Testing the model’s components will require that researchers avail themselves of innovative assessment techniques (such as EMA) and pursue cross-disciplinary collaboration in order to integrate appropriate statistical methods. Irrespective of study design, greater integration of distal and proximal variables will aid in modeling the interplay of tonic and phasic influences on relapse outcomes. As was the case for Marlatt’s original RP model, efforts are needed to systematically evaluate specific theoretical components of the reformulated model [1].
Cognitive neuroscience of self-regulation failure
- These covert antecedents include lifestyle factors, such as overall stress level, one’s temperament and personality, as well as cognitive factors.
- Importantly, there has also been increasing acceptance of non-abstinence outcomes as a metric for assessing treatment effectiveness in SUD research, even at the highest levels of scientific leadership (Volkow, 2020).
- Whereas most theories presume linear relationships among constructs, the reformulated model (Figure (Figure2)2) views relapse as a complex, nonlinear process in which various factors act jointly and interactively to affect relapse timing and severity.
- Chronic alcohol consumption, for example, can lead to a variety of non-neuronal physiological issues, contributing to serious comorbid conditions such as cancer and central nervous system disorders.
- Not surprisingly, molecular genetic approaches have increasingly been incorporated in treatment outcome studies, allowing novel opportunities to study biological influences on relapse.
- Given supportive data for the efficacy of mindfulness-based interventions in other behavioral domains, especially in prevention of relapse of major depression [114], there is increasing interest in MBRP for addictive behaviors.
Based on activation patterns in several cortical regions they were able to correctly identify 17 of 18 participants who relapsed and 20 of 22 who did not. Functional imaging is increasingly being incorporated in treatment outcome studies (e.g., [133]) and there are increasing efforts to use imaging approaches to predict relapse [134]. While the overall number of studies examining neural correlates of relapse remains small at present, the coming years will undoubtedly see a significant escalation in the number of studies using fMRI to predict response to psychosocial and pharmacological treatments. In this context, a critical question will concern the predictive and clinical utility of brain-based measures with respect to predicting treatment outcome. Some researchers propose that the self-control required to maintain behavior change strains motivational resources, and that this “fatigue” can undermine subsequent self-control efforts [78].
Stress, trauma, and adversity effects on addiction risk
- It was noted that in focusing on Marlatt’s relapse taxonomy the RREP did not comprehensive evaluation of the full RP model [121].
- Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal).
- 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.
- In Europe, about half (44–46%) of individuals seeking treatment for AUD have non-abstinence goals (Haug & Schaub, 2016; Heather, Adamson, Raistrick, & Slegg, 2010).
- As outlined in this review, the last decade has seen notable developments in the RP literature, including significant expansion of empirical work with relevance to the RP model.
- Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
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). The realization that HIV had been spreading widely among people who injected drugs in the mid-1980s led to the first syringe services programs (SSPs) in the U.S. (Des Jarlais, 2017). Early attempts to establish pilot SSPs were met with public outcry and were blocked by politicians (Anderson, 1991). In 1988 legislation was passed prohibiting the use of federal funds to support syringe access, a policy which remained in effect until 2015 even as numerous studies demonstrated the effectiveness of SSPs in reducing disease transmission (Showalter, 2018; Vlahov et al., 2001).
2. Relationship between goal choice and treatment outcomes
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. The RP model of relapse is centered around a detailed taxonomy of emotions, events, and situations that can precipitate both lapses and relapses to drinking. This taxonomy includes both immediate relapse determinants and covert antecedents, which indirectly increase a person’s vulnerability to relapse. Based on the classification of relapse determinants and abstinence violation effect high-risk situations proposed in the RP model, numerous treatment components have been developed that are aimed at helping the recovering alcoholic cope with high-risk situations. The results of recent research, particularly the RREP study, likely will lead to modifications of the original RP model, particularly with regard to the assessment of high-risk situations as well as the conceptualization of covert and immediate antecedents of relapse. Overall, however, research findings support both the overall model of the relapse process and the effectiveness of treatment strategies based on the model.
Shiffman, Gwaltney and colleagues have used ecological momentary assessment (EMA; [44]) to examine temporal variations in SE in relation to smoking relapse. Findings from these studies suggested that participants’ SE was lower on the day before a lapse, and that lower SE in the days following a lapse in turn predicted progression to relapse [43,45]. One study [46] reported increases in daily SE during abstinent intervals, perhaps indicating mounting confidence as treatment goals were maintained [45].
On the other hand, if the reason for the violation is attributed to external, unstable, and/or local factors, such as an extremely tempting situation, then the individual is more likely to recover from the violation and get back onto the path of abstinence. Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019). These individuals are considered good candidates for harm reduction interventions because of the severity of substance-related negative consequences, and thus the urgency of reducing these harms. 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).
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. An additional concern is that the lack of research supporting the efficacy of established interventions for achieving nonabstinence goals presents a barrier to implementation. Consistent with the RP model, changes in coping skills, self-efficacy and/or outcome expectancies are the primary putative mechanisms by which CBT-based interventions work [126].
- Ultimately, individuals who are struggling with behavior change often find that making the initial change is not as difficult as maintaining behavior changes over time.
- Also, therapists can provide positive feedback of achievements that the client has been able to make in other facets of life6.
- Relapse, or the return to heavy alcohol use following a period of abstinence or moderate use, occurs in many drinkers who have undergone alcoholism treatment.
What Is Addiction?
This imagery technique is known as “urge surfing” and refers to conceptualizing the urge or craving as a wave that crests and then washes onto a beach. In so doing, the client learns that rather than building interminably until they become overwhelming, urges and cravings peak and subside rather quickly if they are not acted on. The client is taught not to struggle against the wave or give in to it, thereby being “swept away” or “drowned” by the sensation, but to imagine “riding the wave” on a surf board. Like the conceptualization of urges and cravings as the result of an external stimulus, this imagery fosters detachment from the urges and cravings and reinforces the temporary and external nature of these phenomena. Despite its effectiveness, access to MAT has been limited by negative perceptions, lack of knowledge among healthcare providers, and regulatory barriers.
These strategies also focus on enhancing the client’s awareness of cognitive, emotional, and behavioral reactions in order to prevent a lapse from escalating into a relapse. The first step in this process is to teach clients the RP model and to give them a “big picture” view of the relapse process. For example, the therapist can use the metaphor of behavior change as a journey that includes both easy and difficult stretches of highway and for which various “road signs” (e.g., “warning signals”) are available to provide guidance.
