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

Relative to the TAU group, the VM group reported significantly lower levels of substance use and alcohol-related consequences and improved psychosocial functioning at follow-up [116]. There is less research examining the extent to which moderation/controlled use goals are feasible for individuals with DUDs. The most recent national survey assessing rates of illicit drug use and SUDs found that among individuals who report illicit drug use in the past year, approximately 15% meet criteria for one or more DUD (SAMHSA, 2019a). About 10% of individuals who report cannabis use in the past year meet criteria for a cannabis use disorder, while this proportion increases to 18%, 19%, 58%, and 65% of those with past year use of cocaine, opioids (misuse), methamphetamine, and heroin, respectively. These data suggest that non-disordered drug use is possible, even for a substantial portion of individuals who use drugs such as heroin (about 45%).

Definitions of relapse and relapse prevention

• Relapse has been variously defined, depending on theoretical orientation, treatment goals, cultural context, and target substance (Miller, 1996; White, 2007).
• The studies reviewed focus primarily on alcohol and tobacco cessation, however, it should be noted that RP principles have been applied to an increasing range of addictive behaviors [10,11].
• As with all things 12-step, the emphasis on accumulating “time” and community reaction to a lapse varies profoundly from group to group, which makes generalizations somewhat unhelpful.
• 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).
• Relapse prevention (RP) is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours4.
• It is important to highlight that most of the studies cited above did not provide goal-matched treatment; thus, these outcomes generally reflect differences between individuals with abstinence vs. non-abstinence goals who participated in abstinence-based AUD treatment.

Stress and sleeplessness weaken the prefrontal cortex, the executive control center of the brain. Craving is an overwhelming desire to seek a substance, and cravings focus all one’s attention on that goal, shoving aside all reasoning ability. Perhaps the most important thing to know about cravings is that they do not last forever. It is also necessary to know that they are not a sign of failure; they are inevitable.

Balanced lifestyle and Positive addiction

• Mindfulness training, for example, can modify the neural mechanisms of craving and open pathways for executive control over them.
• Experts in addiction recovery believe that relapse is a process that occurs somewhat gradually; it can begin weeks or months before picking up a drink or a drug.
• Before any substance use even occurs, clinicians can talk to clients about the AVE and the cognitive distortions that can accompany it.
• Cognitive-behavioral theories also diverged from disease models in rejecting the notion of relapse as a dichotomous outcome.
• Creating a rewarding life that is built around personally meaningful goals and activities, and not around substance use, is essential.
• They may not recognize that stopping use of a substance is only the first step in recovery—what must come after that is building or rebuilding a life, one that is not focused around use.

If you’re currently lost within the confusion of the abstinence violation effect, we can help. We can give you resources to help you create or tweak your relapse prevention plan. This model notes that those who have the latter mindset are proactive and strive to learn from their mistakes. To do so, they adapt their coping strategies to better deal with future triggers should they arise. This protects their sobriety and enhances their ability to protect themselves from future threats of relapse. Jim is a recovering alcoholic who successfully abstained from drinking for several months.

• 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].
• Among the most important coping skills needed are strategies of distraction that can be quickly engaged when cravings occur.
• Another possible outcome of a lapse is that the client may manage to abstain and thus continue to go forward in the path of positive change, “prolapse”4.
• Addiction and related disorders are chronic lapsing and relapsing disorders where the combination of long term pharmacological and psychosocial managements are the mainstay approaches of management.

Cognitive Behavioural model of relapse

Also critical is building a support network that understands the importance of responsiveness. Not least is developing adaptive ways for dealing with negative feelings and uncertainty. Those ways are essential skills for everyone, whether recovering from addiction or not—it’s just that the stakes are usually more immediate for those in recovery. Many experts believe that people turn to substance use—then get trapped in addiction—in an attempt to escape from uncomfortable feelings. Changing bad habits of any kind takes time, and thinking about success and failure as all-or-nothing is counterproductive.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

It encourages people to see themselves as failures, attributing the cause of the lapse to enduring and uncontrollable internal factors, and feeling guilt and shame. Along with the client, the therapist the abstinence violation effect refers to needs to explore past circumstances and triggers of relapse. Also, the client is asked to keep a current record where s/he can self-monitor thoughts, emotions or behaviours prior to a binge.

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. Future research with a data set that includes multiple measures of risk factors over multiple days could also take advantage of innovative modeling tools that were designed for estimating nonlinear time-varying dynamics [125]. The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.

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. However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. The AVE was introduced into the substance abuse literature within the context of the “relapse process” (Marlatt and Gordon 1985, p. 37). Relapse has been variously defined, depending on theoretical orientation, treatment goals, cultural context, and target substance (Miller 1996; White 2007).

• In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001).
• The dynamic model further emphasizes the importance of nonlinear relationships and timing/sequencing of events.
• It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019).
• It was written based on peer-reviewed medical research, reviewed by medical and/or clinical experts, and provides objective information on the disease and treatment of addiction (substance use disorders).

What Can Clinicians Do To Counteract the AVE?

The expected drug effects do not necessarily correspond with the actual effects experienced after consumption. Based on operant conditioning, the motivation to use in a particular situation is based on the expected positive or negative reinforcement value of a specific outcome in that situation5. Both negative and positive expectancies are related to relapse, with negative expectancies being protective against relapse and positive expectancies being a risk factor for relapse4.

The reformulated cognitive-behavioral model of relapse