In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature. The most promising pharmacogenetic evidence in alcohol interventions concerns the OPRM1 A118G polymorphism as a moderator of clinical response to naltrexone (NTX). An initial retrospective analysis of NTX trials found that OPRM1 influenced treatment response, such that individuals with the Asp40 variant (G allele) receiving NTX had a longer time until the first heavy drinking day and were half as likely to relapse compared to those homozygous for the Asn40 variant (A allele) [92]. This finding was later extended in the COMBINE study, such that G carriers showed a greater proportion of days abstinent and a lower proportion of heavy drinking days compared in response to NTX versus placebo, whereas participants homozygous for the A allele did not show a significant medication response [93]. Moreover, 87.1% of G allele carriers who received NTX were classified as having a good clinical outcome at study endpoint, versus 54.5% of Asn40 homozygotes who received NTX. (Moderating effects of OPRM1 were specific to participants receiving medication management without the cognitive-behavioral intervention [CBI] and were not evident in participants receiving NTX and CBI).
- Substance use and its immediate consequences (e.g., impaired decision-making, the AVE) are additional phasic processes that are set into motion once a lapse occurs.
- Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991).
- Regarding SUD treatment, there has been a significant increase in availability of medication for opioid use disorder, especially buprenorphine, over the past two decades (opioid agonist therapies including buprenorphine are often placed under the “umbrella” of harm reduction treatments; Alderks, 2013).
Relapse prevention for addictive behaviors
Overall, many basic tenets of the RP model have received support and findings regarding its clinical effectiveness have generally been supportive. RP modules are standard to virtually all psychosocial interventions for substance use [17] and an increasing number of self-help manuals are available to assist both therapists and clients. RP strategies can now be disseminated using simple but effective methods; for instance, mail-delivered RP booklets are shown to reduce smoking relapse [135,136]. As noted abstinence violation effect earlier, the broad influence of RP is also evidenced by the current clinical vernacular, as “relapse prevention” has evolved into an umbrella term synonymous with most cognitive-behavioral skills-based interventions addressing high-risk situations and coping responses. While attesting to the influence and durability of the RP model, the tendency to subsume RP within various treatment modalities can also complicate efforts to systematically evaluate intervention effects across studies (e.g., [21]).
Effects of short-term abstinence from alcohol on subsequent drinking patterns of social drinkers
Tonic processes include distal risks–stable background factors that determine an individual’s “set point” or initial threshold for relapse [8,31]. Personality, genetic or familial risk factors, drug sensitivity/metabolism and physical withdrawal profiles are examples of distal variables that could influence relapse liability a priori. Tonic processes also include cognitive factors that show relative stability over time, such as drug-related outcome expectancies, global self-efficacy, and personal beliefs about abstinence or relapse. Whereas tonic processes may dictate initial susceptibility to relapse, its occurrence is determined largely by phasic responses–proximal or transient factors that serve to actuate (or prevent) a lapse. Phasic responses include cognitive and affective processes that can fluctuate across time and contexts–such as urges/cravings, mood, or transient changes in outcome expectancies, self-efficacy, or motivation.
Neurobiology of cue-reactivity, craving, and inhibitory control in non-substance addictive behaviors
Although withdrawal is usually viewed as a physiological process, recent theory emphasizes the importance of behavioral withdrawal processes [66]. Whereas physiological withdrawal symptoms tend to abate in the days or weeks following drug cessation, the unavailability of a conditioned behavioral coping response (e.g., the ritual of drug administration) may leave the former user ill-equipped to cope with ongoing stressors, thus exacerbating and/or prolonging symptoms [66]. Current theory and research indicate that physiological components of drug withdrawal may be motivationally inert, with the core motivational constituent of withdrawal being negative affect [25,66]. Thus, examining withdrawal in relation to relapse may only prove useful to the extent that negative affect is assessed adequately [64]. Relapse poses a fundamental barrier to the treatment of addictive behaviors by representing the modal outcome of behavior change efforts [1-3]. For instance, twelve-month relapse rates following alcohol or tobacco cessation attempts generally range from 80-95% [1,4] and evidence suggests comparable relapse trajectories across various classes of substance use [1,5,6].
- One study found that the Asp40 allele predicted cue-elicited craving among individuals low in baseline craving but not those high in initial craving, suggesting that tonic craving could interact with genotype to predict phasic responses to drug cues [97].
- While AUD treatment studies commonly rely on guidelines set by government agencies regarding a “low-risk” or “nonhazardous” level of alcohol consumption (e.g., Enggasser et al., 2015), no such guidelines exist for illicit drug use.
- These findings may be informative for researchers who wish to incorporate genetic variables in future studies of relapse and relapse prevention.
A common pattern of self-regulation failure occurs for addicts and chronic dieters when they ‘fall off the wagon’ by consuming the addictive substance or violating their diets [5]. Marlatt coined the term abstinence violation effect to refer to situations in which addicts respond to an initial indulgence by consuming even more of the forbidden substance [11]. In one of the first studies to examine this effect, Herman and Mack experimentally violated the diets of dieters by requiring them to drink a milkshake, a high-calorie food, as part of a supposed taste perception study [27].
The expected drug effects do not necessarily correspond with the actual effects experienced after consumption. Based on operant conditioning, the motivation to use in a particular situation is based on the expected positive or negative reinforcement value of a specific outcome in that situation5. Both negative and positive expectancies are related to relapse, with negative expectancies being protective against relapse and positive expectancies being a risk factor for relapse4.
- Current theory and research indicate that physiological components of drug withdrawal may be motivationally inert, with the core motivational constituent of withdrawal being negative affect [25,66].
- Overall, the RP model is characterized by a highly ideographic treatment approach, a contrast to the “one size fits all” approach typical of certain traditional treatments.
- Consistent with the tenets of the reformulated RP model, several studies suggest advantages of nonlinear statistical approaches for studying relapse.
- 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.
Beyond its use as a methodological tool, the possibility of abstinence also being a potentially useful intervention for problematic behaviors needs to be given due consideration within behavioral addiction treatment research. If a behavior is causing problems, abstaining from the behavior appears (at face value) to be a logical solution. For instance, 12-step groups based on the original Alcoholics Anonymous (AA) model advocate an abstinence approach to compulsive behaviors, although abstinence goals across these groups may not always be absolute and may be more nuanced, depending on the behavior involved (Browne, 1991; Efrati & Gola, 2018). Some clinicians treating problematic sexual behavior have even suggested temporary (e.g., 90 days) ‘celibacy contracts’ of complete abstinence from any sexual behavior in early phases of treatment (Carnes, 1989).
Systematic reviews and large-scale treatment outcome studies
Dr Neighbors has authored more than 120 peer-reviewed scholarly publications, the majority of which have focused on addictive behaviors among young adults. There are many relapse prevention models used in substance abuse treatment to counter AVE and give those in recovery important tools and coping skills. 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. 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).
Journal of Behavioral Addictions
- Here the assessment and management of both the intrapersonal and interpersonal determinants of relapse are undertaken.
- This can create a cycle of self-recrimination and further substance use, making it challenging to maintain long-term abstinence.
- Equally bad can be the sense of failure and shame that a formerly “clean” individual can experience following a return to substance use.
- Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation, there is evidence for the effectiveness of relapse prevention compared with no treatment controls.
- Other more general strategies include helping the person develop positive addictions and employing stimulus-control and urge-management techniques.