This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD. We define nonabstinence treatments as those without an explicit goal of abstinence from psychoactive substance use, including treatment aimed at achieving moderation, reductions in use, and/or reductions in substance-related harms. We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research. 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. Because relapse is the most common outcome of treatment for addictions, it must be addressed, anticipated, and prepared for during treatment.
Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a). Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization. Instead, the literature indicates that most people with SUD do not want or need – or are not ready for – what the current treatment system is offering. In psychotherapy, an abstinence violation effect refers to the negative cognitive and affective reactions one experiences after returning to substance use after a period of abstinence. As a result of AVE, a person may experience uncontrollable, stable attributions, and feelings of shame and guilt after a relapse. Does it mean a person must continue to drink or drug until the use returns to the initial level?
2. Relationship between goal choice and treatment outcomes
The hallmark of CBT is collaborative empiricism and describes the nature of therapeutic relationship. 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). Patterns of movement through the various stages are categorized as stable, progressive or unstable11. (a) When restrained eaters’ diets were broken by consumption of a high-calorie milkshake preload, they subsequently show disinhibited eating (e.g. increased grams of ice-cream consumed) compared to control subjects and restrained eaters who did not drink the milkshake (figure based on data from ). (b) Restrained eaters whose diets were broken by a milkshake preload showed increased activity in the nucleus accumbens (NAcc) compared to restrained eaters who did not consume the preload and satiated non-dieters . In addition to this, booster sessions over at least a 12 month period are advisable to ensure that a safety net is available since gamblers are renown for not recontacting sufficiently hastily when difficulties arise.
Alternatively, researchers who conduct trials in community-based treatment centers will need to obtain buy-in to test nonabstinence approaches, which may necessitate waiving facility policies regarding drug use during treatment – a significant hurdle. 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. Those in addiction treatment or contemplating treatment can benefit from this aspect of relapse prevention.
2. Established treatment models compatible with nonabstinence goals
Also, the client is asked to keep a current record where s/he can self-monitor thoughts, emotions or behaviours prior to a binge. One is to help clients identify warning signs such as on-going stress, seemingly irrelevant decisions and significant positive outcome expectancies with the substance so that they can avoid the high-risk situation. The second is assessing coping skills of the client and imparting general skills such as relaxation, meditation abstinence violation effect definition or positive self-talk or dealing with the situation using drink refusal skills in social contexts when under peer pressure through assertive communication6. One of the most critical predictors of relapse is the individual’s ability to utilize effective coping strategies in dealing with high-risk situations. Coping is defined as the thoughts and behaviours used to manage the internal and external demands of situations that are appraised as stressful.
For example, Bandura, who developed Social Cognitive Theory, posited that perceived choice is key to goal adherence, and that individuals may feel less motivation when goals are imposed by others (Bandura, 1986). Miller, whose seminal work on motivation and readiness for treatment led to multiple widely used measures of SUD treatment readiness and the development of Motivational Interviewing, also argued for the importance of goal choice in treatment (Miller, 1985). Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches.
4. Consequences of abstinence-only treatment
A physical relapse occurs when you take your first drug or drink after achieving sobriety. Marlatt differentiates between slipping into abstinence for the first time and totally abandoning the goal. 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 current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment.
- In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985).
- Put simply, the AVE occurs when a client perceives no intermediary step between a lapse and a relapse.
- This may be due to the fact that the vast majority of participants (78%) consumed alcohol during the trial, such that the drinking mediated effects of naltrexone were not restricted to patients with controlled drinking goals.
- Participants with a goal of controlled drinking had the worst drinking outcomes, whereas those with a conditional abstinence goal comprise an intermediate group between complete abstinence and controlled drinking.
Likewise, further research should consider matching patients’ drinking goals to specific treatment modalities, whether behavioral or pharmacological in nature. Earlier research utilizing drug use goals analogous to goals used in the present study found commitment to absolute abstinence, measured at the end of treatment, to predict days to relapse across nicotine, alcohol, and opiate dependence (Hall & Havassy, 1986; Hall, Havassy, & Wasserman, 1990). These findings were such that participants committed to complete abstinence took longer to slip and longer to relapse, defined as drug use on four or more days in a week. Critically, Hall et al. (1986, 1990) examined participants with an abstinence goal allowing for occasional slips and found that these participants did not fare as well as participants with complete abstinence goals. Relapse prevention (RP) is a cognitive behavioural treatment program, based on the relapse prevention model27,28.