Although withdrawal is usually viewed as a physiological process, recent theory emphasizes the importance of behavioral withdrawal processes . Withdrawal tendencies can develop early in the course of addiction and symptom profiles can vary based on stable intra-individual factors , suggesting the involvement of tonic processes. Additionally, the intervention had no effect on subjective measures of craving, suggesting the possibility that intervention effects may have been specific to implicit cognitive processes . Relative to a control condition, ABM resulted in significantly improved ability to disengage from alcohol-related stimuli during attentional bias tasks. One study found that smokers’ attentional bias to tobacco cues predicted early lapses during a quit attempt, but this relationship was not evident among people receiving nicotine replacement therapy, who showed reduced attention to cues .
Also, many studies have focused solely on pharmacological interventions, and are therefore not directly related to the RP model. It is important to note that these studies were not designed to evaluate specific components of the RP model, nor do these studies explicitly espouse the RP model. Given the rapid growth in this area, we allocate a portion of this review to discussing initial evidence for genetic associations with relapse.
- Finally, the results of Miller and colleagues (1996) support the role of the abstinence violation effect in predicting which participants would experience a full-blown relapse following an initial lapse.
- We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research.
- It has also been shown to promote a decrease in symptoms of anxiety, depression, and specific phobias, all which have a comorbid relationship with substance use disorders.
- There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment.
- This may be at least in part because of the high prevalence of polysubstance use; indeed, multiple SUD diagnoses are the norm rather than the exception (Rounsaville, Petry, & Carroll, 2003), and about 1 in 8 individuals with SUD have co-occurring AUD and DUD (SAMHSA, 2019a).
Changing how recovery is viewed
Advocates of managed alcohol programs also note that individuals with severe AUD and structural vulnerabilities often have low interest in and utilization of abstinence-oriented treatment, and that these treatments are less effective for this population (Ivsins et al., 2019), though there is limited research examining these claims. A primary concern regarding nonabstinence goals is that individuals with SUD will not be able to achieve moderate or controlled use. The abstinence violation effect is believed to result from an inflexible, binary view that those with SUD are only capable of abstinence or disordered use; thus, any substance use is equated with a “full-blown reversal” or treatment failure (Miller, 1996, p. S22). In this context, researchers have argued that strategies for managing returns to substance use are essential components of effective SUD treatment, and that inflexibility around abstinence can lead to poorer outcomes (Larimer, Palmer, & Marlatt, 1999; Miller, 1996).
Continued empirical evaluation of the RP model
- 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 .
- The Relapse Prevention (RP) model has been a mainstay of addictions theory and treatment since its introduction three decades ago.
- One study found that smokers’ attentional bias to tobacco cues predicted early lapses during a quit attempt, but this relationship was not evident among people receiving nicotine replacement therapy, who showed reduced attention to cues .
- Research supports that expectancies could partly mediate influences such as personality factors , genetic variations 51,52, and negative affect on drinking.
- The realization that HIV had been spreading widely among people who injected drugs in the mid-1980s led to the first syringe services programs (SSPs) in the U.S. (Des Jarlais, 2017).
For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986). Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008). There were no significant differences in problems related to other drug or alcohol use, medical issues, family, or employment at months 6 or 12 (Roos et al., 2019). Indeed, a prominent harm reduction psychotherapist and researcher, Rothschild, argues that the harm reduction approach represents a “third wave of addiction treatment” which follows, and is replacing, the moral and disease models (Rothschild, 2015a). 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). 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).
Genetic influences on relapse have been studied most extensively in the context of pharmacogenetics, with the bulk of studies focusing on nicotine dependence (for recent reviews see 83,84). Second, the likelihood of abstinence following a behavioral or pharmacological intervention can be moderated by genetic influences on metabolic processes, receptor activity/expression, and/or incentive value specific to the addictive substance in question. Broadly speaking, there are at least three primary contexts in which genetic variation could influence liability for relapse during or following treatment. Specifically, we focus on recent, representative findings from studies evaluating candidate single nucleotide polymorphisms (SNPs) as moderators of response to substance use interventions.
Outcome expectancies
As the client gains new skills and feels successful in implementing them, he or she can view the process of change as similar to other what is end-stage alcoholism situations that require the acquisition of a new skill. In the RP model, the client is encouraged to adopt the role of colleague and to become an objective observer of his or her own behavior. One of the most important efficacy-enhancing strategies employed in RP is the emphasis on collaboration between the client and therapist instead of a more typical “top down” doctor-patient relationship.
Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence. Research on nonabstinence DUD treatment has generally focused on medication for opioid use disorder (OUD), including the opioid agonist medications methadone and buprenorphine (Drucker, Anderson, & Haemmig, 2016), while very few studies have examined psychosocial DUD treatments. One mechanism theorized to explain this finding is the “abstinence violation effect,” which refers to a negative cognitive and affective response experienced after a return to substance use that contributes to more severe and problematic episodes of use (Marlatt & Gordon, 1985).
2. Relationship between goal choice and treatment outcomes
People susceptible to AVE are theorized to engage in all-or-nothing thinking in which they interpret any use as total failure and not as a temporary setback. Encyclopedia of behavioral medicine. These groups can help you understand that you are not alone; others have had your concerns, and you can learn helpful information from these groups to help you with your goals. Positive—I know I can do this because I have already shown it, I have a dedicated support network, and I can continue this journey one day at a time. I can use this lapse as a teachable moment—progress, not perfection. For example, I am a failure (labeling) and will never be successful with abstaining from drinking, eating healthier, or exercising (jumping to conclusions).
Mindfulness-based relapse prevention
Thus, one could test whether increasing self-efficacy in an experimental design is related to better treatment outcomes. Although many developments over the last decade encourage confidence in the RP model, additional research is needed to test its predictions, limitations and applicability. RP modules are standard to virtually all psychosocial interventions for substance use and an increasing number of self-help manuals are available to assist both therapists and clients. 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. Over the past decade RP principles have been incorporated across an increasing array of behavior domains, with addictive behaviors continuing to represent the primary application. Implicit cognitive processes are also being examined as an intervention target, with some potentially promising results .
As a result of identifying those warning signals, the client may be able to take some evasive action (e.g., escape from the situation) or possibly avoid the high-risk situation entirely. Such warning signals to be recognized may include, for example, AIDs, stress and lack of lifestyle balance, and strong positive expectances about drinking. Even in clients who have already become abstinent, self-monitoring can still be used to assess situations in which urges are more prevalent. Ongoing cravings, in turn, may erode the client’s commitment to maintaining abstinence as his or her desire for immediate gratification increases.
Based on the classification of relapse determinants and high-risk situations proposed in the RP model, numerous treatment components have been developed that are aimed at helping the recovering alcoholic cope with high-risk situations. Finally, therapists can assist clients with developing relapse road maps—that is, cognitive-behavioral analyses of high-risk situations that emphasize the different choices available to clients for avoiding or coping with these situations as well as their consequences. The cognitive-behavioral model of the relapse process posits a central role for high-risk situations and for the drinker’s response to those situations. However, it is also possible that adaptations will be needed for individuals with nonabstinence goals (e.g., additional support with goal setting and monitoring drug use; ongoing care to support maintenance goals), and currently there is a dearth of research in this area. This could include further evaluating established intervention models (e.g., MI and RP) among individuals with DUD who have nonabstinence goals, adapting existing abstinence-focused treatments (e.g., Contingency Management) to nonabstinence applications, and testing the efficacy of newer models (e.g., harm reduction psychotherapy). Given low treatment engagement and high rates of health-related harms among individuals who use drugs, combined with evidence of nonabstinence goals among a substantial portion of treatment-seekers, testing nonabstinence treatment for drug use is a clear next step for the field.
Findings also suggested that these relationships varied based on individual differences, suggesting the interplay of static and dynamic factors in AVE responses. Shiffman and colleagues found that restorative coping following a smoking lapse decreased the likelihood of a second lapse the same day. One study found that momentary coping differentiated smoking lapses from temptations, such that coping responses were reported in 91% of successful resists vs. 24% of lapses. One study found evidence suggesting a feedback cycle of mood and drinking whereby elevated daily levels of NA predicted alcohol use, which in turn predicted spikes in NA. Knowledge about the role of NA in drinking behavior has benefited from daily process studies in which participants provide regular reports of mood and drinking. Heavier and more frequent alcohol use predicted a greater probability of high negative affect and increased negative affect over time.
Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization. There are significant practical barriers to treatment access in much of the U.S. (e.g., availability of treatment, distance from treatment, cost, lack of insurance; Park-Lee, Lipari, Hedden, Kroutil, & Porter, 2017, Priester et al., 2016), but evidence suggests these barriers account for only part of the disparity between the need for and receipt of treatment. For those who do receive treatment, about 30% of all psychosocial SUD treatment episodes are terminated prematurely (including all causes; Lappan, Brown, & Hendricks, 2020).
1.1. Harm reduction treatments specific to alcohol use disorder
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. In such a matrix, the client lists both the positive and negative immediate and delayed consequences of remaining abstinent versus resuming drinking. In addition, specific cognitive-behavioral skills training approaches, such as relaxation training, stress-management, and time management, can be used to help clients achieve greater lifestyle balance. This reframing of lapse episodes can help decrease the clients’ tendency to view lapses as the result of a personal failing or moral weakness and remove the self-fulfilling prophecy that a lapse will inevitably lead to relapse. This perspective considers lapses key learning opportunities resulting from an interaction between coping and situational determinants, both of which can be modified in the future. Thus, clients are taught to reframe their perception of lapses—to view them not as failures or indicators of a lack of willpower but as mistakes or errors in learning that signal the need for increased planning to cope more effectively in similar situations in the future.
Whereas tonic processes may dictate initial susceptibility to relapse, its occurrence is determined largely by phasic responses–proximal or transient factors that serve to actuate (or prevent) a lapse. Against this backdrop, both tonic (stable) and phasic (transient) influences interact to determine relapse likelihood. 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.
A therapist can help you with self-compassion, restructuring negative thinking, exploring coping strategies, and support you with the goals you have set for yourself. The current review highlights multiple directions for future research, including testing the effectiveness of nonabstinence treatments for drug use and addressing barriers to implementation. Though decades of empirical evidence support nonabstinence interventions for AUD, there is a clear gap in research examining nonabstinence psychosocial treatment for DUDs. Thus, while it is vital to empirically test nonabstinence treatments, implementation research examining strategies to obtain buy-in from agency leadership may be just as impactful. Additional research is needed to further examine this relationship; for example, researchers who develop and test interventions to reduce drug use stigma may also consider whether these interventions could lead to greater acceptance of nonabstinence outcomes among treatment providers. Low acceptance of nonabstinence goals among providers remains a significant barrier to implementing nonabstinence SUD treatments (Rosenberg et al., 2020), even for AUD treatments with established effectiveness.
Irrespective of study design, greater integration of distal and proximal variables will aid in modeling the interplay of tonic and phasic influences on relapse outcomes. Ideally, assessments of coping, interpersonal stress, self-efficacy, craving, mood, and other proximal factors could be collected multiple times per day over the course of several months, and combined with a thorough pre-treatment assessment battery of distal risk factors. The merger of mindfulness and cognitive-behavioral approaches is appealing from both theoretical and practical standpoints and MBRP is a potentially effective and cost-efficient adjunct to CBT-based treatments. Findings from numerous non-treatment studies are also relevant to the possibility of genetic influences on relapse processes. In another psychosocial treatment study, researchers in Poland examined genetic moderators of relapse following inpatient alcohol treatment . In a secondary analysis of the Project MATCH data, researchers evaluated posttreatment drinking outcomes in relation to a GABRA2 variant previously implicated in the risk for alcohol dependence .
