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

Perhaps the most notable gap identified by this review is the dearth of research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. 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. Ultimately, nonabstinence treatments may overlap significantly with abstinence-focused treatment models. Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness). 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.

  • 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.
  • Because the volume and scope of this work precludes an exhaustive review, the following section summarizes a select body of findings reflective of the literature and relevant to RP theory.
  • This can be worked on by creating a decisional matrix where the pros and cons of continuing the behaviour versus abstaining are written down within both shorter and longer time frames and the therapist helps the client to identify unrealistic outcome expectancies5.
  • 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).
  • However, if one lacks skills, then the model predicts a decrease in self-efficacy and an increase in positive outcome expectancies for the effects of using the substance.
  • Although non-dieters ate less after consuming the milkshakes, presumably because they were full, dieters paradoxically ate more after having the milkshake (Figure 1a).

The focus of CBT is manifold and the focus is on targeting maintaining factors of addictive behaviours and preventing relapse. Relapse prevention programmes are based on social cognitive and cognitive behavioural principles. More recent developments in the area of managing addictions include third wave behaviour therapies. Third wave behaviour therapies are focused on improving building awareness, and distress tolerance skills using mindfulness practices. These approaches have shown promise, and more recently the neurobiological underpinnings of mindfulness strategies have been studied. The article provides an overview of cognitive behavioural approaches to managing addictions.

1. Review aims

Role play, behavioural rehearsal and modeling are used to train patients in assertiveness. Patient is instructed not to provide explanations for abstinence so as to avoid counter arguments. Specific training steps to suit patients in the Indian setting have been described16,17. The Trans theoretical model (TTM), describes stages of behavioral change, processes of change and the decisional balance and self-efficacy which https://ecosoberhouse.com/ are believed to be intertwined to determine an individual’s behaviour11. Relapse Prevention (RP) is a cognitive-behavioral approach originally developed for treatment of addictions and has since become an effective and popular method for treating sexual offenders. The Abstinence Violation Effect (AVE) is a pivotal RP construct describing one’s cognitive and affective response to re-engaging in a prohibited behavior.

  • There are no specific time frames within which a person navigates through the stages, and may also remain at stage for a long time before moving forwards or backwards (for example a person may remain in the stage of contemplation or preparation for years without moving on to action).
  • 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).
  • In a subsequent meta-analysis by Irwin, twenty-six published and unpublished studies representing a sample of 9,504 participants were included.
  • Shiffman, Gwaltney and colleagues have used ecological momentary assessment (EMA; [44]) to examine temporal variations in SE in relation to smoking relapse.
  • It occurs when the client perceives no intermediary step between a lapse and relapse i.e. since they have violated the rule of abstinence, “they may get most out” of the lapse5.

” I refer to this as a case of the “screw-it’s” (although harsher language is not uncommon!); a sense of giving up. In a study by McCrady evaluating the effectiveness of psychological interventions for alcohol use disorder such as Brief Interventions and Relapse Prevention was classified as efficacious23. The myths related to substance use can be elicited by exploring the outcome expectancies as well as the cultural background of the client.

A Good Treatment Program Can Help You To Avoid The Abstinence Violation Effect

In addition to shaping mainstream addiction treatment, the abstinence-only 12-Step model also had an indelible effect on the field of SUD treatment research. Most scientists who studied SUD treatment believed that abstinence was the only acceptable treatment goal until at least the 1980s (Des Jarlais, 2017). Abstinence rates became the primary outcome for determining SUD treatment effectiveness (Finney, Moyer, & Swearingen, 2003; Kiluk, Fitzmaurice, Strain, & Weiss, 2019; Miller, 1994; Volkow, 2020), a standard which persisted well into the 1990s (Finney et al., 2003). Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. The AVE was introduced into the substance abuse literature within the context of the “relapse process” (Marlatt and Gordon 1985, p. 37).

  • 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.
  • One study found that among those who did not complete an abstinence-based (12-Step) SUD treatment program, ongoing/relapse to substance use was the most frequently-endorsed reason for leaving treatment early (Laudet, Stanick, & Sands, 2009).
  • If the reason for the violation is attributed to internal, stable, and/or global factors, such as lack of willpower or possession of an underlying disease, then the individual is more likely to have a full-blown relapse after the initial violation occurs.
  • The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.
  • There are two major types of high-risk situations, those with intrapersonal determinants, in which the person’s response is physical or psychological in nature, and interpersonal determinants, those that are influenced by other individuals or social networks.
  • One study published in the Journal of Health Communication found the “Not Me, Not Now” campaign in Monroe County, New York, was strongly connected to a decline in teen pregnancy rates for that county.

The technique involves exposure to a hierarchy of cues, which signal craving and subsequently substance use. These are presented repeatedly without the previously learned pattern of drinking so as to lead to extinction. Despite work on cue reactivity, there is limited abstinence violation effect empirical support for the efficacy of cue exposure in recent literature14. As seen in Rajiv’s case illustration, internal (social anxiety, craving) and external cues (drinking partner, a favourite brand of drink) were identified as triggers for his craving.

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