There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge. Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance abstinence violation effect use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008). 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). In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008). Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation. Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged.
Is a Relapse Dangerous?
CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript. SD assisted with conceptualization of the review, and SD and KW both identified relevant literature for the review and provided critical review, commentary and revision. Considering the numerous developments related to RP over the last decade, empirical and clinical extensions of the RP model will undoubtedly continue to evolve. In addition to the recent advances outlined above, we highlight selected areas that are especially likely to see growth over the next several years. This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
False Sense of Control – One Drink Won’t Hurt
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 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.
The Abstinence Violation Effect Following Smoking Lapses and Temptations
- Moreover, 87.1% of G allele carriers who received NTX were classified as having a good clinical outcome at study endpoint, versus 54.5% of Asn40 homozygotes who received NTX.
- This is called the abstinence violation effect; since we have already “fallen off the wagon,” we might as well go the whole way.
- 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.
- Upon breaking the self-imposed rule, individuals often experience negative emotions such as guilt, shame, disappointment, and a sense of failure.
Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. 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; drug addiction treatment Kiluk et al., 2019). While AUD treatment studies commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity). 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.
- 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.
- Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985).
- For instance, twelve-month relapse rates following alcohol or tobacco cessation attempts generally range from 80-95% 1,4 and evidence suggests comparable relapse trajectories across various classes of substance use 1,5,6.
- An additional concern is that the lack of research supporting the efficacy of established interventions for achieving nonabstinence goals presents a barrier to implementation.
- Given supportive data for the efficacy of mindfulness-based interventions in other behavioral domains, especially in prevention of relapse of major depression 114, there is increasing interest in MBRP for addictive behaviors.
- The RP model developed by Marlatt 7,16 provides both a conceptual framework for understanding relapse and a set of treatment strategies designed to limit relapse likelihood and severity.
The Abstinence Violation Effect and Overcoming It
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). A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.
