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

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.

Ecological momentary assessment of temptations and lapses in non-daily smokers

Additionally, the support of a solid social network and professional help can play a pivotal role. Encouragement and understanding from friends, family, or support groups can help individuals overcome the negative emotional aftermath of the AVE. Explore the benefits of an individualized treatment plan for addiction counseling and why it’s a game-changer on the path to recovery. Getting through the holidays while maintaining recovery, especially for people newer to this life-changing process, is an accomplishment worthy of celebration in its own right. When an urge to use hits, it can be helpful to engage the brain’s reward pathway in an alternative direction by quickly substituting a thought or activity that’s more beneficial or fun— taking a walk, listening to a favorite piece of music.

Cognitive Behavioural model of relapse

Instead of surrendering to the negative spiral, individuals can benefit from reframing the lapse as a learning opportunity and teachable moment. Recognizing the factors that contributed to the lapse, such as stressors or triggers, helps individuals to develop strategies and techniques to navigate similar challenges in the future. Note that these script ideas were pulled from a UN training on cognitive behavioral therapy that is available online.

Self-control and coping responses

• 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).
• Furthermore, the strength of proximal influences on relapse may vary based on distal risk factors, with these relationships becoming increasingly nonlinear as distal risk increases [31].
• These covert antecedents include lifestyle factors, such as overall stress level, one’s temperament and personality, as well as cognitive factors.
• More recent versions of RP have included mindfulness-based techniques (Bowen, Chawla, & Marlatt, 2010; Witkiewitz et al., 2014).

We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. 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. For example, it has been shown that self-efficacy for abstinence can be manipulated [137]. Thus, one could test whether increasing self-efficacy in an experimental design is related to better treatment outcomes. 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.

• Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse.
• Multiple theories of motivation for behavior change support the importance of self-selection of goals in SUD treatment (Sobell et al., 1992).
• In high-risk situations, the person expects alcohol to help him or her cope with negative emotions or conflict (i.e. when drinking serves as “self-medication”).
• Additionally, we review the nascent but rapidly growing literature on genetic predictors of relapse following substance use interventions.
• They assume a distinction between stress coping skills, which are responses intended to deal with general life stress, and temptation coping skills, which are coping responses specific to situations in which there are temptations for substance which could contribute to relapse13.

In a prospective study among both men and women being treated for alcohol dependence using the Situational Confidence Questionnaire, higher self-efficacy scores were correlated to a longer interval for relapse to alcohol use8. The relationship between self-efficacy and relapse is possibly bidirectional, meaning that individuals who are more successful report greater self-efficacy and individuals who have lapsed report lower self-efficacy4. Chronic stressors may also overlap between self-efficacy and other areas of intrapersonal determinants, like emotional states, by presenting more adaptational strain on the treatment-seeking client4. Additionally, this model acknowledges the contributions of social cognitive constructs to the maintenance of substance use or addictive behaviour and relapse1.

Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches. 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). In terms of clinical applications abstinence violation effect of RP, the most notable development in the last decade has been the emergence and increasing application of Mindfulness-Based Relapse Prevention (MBRP) for addictive behaviors [112,113]. 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.

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. In the case of addiction, brains have been changed by behavior, and changing them back is not quick. Research shows that those who forgive themselves for backsliding into old behavior perform better in the future.

Relapse road maps

Because the scope of this literature precludes an exhaustive review, we highlight select findings that are relevant to the main tenets of the RP model, in particular those that coincide with predictions of the reformulated model of relapse. Using a wave metaphor, urge surfing is an imagery technique to help clients gain control over impulses to use drugs or alcohol. In this technique, the client is first taught to label internal sensations and cognitive preoccupations as an urge, and to foster an attitude of detachment from that urge. The focus is on identifying and accepting the urge, not acting on the urge or attempting to fight it4. Various psychological factors were significant in initiating and maintaining Rajiv’s dependence on alcohol. At the start of treatment, Rajiv was not keen engage to in the process of recovery, having failed at multiple attempts over the years (motivation to change, influence of past learning experiences with abstinence).

Mechanisms of treatment effects

• 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.
• Training in assertiveness involves two steps, a minimal effective response and escalation.
• In CBT for addictive behaviours cognitive strategies are supported by several behavioural strategies such as coping skills.
• The terms “relapse” and “relapse prevention” have seen evolving definitions, complicating efforts to review and evaluate the relevant literature.

Viewing a lapse as a personal failure may lead to feelings of guilt and abandonment of the behavior change goal [24]. This reaction, termed the Abstinence Violation Effect (AVE; [16]), is considered more likely when one holds a dichotomous view of relapse and/or neglects to consider situational explanations for lapsing. In sum, the RP framework emphasizes high-risk contexts, coping responses, self-efficacy, affect, expectancies and the AVE as primary relapse antecedents. A basic assumption is that relapse events are immediately preceded by a high-risk situation, broadly defined as any context that confers vulnerability for engaging in the target behavior. Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal). Although some high-risk situations appear nearly universal across addictive behaviors (e.g., negative affect; [25]), high-risk situations are likely to vary across behaviors, across individuals, and within the same individual over time [10].