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%). However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD. Understanding the AVE is crucial for individuals in recovery and those focused on healthier lifestyle choices.
Specific Intervention Strategies
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. There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment. Among those seeking treatment for alcohol use disorder (AUD), studies with large samples have cited rates of nonabstinence goals ranging from 17% (Berglund et al., 2019) to 87% (Enggasser et al., 2015).
1. Nonabstinence treatment effectiveness
In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010). In the U.S., about 25% of patients seeking treatment for AUD endorsed nonabstinence goals in the early 2010s (Dunn & Strain, 2013), while more recent clinical trials have found between 82 and 91% of those seeking treatment for AUD prefer nonabstinence goals (Falk et al., 2019; Witkiewitz et al., 2019). Rather, when people with SUD are surveyed about reasons they are not in treatment, not being ready to stop using substances is consistently the top reason cited, even among individuals who perceive a need for treatment (SAMHSA, 2018, 2019a). 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.
Overcoming the Abstinence Violation Effect:
If the person succumbs to the urge and violates their self-imposed rule, the Abstinence Violation Effect is activated. There may be an internal conflict abstinence violation effect between resisting thoughts about drugs and compulsions to use them. There is a possibility that you might rationalize why you might not experience the same consequences if you continue to use.
- Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process.
- Global self-control strategies are designed to modify the client’s lifestyle to increase balance as well as to identify and cope with covert antecedents of relapse (i.e., early warning signals, cognitive distortions, and relapse set-ups).
- Marlatt differentiates between slipping into abstinence for the first time and totally abandoning the goal.
- Positive expectancies regarding alcohol’s effects often are based on myths or placebo effects of alcohol (i.e., effects that occur because the drinker expects them to, not because alcohol causes the appropriate physiological changes).
- People who attribute the lapse to their own personal failure are likely to experience guilt and negative emotions that can, in turn, lead to increased drinking as a further attempt to avoid or escape the feelings of guilt or failure.
- The limit violation effect describes what happens when these individuals fail to restrict their use within their predetermined limits and the subsequent effects of this failure.
About 26% of all U.S. treatment episodes end by individuals leaving the treatment program prior to treatment completion (SAMHSA, 2019b). Studies which have interviewed participants and staff of SUD treatment centers have cited ambivalence about abstinence as among the top reasons for premature treatment termination (Ball, Carroll, Canning-Ball, & Rounsaville, 2006; Palmer, Murphy, Piselli, & Ball, 2009; Wagner, Acier, & Dietlin, 2018). 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). A recent qualitative study found that concern about missing substances was significantly correlated with not completing treatment (Zemore, Ware, Gilbert, & Pinedo, 2021).
Longitudinal investigation of the abstinence violation effect in binge eaters
- Thus, instead of focusing on a distant end goal (e.g., maintaining lifelong abstinence), the client is encouraged to set smaller, more manageable goals, such as coping with an upcoming high-risk situation or making it through the day without a lapse.
- The Minnesota Model involved inpatient SUD treatment incorporating principles of AA, with a mix of professional and peer support staff (many of whom were members of AA), and a requirement that patients attend AA or NA meetings as part of their treatment (Anderson, McGovern, & DuPont, 1999; McElrath, 1997).
- Before you know it, you’re back in the old pattern—hangovers, drunk arguments, the endless obsession around the wine o’clock.
- Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008).
- Two publications, Cognitive Behavioral Coping Skills Training for Alcohol Dependence (Kadden et al., 1994; Monti, Kadden, Rohsenow, Cooney, & Abrams, 2002) and Cognitive Behavioral Therapy for Cocaine Addiction (Carroll, 1998), are based on the RP model and techniques.
Indeed, this argument has been central to advocacy around harm reduction interventions for people who inject drugs, such as SSPs and safe injection facilities (Barry et al., 2019; Kulikowski & Linder, 2018). 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). This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention.
MeSH terms
CBT treatments are usually guided by a manual, are relatively short term (12 to 16 weeks) in duration, and focus on the present and future. Clients are expected to monitor substance use (see Table 8.1) and complete homework exercises between sessions. The second strategy, which is possibly the most important aspect of RP, involves evaluating the client’s existing motivation and ability to cope with specific high-risk situations and then helping the client learn more effective coping skills. The desire for immediate gratification can take many forms, and some people may experience it as a craving or urge to use alcohol. Although many researchers and clinicians consider urges and cravings primarily physiological states, the RP model proposes that both urges and cravings are precipitated by psychological or environmental stimuli. Ongoing cravings, in turn, may erode the client’s commitment to maintaining abstinence as his or her desire for immediate gratification increases.
Normalize Relapse
Therapists also can enhance self-efficacy by providing clients with feedback concerning their performance on other new tasks, even those that appear unrelated to alcohol use. In general, success in accomplishing even simple tasks (e.g., showing up for appointments on time) can greatly enhance a client’s feelings of self-efficacy. This success can then motivate the client’s effort to change his or her pattern of alcohol use and increase the client’s confidence that he or she will be able to successfully master the skills needed to change. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment. We summarize historical factors relevant to non-abstinence treatment development to illuminate reasons these approaches are understudied. Addressing the AVE in the context of addiction treatment involves helping people develop healthier coping strategies and challenging negative beliefs that contribute to addiction.
- Participants with controlled use goals in this center are typically able to achieve less problematic (38%) or non-problematic (32%) use, while a minority achieve abstinence with (8%) or without (6%) incidental relapse (outcomes were not separately assessed for those with AUD vs. DUD; Schippers & Nelissen, 2006).
- Those in addiction treatment or contemplating treatment can benefit from this aspect of relapse prevention.
- Therefore, one global self-management strategy involves encouraging clients to pursue again those previously satisfying, non-drinking recreational activities.
- While relapse doesn’t mean you can’t achieve lasting sobriety, it can be a disheartening setback in your recovery.
Theoretical and empirical rationale for nonabstinence treatment
These choices have been termed “apparently irrelevant decisions” (AIDs), because they may not be overtly recognized as related to relapse but nevertheless help move the person closer to the brink of relapse. 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. It is essential to understand what individuals with SUD are rejecting when they say they do not need treatment. In this model, treatment success is defined as achieving and sustaining total abstinence from alcohol and drugs, and readiness for treatment is conflated with commitment to abstinence (e.g., Harrell, Trenz, Scherer, Martins, & Latimer, 2013).