Expanding the continuum of substance use disorder treatment: Nonabstinence approaches PMC

Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020). Regarding SUD treatment, there has been a significant increase in availability of medication for opioid use disorder, especially buprenorphine, over the past two decades (opioid agonist therapies including buprenorphine are often placed under the “umbrella” of harm reduction treatments; Alderks, 2013). Nonabstinence goals have become more widely accepted in SUD treatment in much of Europe, and evidence suggests that acceptance of controlled drinking has increased among U.S. treatment providers since the 1980s and 1990s (Rosenberg, Grant, & Davis, 2020). Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020). Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches.

  • Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness).
  • Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
  • Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020).
  • Phasic responses include cognitive and affective processes that can fluctuate across time and contexts–such as urges/cravings, mood, or transient changes in outcome expectancies, self-efficacy, or motivation.

2. Controlled drinking

Additionally, in the United Kingdom, where there is greater access to nonabstinence treatment (Rosenberg & Melville, 2005; Rosenberg & Phillips, 2003), the proportion of individuals with opioid use disorder engaged in treatment is more than twice that of the U.S. (60% vs. 28%; Burkinshaw et al., 2017). The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition the abstinence violation effect refers to of controlled drinking; see McCrady, 1985). A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982). Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995).

G Alan Marlatt

Most notably, we provide a recent update of the RP literature by focusing primarily on studies conducted within the last decade. We also provide updated reviews of research areas that have seen notable growth in the last few years; in particular, the application of advanced statistical modeling techniques to large treatment outcome datasets and the development of mindfulness-based relapse prevention. Additionally, we review the nascent but rapidly growing literature on genetic predictors of relapse following substance use interventions. The use of functional magnetic resonance imaging (fMRI) techniques in addictions research has increased dramatically in the last decade [131] and many of these studies have been instrumental in providing initial evidence on neural correlates of substance use and relapse. 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.

Specific Intervention strategies in Relapse Prevention

what is the abstinence violation effect

Although it may be helpful for treatment centers to incorporate small penalties or rewards for specific client behaviors (for example, as part of a contingency management program), enforcing harsh consequences when clients do not maintain total abstinence will only exacerbate the AVE. Recently, Magill and Ray [41] conducted a meta-analysis of 53 controlled trials of CBT for substance use disorders. As noted by the authors, the CBT studies evaluated in their review were based primarily on the RP model [29]. Overall, the results were consistent with the review conducted by Irvin and colleagues, in that the authors concluded that 58% of individuals who received CBT had better outcomes than those in comparison conditions.

  • It occurs when the client perceives no intermediary step between a lapse and relapse i.e. since they have violated the rule of abstinence, “they may get most out” of the lapse5.
  • Creating, implementing, and adhering to a relapse prevention plan helps to protect your sobriety and prevent the AVE response.
  • Therapy not only gives people insight into their vulnerabilities but teaches them  healthy tools for handling emotional distress.
  • Clients are taught to reframe their perception of lapses, to view them not as failures but as key learning opportunities resulting from an interaction between various relapse determinants, both of which can be modified in the future.

In general, the longer a person has not used a substance, the lower their desire to use. Self-efficacy (SE), the perceived ability to enact a given behavior in a specified context [26], is a principal determinant of health behavior according to social-cognitive theories. Although SE is proposed as a fluctuating and dynamic construct [26], most studies rely on static measures of SE, preventing evaluation of within-person changes over time or contexts [43].

what is the abstinence violation effect

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

It should also teach a person how to stop the progression from a lapse into relapse. In order to cope or avoid these damaging thoughts, these individuals turn back to drugs or alcohol to numb the pain. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied.

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  • In our era of heightened overdose risk, the AVE is more likely than ever to have tragic effects.
  • Overall, a large volume of research has yielded no consensus operational definition of the term [14,15].
  • If you are at a gathering where provocation arises because alcohol or other substances are available, leave.
  • Preventing relapse or minimizing its extent is therefore a prerequisite for any attempt to facilitate successful, long-term changes in addictive behaviors.
  • One study [76] found that momentary coping differentiated smoking lapses from temptations, such that coping responses were reported in 91% of successful resists vs. 24% of lapses.

The reformulated cognitive-behavioral model of relapse

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