Other, more subtle items that may serve as conditioned cues for drinking may include the favorite living room easy chair or the music the client typically listened to while unwinding in the evening with several of his or her favorite drinks. Clients who used to hide or stash alcoholic beverages should make a concerted effort to remember and remove alcohol from all possible hiding places, because these hidden or forgotten bottles can serve as a powerful temptation when found “accidentally” after a period of sobriety. This includes eliminating, at least temporarily, all alcohol supplies, including those typically kept for “guests,” as well as packing away wine or shot glasses, corkscrews, and similar items. Helping the client to develop “positive addictions” (Glaser 1976)—that is, activities (e.g., meditation, exercise, or yoga) that have long-term positive effects on mood, health, and coping—is another way to enhance lifestyle balance. Therefore, one global self-management strategy involves encouraging clients to pursue again those previously satisfying, non-drinking recreational activities.

  • It often takes the form of a binge following a lapse in sobriety from alcohol or drugs, but it can also occur in other contexts.
  • In many cases, initial lapses occur in high-risk situations that are completely unexpected and for which the drinker is often unprepared.
  • The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.
  • Three decades since its introduction , the RP model remains an influential cognitive-behavioral approach in the treatment and study of addictions.

The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. Thus, despite RP’s compatibility with the harm reduction philosophy, there is limited evidence of its effectiveness in helping clients – especially those with DUD – achieve nonabstinence goals. However, like the body of research on MI, most studies of RP and MBRP have been conducted in the context of abstinence-focused treatment.

Understanding the Abstinence Violation Effect

  • Whereas most theories presume linear relationships among constructs, the reformulated model (Figure 2) views relapse as a complex, nonlinear process in which various factors act jointly and interactively to affect relapse timing and severity.
  • Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization.
  • Additionally, other findings suggest the influence of a DRD4 variable number of tandem repeats (VNTR) polymorphism on response to olanzapine, a dopamine antagonist that has been studied as an experimental treatment for alcohol problems.
  • Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019).

Evidence further suggests that negative affect can promote positive outcome expectancies or undermine situational self-efficacy , outcomes which could in turn promote a lapse. 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. Initial evidence suggests that implicit measures of expectancies are correlated with relapse outcomes, as demonstrated in one study of heroin users . Implicit measures of alcohol-related cognitions can discriminate among light and heavy drinkers and predict drinking above and beyond explicit measures . Recent reviews provide a convincing rationale for the putative role of implicit processes in addictive behaviors and relapse 54,56,57. In the first study to examine how daily fluctuations in expectancies predict relapse , researchers assessed positive outcome expectancies for smoking (POEs) among participants during a tobacco cessation attempt.

Historical context of nonabstinence approaches

This article reviews various immediate and covert triggers of relapse proposed by the RP model, as well as numerous specific and general intervention strategies that may help patients avoid and cope with relapse-inducing situations. According to these models, the relapse process begins prior to the first posttreatment alcohol use and continues after the initial use. Traditional alcoholism treatment approaches often conceptualize relapse as an end-state, a negative outcome equivalent to treatment failure. The RP model also incorporates numerous specific and global intervention strategies that allow therapist and client to address each step of the relapse process. This whole idea comes from a tried-and-true cognitive-behavioral model for relapse prevention. Practicing healthy coping strategies, making appropriate lifestyle changes, and getting outside support may help to prevent relapse and maintain mental well-being.

AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008). 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. Not coincidentally, those who enter treatment are more likely than non-treatment-seekers with SUD to have already experienced severe negative consequences from substance use (Kwiatkowski, Booth, & Lloyd, 2000), suggesting that it is common to wait to seek treatment until SUD-related problems have escalated. Rather, when people with SUD are surveyed about reasons they are not in treatment, not being ready to stop using substances is consistently the top reason cited, even among individuals who perceive a need for treatment (SAMHSA, 2018, 2019a).

1. Nonabstinence psychosocial treatment models

In addition to these areas, which already have initial empirical data, we predict that we could learn significantly more about the relapse process using experimental manipulation to test specific aspects of the cognitive-behavioral model of relapse. Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., ) and there are increasing efforts to use imaging approaches to predict relapse . Given supportive data for the efficacy of mindfulness-based interventions in other behavioral domains, especially in prevention of relapse of major depression , there is increasing interest in MBRP for addictive behaviors. Those carrying the high-risk GABRA2 allele showed a significantly increased likelihood of relapse following treatment, including a twofold increase in the likelihood of heavy drinking. Not surprisingly, molecular genetic approaches have increasingly been incorporated in treatment outcome studies, allowing novel opportunities to study biological influences on relapse. In one study, researchers used catastrophe models to examine proximal and distal predictors of post-treatment drinking among individuals with alcohol use disorders .

Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment. Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992).

5. Feasibility of nonabstinence goals

We focus our review on two well-studied approaches that were initially conceptualized – and have been frequently discussed in the empirical literature – as client-centered alternatives to abstinence-based treatment. While there are multiple such intervention approaches for treating AUD with strong empirical support, we highlight a dearth of research testing models of harm reduction treatment for DUD. While there is evidence that a subset of individuals who use drugs engage in low-frequency, non-dependent drug use, there is insufficient research on this population to determine the proportion for whom moderation is a feasible treatment goal.

Coping

In the 1970s, the pioneering work of a small number of alcohol researchers began to challenge the existing abstinence-based paradigm in AUD treatment research. Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. In a national study of SUD treatment centers that same year, 95% of treatment center administrators reported their programs were based on AA’s 12-Step model; demonstrating the wide adoption of AA’s abstinence-focused approach, 90% of administrators indicated that abstinence was the only acceptable goal for recovery from SUD (Miller, 1994).

Eliminating Myths and Placebo Effects

Broad implementation of a continuing care approach will require policy change at numerous levels, including the adoption of long-term patient-based and provider-based strategies and contingencies to optimize and sustain treatment outcomes 139,140. As noted by McLellan and others , it is imperative that policy makers support adoption of treatments that incorporate a continuing care approach, such that addictions treatment is considered from a chronic (rather than acute) care perspective. Similarly, self-regulation ability, outcome expectancies, and the abstinence violation effect could all be experimentally manipulated, which could eventually lead to further refinements of RP strategies. While attesting to the influence and durability of the RP model, the tendency to subsume RP within various treatment modalities can also complicate efforts to systematically evaluate intervention effects across studies (e.g., ). RP strategies can now be disseminated using simple but effective methods; for instance, mail-delivered RP booklets are shown to reduce smoking relapse 135,136. In one study of treatment-seeking methamphetamine users , researchers examined fMRI activation during a decision-making task and obtained information on relapse over one year later.

Although the reviews differ in their methodology and in their criteria for including or excluding certain treatments, the conclusions regarding overall effectiveness of the RP approach are similar. For example, if arguments with a former spouse are a high-risk situation, the therapist can help the client map out several possible scenarios for interacting with the ex-spouse, including the likelihood of precipitating an argument in each scenario. In one clinical intervention based on this approach, the client is taught to visualize the urge or craving as a wave, watching it rise and fall as an observer and not to be “wiped out” by it. Therefore, an important aspect of the RP model is to teach clients to anticipate and accept these reactions as a “normal” conditioned response to an external stimulus.

What experiencing the AVE may feel like

This is called the abstinence violation effect, which can be experienced by anyone but is particularly common in those recovering from substance use disorders. The abstinence violation effect (AVE) is a construct for explaining why some people who use a substance again after a period of abstinence experience more serious recurrence of use. An overview of Marlatt’s cognitive-behavioral model. In conclusion, the abstinence violation effect is a psychological effect that impacts those in recovery, as well as those who are focused on making more positive behavioral choices in their lives. Encouragement and understanding from friends, family, or support groups can help individuals overcome the negative emotional aftermath of the AVE.

Indeed, individuals with abstinence goals demonstrate heavier alcohol use on days when drinking occurs compared to individuals with controlled drinking goals, though they also experience more days of abstinence (Adamson et al., 2010; Bujarski et al., 2013; Heather et al., 2010). A singular focus on abstinence may negatively impact the long-term effectiveness of SUD treatment by increasing the likelihood and severity of relapse and discouraging continued attempts at recovery. While there have been calls for abstinence-focused treatment settings to relax punitive policies around substance use during treatment (Marlatt et al., 2001; White et al., 2005), there may also be specific benefits provided by nonabstinence treatment in retaining individuals who continue to use (or return to use) during treatment. Given data demonstrating a clear link between abstinence goals and treatment engagement in a primarily abstinence-based SUD treatment system, it is reasonable to hypothesize that offering nonabstinence treatment would increase overall engagement by appealing to those with nonabstinence goals.

In realistic, healthy approaches to addiction recovery, relapse is seen as a very real possibility, and actions are taken to minimize the risks involved. It can also support the development of healthier attitudes toward lapses and the possibility of relapse at some point in time. People may sometimes feel that relapse is an indication of an inherent flaw or an entirely uncontrollable aspect of what is mdma national institute on drug abuse nida their disease, causing them to experience cognitive dissonance and feel ashamed, hopeless, or unable to combat relapse.

Who might experience the AVE?

Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013). Studies have also identified positive associations between abstinence goals and likelihood of “non-hazardous” or “low-risk drinking” (Adamson et al., 2010; Berglund et al., 2019; Haug, Castro, Eggli, & Schaub, 2018). Evidence comparing long-term outcomes between individuals with abstinence vs. nonabstinence goals is mixed, and to date no published meta-analyses have systematically examined this question.

After identifying those characteristics, the therapist works forward by analyzing the individual drinker’s response to these situations, as well as backward to examine the lifestyle factors that increase the drinker’s exposure to high-risk situations. The initial trigger is a lapse—breaking a rule you set for your own abstinence. When you’re first learning about the abstinence violation effect, it can feel like a lot to take in.