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

When abstinence is violated, individuals typically also have an emotional response consisting of guilt, shame, hopelessness, loss of control, and/or a sense of failure; they may use drugs or alcohol in an attempt to cope with the negative feelings that resulted from their abstinence violation. A person may experience a particularly stressful emotional event in their lives and may turn to alcohol and/or drugs to cope with these negative emotions. An abstinence violation can also occur in individuals with low self-efficacy, since they do not feel very confident in their ability to carry out their goal of abstinence.

  • For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type.
  • However, evidence regarding its superiority relative to other active treatments has been less consistent.
  • Based on the cognitive-behavioral model of relapse, RP was initially conceived as an outgrowth and augmentation of traditional behavioral approaches to studying and treating addictions.
  • Participants had to smoke at least 15 cigarettes per day, to have been smoking for at least 5 years, to be between the ages of 21 and 65.
  • Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge.

Given that CBT is often used as a stand-alone treatment it may include additional components that are not always provided in RP. For example, the CBT intervention developed in Project MATCH [18] (described below) equated to RP with respect to the core sessions, but it also included elective sessions that are not typically a focus in RP (e.g., job-seeking skills, family involvement). As outlined in this review, the last decade has seen notable developments in the RP literature, including significant expansion of empirical work with relevance to the RP model. Overall, many basic tenets of the RP model have received support and findings regarding its clinical effectiveness have generally been supportive.

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Rather than being viewed as a state or endpoint signaling treatment failure, relapse is considered a fluctuating process that begins prior to and extends beyond the return to the target behavior [8,24]. From this standpoint, an initial return to the target behavior after a period of volitional abstinence (a lapse) is seen not as a dead end, but as a fork in the road. While a lapse might prompt a full-blown relapse, another possible outcome is that the problem behavior is corrected and the desired behavior re-instantiated–an event referred to as prolapse. A critical implication is that rather than signaling a failure in the behavior change process, lapses can be considered temporary setbacks that present opportunities for new learning to occur. In viewing relapse as a common (albeit undesirable) event, emphasizing contextual antecedents over internal causes, and distinguishing relapse from treatment failure, the RP model introduced a comprehensive, flexible and optimistic alternative to traditional approaches.

abstinence violation effect definition

Efforts to develop, test and refine theoretical models are critical to enhancing the understanding and prevention of relapse [1,2,14]. A major development in this respect was the reformulation of Marlatt’s cognitive-behavioral relapse model to place greater emphasis on dynamic relapse processes [8]. Whereas most theories presume linear relationships among constructs, the reformulated model (Figure ​(Figure2)2) views relapse as a complex, nonlinear process in which various factors act jointly and interactively to affect relapse timing and severity. Against this backdrop, both tonic (stable) and phasic (transient) influences interact to determine relapse likelihood. Tonic processes include distal risks–stable background factors that determine an individual’s «set point» or initial threshold for relapse [8,31].

Abstinence violation effect

Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008). Important features common to these groups include low program barriers (e.g., drop-in groups, few rules) and inclusiveness of clients with difficult presentations (Little & Franskoviak, 2010). 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. Indeed, there is anecdotal evidence that this may be the case; for example, a qualitative study of nonabstinence drug treatment in Denmark described a client saying that he would not have presented to abstinence-only treatment due to his goal of moderate use (Järvinen, 2017).

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  • As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014).
  • We also take the perspective that relapse is best conceptualized as a dynamic, ongoing process rather than a discrete or terminal event (e.g., [1,8,10]).
  • As an HR professional, Brie’s primary focus is on ensuring that our organization attracts and retains the most talented and qualified individuals to help us fulfill our mission of providing compassionate care to those struggling with addiction.

The focus is on identifying and accepting the urge, not acting on the urge or attempting to fight it4. Relapse prevention initially evolved as a calculated response to the longer-term treatment failures of other therapies. The assumption of RP is that it is problematic to expect that the effects of a treatment that is designed to moderate or eliminate an undesirable behaviour will endure beyond the termination of that treatment. Further, there are reasons to presume a problem will re-emerge on returning to the old environment that elicited and maintained the problem behaviour; for instance, forgetting the skills, techniques, and information taught during therapy; and decreased motivation5. In the multifaceted journey of overcoming addiction and living a healthier life, individuals often encounter a psychological phenomenon known as the abstinence violation effect (AVE). It sheds light on the challenges individuals face when attempting to maintain abstinence and how a single lapse can trigger a surge of negative emotions, potentially leading to a full relapse or a return to unhealthy living (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999).

Balanced lifestyle and Positive addiction

In a similar fashion, the nature of these attributions determines whether the violation will lead to full-blown relapse. The analysis was based on data from a randomized, double-blind, placebo-controlled clinical trial of high-dose nicotine patch for smoking cessation. Clinical outcomes have been reported elsewhere (Shiffman, Ferguson, & Gwaltney, 2006; Shiffman, Scharf, et al., 2006). Brie works closely with the leadership team to develop and implement effective HR strategies that support our organization’s goals and values. As an HR professional, Brie’s primary focus is on ensuring that our organization attracts and retains the most talented and qualified individuals to help us fulfill our mission of providing compassionate care to those struggling with addiction.

Outcomes in which relapse prevention may hold particular promise include reducing severity of relapses, enhanced durability of effects, and particularly for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity21. In addition to issues with administrative discharge, abstinence-only treatment may contribute to high rates of individuals not completing SUD treatment. About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). 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).

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]. The recently introduced dynamic model of relapse [8] takes many of the RREP criticisms into account. Additionally, the revised model has generated enthusiasm among researchers and clinicians who have observed these processes in their data and their clients [122,123]. Still, some have criticized the model for not emphasizing interpersonal factors as proximal or phasic influences [122,123]. Other critiques include that nonlinear dynamic systems approaches are not readily applicable to clinical interventions [124], and that the theory and statistical methods underlying these approaches are esoteric for many researchers and clinicians [14]. Rather than signaling weaknesses of the model, these issues could simply reflect methodological challenges that researchers must overcome in order to better understand dynamic aspects of behavior [45].

However, these interventions also typically lack an abstinence focus and sometimes result in reductions in drug use. Elucidating the «active ingredients» of CBT treatments remains an important and challenging goal. 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 abstinence violation effect work [126]. 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 [69]. Further, there was strong support that increases in self-efficacy following drink-refusal skills training was the primary mechanism of change.

2. Controlled drinking

Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. Many smoking cessation studies have sought to identify factors that influence cessation success versus failure. Rather than focusing on binary and distal relapse outcomes, our analyses aimed to advance understanding of factors that influence the dynamic process of recurrent lapse episodes recorded as participants attempted to maintain abstinence from smoking.

abstinence violation effect definition

Additionally, momentary coping responses can serve as phasic events that may determine whether a high-risk situation culminates in a lapse. Substance use and its immediate consequences (e.g., impaired decision-making, the AVE) are additional phasic processes that are set into motion once a lapse occurs. Thus, whereas tonic processes can determine who is vulnerable for relapse, phasic processes determine when relapse occurs [8,31]. Despite the empirical support for many components of the cognitive-behavioral model, there have also been many criticisms of the model for being too static and hierarchical. In response to these criticisms, Witkiewitz and Marlatt proposed a revision of the cognitive-behavioral model of relapse that incorporated both static and dynamic factors that are believed to be influential in the relapse process.