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. Once a person’s high-risk situations have been identified, two types of intervention strategies can be used to lessen the risks posed by those situations. To anticipate and plan accordingly for high-risk situations, the person first must identify the situations in which he or she may experience difficulty coping and/or an increased desire to drink.
How AVE Shows Up in Real Life
It often takes the form of a binge following a lapse in sobriety from alcohol or drugs, but it can also occur in other contexts. They can help you reframe your recovery journey and develop healthier coping mechanisms for triggers and relapses. Continuing to work with a mental health professional can help you learn to cover gaps that may have been missed by developing healthy coping mechanisms that can improve your response to future triggers and/or relapses. This is at least partly because relapses may signify gaps in the coping and recovering process that might have been there to begin with. When a lapse or relapse has occurs, seeking appropriate mental health support from a qualified professional can be a helpful first step toward resuming your journey on the road to recovery and decreasing the likelihood of repeated lapses. Although many view recovery as a static state that must be achieved, practitioners and individuals working to combat the AVE recognize that recovery is a spectrum, and that lapse and relapse operate on that spectrum.
2. Controlled drinking
A key point in Miller’s theory is that motivation for change is “action-specific”; he argues that no one is “unmotivated,” but that people are motivated to specific actions or goals (Miller, 2006). 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). The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research. 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). 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). Abstinence rates became the primary outcome for determining SUD treatment effectiveness (Finney, Moyer, & Swearingen, 2003; Kiluk, Fitzmaurice, Strain, & Weiss, 2019; Miller, 1994; Volkow, 2020), a standard which persisted well into the 1990s (Finney et al., 2003).
2. Relationship between goal choice and treatment outcomes
The use of functional magnetic resonance imaging (fMRI) techniques in addictions research has increased dramatically in the last decade and many of these studies have been instrumental in providing initial evidence on neural correlates of substance use and relapse. Additionally, lab-based studies will be needed to capture dynamic processes involving cognitive/neurocognitive influences on lapse-related phenomena. Dual process accounts of addictive behaviors 56,57 are likely to be useful for generating hypotheses about dynamic relapse processes and explaining variance in relapse, including episodes of sudden divergence from abstinence to relapse.
Eliminating Myths and Placebo Effects
These groups tend to include individuals who use a range of substances and who endorse a range of goals, including reducing substance use and/or substance-related harms, controlled/moderate use, and abstinence (Little, 2006). Publications about harm reduction psychotherapy have included numerous case studies and client examples that highlight the utility of the approach for helping clients achieve reductions in drug and alcohol use and related problems, moderate/controlled use, and abstinence (Rothschild, 2015b; Tatarsky, 2002; Tatarsky & Kellogg, 2010). Here we provide a brief review of existing models of nonabstinence psychosocial treatment, with the goal of summarizing the state of the literature and identifying notable gaps and directions for future research. Although medication is the gold standard of care for OUD (Connery, 2015), psychosocial treatment is important for those who use non-opioid drugs (for which there are no evidence-based medications), those who prefer psychotherapy to medication, and those who need psychosocial support while taking medication. In sum, research suggests that achieving and sustaining moderate substance use after treatment is feasible for between one-quarter to one-half of individuals with AUD when defining moderation as nonhazardous drinking.
These findings may be informative for researchers who wish to incorporate genetic variables in future studies of relapse and relapse prevention. However, we review these findings in order to illustrate the scope of initial efforts to include genetic predictors in treatment studies that examine relapse as a clinical outcome. Consistent with the tenets of the reformulated RP model, several studies suggest advantages of nonlinear statistical approaches for studying relapse. Other studies have similarly found that relationships between daily events and/or mood and drinking can vary based on intraindividual or situational factors , suggesting dynamic interplay between these influences. Overall, the results showed that individuals who reported higher negative affect or increased negative affect over time had the highest probability of heavy and frequent drinking following treatment, and had a near-zero probability of transitioning to moderate drinking.
For instance, in a high-risk context, a slight and momentary drop in self-efficacy could have a disproportionate impact on other relapse antecedents (negative affect, expectancies) . 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. Moreover, an emphasis on post-treatment maintenance renders RP a useful adjunct to various treatment modalities (e.g., cognitive-behavioral, twelve step programs, pharmacotherapy), irrespective of the strategies used to enact initial behavior change. Examples of specific intervention strategies include enhancing self-efficacy (e.g., by setting achievable behavioral goals) and eliminating myths and placebo effects (e.g., by challenging misperceptions about the effects of substance use).
- 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).
- The last decade has seen numerous developments in the RP literature, including the publication of Relapse Prevention, Second Edition and its companion text, Assessment of Addictive Behaviors, Second Edition .
- Secondary analyses showed that compared to TAU, MBRP participants evinced a decreased relation between depressive symptoms and craving following treatment.
- In contrast to the holistic approach of harm reduction psychotherapy, risk reduction interventions are generally designed to target specific HIV risk behaviors (e.g., injection or sexual risk behaviors) without directly addressing mechanisms of SUD, and thus are quite limited in scope.
- In sum, research suggests that achieving and sustaining moderate substance use after treatment is feasible for between one-quarter to one-half of individuals with AUD when defining moderation as nonhazardous drinking.
- 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.
Theoretical and Practical Support for the RP Model
Further, a randomized trial of olanzapine led to significantly improved drinking outcomes in DRD4 L but not DRD4 S individuals . Olanzapine was found to reduce alcohol-related craving those with the long-repeat VNTR (DRD4 L), but not individuals with the short-repeat version (DRD4 S; 100,101). 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 . (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). The most promising pharmacogenetic evidence in alcohol interventions concerns the OPRM1 A118G polymorphism as a moderator of clinical response to naltrexone (NTX). Additionally, post-hoc analyses indicated that Asp40 carriers were more likely to regain abstinence following a lapse, suggesting a possible role of the genotype in predicting prolapse.
Developments in Relapse Prevention: 2000-2010
Existing harm reduction psychotherapies draw from multiple evidence-based treatment modalities but have not yet been tested systematically. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity). Drug use behaviors are generally considered the most important outcomes, but there is disagreement about definitions of moderate and controlled drinking and drug use (e.g., Järvinen, 2017; McCrady, 1985) as well as ongoing debate about whether health and quality of life outcomes should be prioritized (Donovan et what is heroin addiction risk, safety, and how to get support al., 2012; Kiluk et al., 2019). Early applications of MI by Miller and Rollnick targeted problem drinking through a harm reduction framework that encouraged patients to set attainable drinking goals (Miller, Sovereign, & Krege, 1988; Rollnick & Heather, 1992). Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically.
5. Feasibility of nonabstinence goals
Indeed, SUDs are defined by compulsive substance use despite negative consequences (American Psychiatric Association, 2013), and there are no other major health problems “for which one is admitted for treatment and then thrown out for becoming symptomatic in the service setting” (White et al., 2005, p. 4). However, it is a common practice in abstinence-based SUD treatment centers to involuntarily discharge participants who return to use during a treatment episode (White et al., 2005). This finding supplements the numerous studies that identify lack of readiness for abstinence as the top reason for non-engagement in SUD treatment, even among those who recognize a need for treatment (e.g., Chen, Strain, Crum, & Mojtabai, 2013; SAMHSA, 2019a). This literature – most of which has been conducted in the U.S. – suggests a strong link between abstinence goals and treatment entry.
Relative to the TAU group, the VM group reported significantly lower levels of substance use and alcohol-related consequences and improved psychosocial functioning at follow-up . Those participating in VM were compared to a treatment as usual (TAU) group on measures of post-incarceration substance use and psychosocial functioning. Results of a preliminary nonrandomized trial supported the potential utility of MBRP for reducing substance use. In contrast to the cognitive restructuring strategies typical of traditional CBT, MBRP stresses nonjudgmental attention to thoughts or urges. Finally, an intriguing direction is to evaluate whether providing clients with personalized genetic information can facilitate reductions in substance use or improve treatment adherence 110,111.
- Similarly, most studies of MBRP have tested the approach as an adjunct to abstinence-based outpatient and residential treatment (Grant et al., 2017).
- Dual process accounts of addictive behaviors 56,57 are likely to be useful for generating hypotheses about dynamic relapse processes and explaining variance in relapse, including episodes of sudden divergence from abstinence to relapse.
- Those carrying the high-risk GABRA2 allele showed a significantly increased likelihood of relapse following treatment, including a twofold increase in the likelihood of heavy drinking.
- The “12 Steps” to recovery borne of AA include admitting powerlessness over alcohol and being “ready to have God remove all… defects of character” (Alcoholics Anonymous, 1981).
Instead of seeing a lapse for what it is—a single event you can learn from—your mind frames it as a catastrophic failure. Depending on the substance used, addiction may also have the potential to damage the brain itself. For example, someone might decide to quit smoking to lower their health risks later in life, even if a single cigarette might not be life-threatening in the moment. Some other examples of things a person might abstain from include drugs, sexual behaviors, unhealthy foods, tobacco, and social media. These variations can depend on things like individual self-control, the motivation for the abstinence, and other factors.
In viewing relapse as a common (albeit undesirable) event, emphasizing contextual antecedents over internal causes, and distinguishing relapse from treatment failure, the RP model introduced a comprehensive, flexible and optimistic alternative to traditional approaches. Cognitive-behavioral theories also diverged from disease models in rejecting the notion of relapse as a dichotomous outcome. Three decades since its introduction , the RP model remains an influential cognitive-behavioral approach in the treatment and study of addictions. 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. We also review the emergent literature on genetic correlates of relapse following pharmacological and behavioral treatments. The key relapse episode was defined as the most recent use of alcohol following at least 4 days of abstinence (Longabaugh et al. 1996).
Conversely, people with ineffective coping responses will experience decreased self-efficacy, which, together with the expectation that alcohol use will have a positive effect (i.e., positive outcome expectancies), can result in an initial lapse. People with effective coping responses have confidence that they can cope with the situation (i.e., increased self-efficacy), thereby reducing the probability of a relapse. Certain situations or events, however, can pose a threat to the person’s sense of control and, consequently, precipitate a relapse crisis. According to the model, a person who has initiated a behavior change, such as alcohol abstinence, should begin experiencing increased self-efficacy or mastery over his or her behavior, which should grow as he or she continues to maintain the change. This relapse prevention (RP) model, which was developed by Marlatt and Gordon (1985) and which has been widely used in recent years, has been the focus of considerable research. This conceptualization provides a broader conceptual framework for intervening in the relapse process to prevent or reduce relapse episodes and thereby improve treatment outcome.
I have lost all that time,” which can trigger a self-destructive mindset and potentially lead to further relapse. The abstinence violation effect might induce Jim to think, “I have failed. Jim is a recovering alcoholic who successfully abstained from drinking for several months. It can impact someone who is trying to be abstinent from alcohol and drug use in addition to someone trying to make positive changes to their diet, exercise, and other aspects of their lives. Research suggests that empirical evidence supporting harm reduction is often insufficient to create policy change (Allen, Ruiz, & O’Rourke, 2015). However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to treatment.
