Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Relapse prevention includes understanding what triggers substance abuse, which varies from person to person. As an example, when out with friends at their favorite hangout, someone with alcohol use disorder may feel like having a drink. The Abstinence Violation Effect is a psychological phenomenon that occurs when a person experiences relapse after attempting to abstain from drug or alcohol use.

Computers in Human Behavior

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 abstinence violation effect nonabstinence treatments for drug use and address barriers to implementation. The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use.

Relapse to smoking

More recent versions of RP have included mindfulness-based techniques (Bowen, Chawla, & Marlatt, 2010; Witkiewitz et al., 2014). The RP model has been studied among individuals with both AUD and DUD (especially Cocaine Use Disorder, e.g., Carroll, Rounsaville, & Gawin, 1991); with the largest effect sizes identified in the treatment of AUD (Irvin, Bowers, Dunn, & Wang, 1999). As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014). Individuals with greater SUD severity tend to be most receptive to therapist input about goal selection (Sobell, Sobell, Bogardis, Leo, & Skinner, 1992). This suggests that treatment experiences and therapist input can influence participant goals over time, and there is value in engaging patients with non-abstinence goals in treatment.

Effects of short-term abstinence from alcohol on subsequent drinking patterns of social drinkers

As a result of AVE, a person may experience uncontrollable, stable attributions, and feelings of shame and guilt after a relapse. Unfortunately, a single lapse can cause you to fall into a full relapse because of something called the abstinence violation effect (AVE). It is not necessarily a failure of self-control nor a permanent failure to abstain from using a substance of abuse.

Clinical Psychology Review

In the United Kingdom, where there is greater acceptance of nonabstinence goals and availability of nonabstinence treatment (Rosenberg et al., 2020; Rosenberg & Melville, 2005), the rate of administrative discharge is much lower than in the U.S. (1.42% vs. 6% of treatment episodes; Newham, Russell, & Davies, 2010; SAMHSA, 2019b). When abstinence is violated, individuals typically also have an emotional response consisting of guilt, shame, hopelessness, loss of control, and/or a sense of failure; they may use drugs or alcohol in an attempt to cope with the negative feelings that resulted from their abstinence violation. A person may experience a particularly stressful emotional event in their lives and may turn to alcohol and/or drugs to cope with these negative emotions.

• The study was especially notable because most other treatment readiness measures have been validated on treatment-seeking samples (see Freyer et al., 2004).
• Overall, the Abstinence Violation Effect is a complex phenomenon influenced by a combination of cognitive, emotional, and biological factors.
• For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment.
• In the 1980s and 1990s, the HIV/AIDS epidemic prompted recognition of the role of drug use in disease transmission, generating new urgency around the adoption of a public health-focused approach to researching and treating drug use problems (Sobell & Sobell, 1995).

Decoupling Goal Striving From Resource Depletion by Forming Implementation Intentions

This model both accelerated the spread of AA and NA and helped establish the abstinence-focused 12-Step program at the core of mainstream addiction treatment. By 1989, treatment center referrals accounted for 40% of new AA memberships (Mäkelä et al., 1996). This standard persisted in SUD treatment even as strong evidence emerged that a minority of individuals who receive 12-Step treatment achieve and maintain long-term abstinence (e.g., Project MATCH Research Group, 1998). 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.

Cognitive Factors in Addictive Processes

• Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002).
• If they drink or drug again, they can slip into full-blown relapse, even after months or years of abstinence.
• However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD.
• 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).
• Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010).

Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. 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). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness. This resistance to nonabstinence treatment persists despite strong theoretical and empirical arguments in favor of harm reduction approaches. 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.