovery, AVE refers to relapsing heavily after a single violation. Additionally, individuals may engage in cognitive distortions or negative self-talk, such as believing that the relapse is evidence of personal weakness. A mindset shift caused by triggers or stress may lead you to take that drink or start using drugs again. A relapse can be caused by a cascading effect that includes several issues that occur before you begin using again, according to Marlatt. When someone abuses a substance for a long time, they will have a higher tolerance for its effects.

• During a smoking cessation attempt, participants reported on SE, negative affect and urges at random intervals.
• For instance, genetic factors could influence relapse in part via drug-specific cognitive processes.
• Although many developments over the last decade encourage confidence in the RP model, additional research is needed to test its predictions, limitations and applicability.
• Furthermore, the strength of proximal influences on relapse may vary based on distal risk factors, with these relationships becoming increasingly nonlinear as distal risk increases 31.
• Alternatively, researchers who conduct trials in community-based treatment centers will need to obtain buy-in to test nonabstinence approaches, which may necessitate waiving facility policies regarding drug use during treatment – a significant hurdle.
• A mindset shift caused by triggers or stress may lead you to take that drink or start using drugs again.

Common Features Of The Abstinence Violation Effect

• Those in addiction treatment or contemplating treatment can benefit from this aspect of relapse prevention.
• Current theory and research indicate that physiological components of drug withdrawal may be motivationally inert, with the core motivational constituent of withdrawal being negative affect 25,66.
• It occurs when individuals who have set strict rules for themselves regarding certain behaviors or habits (e.g., alcohol consumption, smoking, or eating certain foods) engage in the prohibited behavior, leading to feelings of guilt, shame, and loss of control.
• Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged.

In one study of treatment-seeking methamphetamine users 132, researchers examined fMRI activation during a decision-making task and obtained information on relapse over one year later. Based on activation patterns in several cortical regions they were able to correctly identify 17 of 18 participants who relapsed and 20 of 22 who did not. Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., 133) and there are increasing efforts to use imaging approaches to predict relapse 134.

Historical context of nonabstinence approaches

It is also important that policy makers and funding entities support initiatives to evaluate RP and other established interventions in the context of continuing care models. In general, more research on the acquisition and long-term retention of specific RP skills is necessary to better understand which RP skills will be most useful in long-term and aftercare treatments for addictions. In the first study to examine relapse in relation to phasic changes in SE 46, researchers reported results that appear consistent with the dynamic model of relapse. During a smoking cessation attempt, participants reported on SE, negative affect and urges at random intervals.

Empirical findings relevant to the RP model

Establishing lapse management plans can aid the client in self-correcting soon after a slip, and cognitive restructuring can help clients to re-frame the meaning of the event and minimize the AVE 24. A final emphasis in the RP approach is the global intervention of lifestyle balancing, designed to target more pervasive factors that can function as relapse antecedents. For example, clients can be encouraged to increase their engagement in rewarding or stress-reducing activities into their daily routine. Overall, the RP model is characterized by a highly ideographic treatment approach, a contrast to the «one size fits all» approach typical of certain traditional treatments.

Genetic influences on treatment response and relapse

For example, at a large outpatient SUD treatment center in Amsterdam, goal-aligned treatment for drug and alcohol use involves a version of harm reduction psychotherapy that integrates MI and CBT approaches, and focuses on motivational enhancement, self-control training, and relapse prevention (Schippers & Nelissen, 2006). 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). This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD. We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms. We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. 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.

Relapse prevention, recovery management, recovery transcendence

Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009). A abstinence violation effect recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021). Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013).