While multiple harm reduction-focused treatments for AUD have strong empirical support, there is very little research testing models of nonabstinence treatment for drug use. Despite compatibility with harm reduction in established SUD treatment models such as MI and RP, there is a dearth of evidence testing these as standalone treatments for helping patients achieve nonabstinence goals; this is especially true regarding DUD (vs. AUD). 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.
In order to cope or avoid these damaging thoughts, these individuals turn back to drugs or alcohol to numb the pain. AVE is not just about the lapse itself but the way the individual interprets and responds to it. For many, the initial slip is seen as a catastrophic failure, leading to a “what’s the point?” attitude, which can drive them back into full-blown substance use. This is particularly dangerous because it can turn what might have been a single, manageable lapse into a full relapse, undoing the progress made in recovery. 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.
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. Understanding the AVE is crucial for individuals in recovery and those focused on healthier lifestyle choices.
Like the Sobells, Marlatt showed that reductions in drinking and harm were achievable in nonabstinence treatments (Marlatt & Witkiewitz, 2002). In the 1970s, the pioneering work of a small number of alcohol researchers began to challenge the existing abstinence-based paradigm in AUD treatment research. They found that their controlled drinking intervention produced significantly better outcomes compared to usual treatment, and that about a quarter of the individuals in this condition maintained controlled drinking for one year post treatment (Sobell & Sobell, 1973). Administrative discharge due to substance use is not a necessary practice even within abstinence-focused treatment (Futterman, Lorente, & Silverman, 2004), and is likely linked to the assumption that continued use indicates lack of readiness for treatment, and that abstinence is the sole marker of treatment success. In the United Kingdom, where there is greater acceptance of nonabstinence goals and availability of nonabstinence treatment (Rosenberg et al., 2020; Rosenberg & Melville, 2005), the rate of administrative discharge is much lower than in the U.S. (1.42% vs. 6% of treatment episodes; Newham, Russell, & Davies, 2010; SAMHSA, 2019b). Given data demonstrating a clear link between abstinence goals and treatment engagement in a primarily abstinence-based SUD treatment system, it is reasonable to hypothesize that offering nonabstinence treatment would increase overall engagement by appealing to those with nonabstinence goals.
The abstinence violation effect occurs when an individual has a lapse in their recovery. Instead of learning and growing from their mistake, an individual may believe that they are unable to complete a successful recovery and feel shame and guilt. Additionally, individuals may engage in cognitive distortions or negative self-talk, such as believing that the relapse is evidence of personal weakness. The Abstinence Violation Effect is a psychological phenomenon that occurs when a person experiences relapse after attempting to abstain from drug or alcohol use.
For instance, a person recovering from alcohol use disorder who has a drink may feel a sense of confusion or a lack of control and they may make unhealthy attributions or rationalizations to try to define and understand what they’re doing. AVE also involves cognitive dissonance, a distressing experience people go through when their internal thoughts, beliefs, actions, or identities are put in conflict with one another. A relapse is the result of a series of events that occur over time, according to psychologist and researcher Alan Marlatt, Ph.D. CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript.
This model notes that those who have the latter mindset are proactive and strive to learn from their mistakes. To do so, they adapt their coping strategies to better deal with future triggers should they arise. This protects their sobriety and enhances their ability to protect themselves from future threats of relapse. Addressing the AVE in the context of addiction treatment involves helping people develop healthier coping strategies and challenging negative beliefs that contribute to addiction. The AVE describes the negative emotional response that often accompanies a failure to maintain abstinence from drugs or alcohol. 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.
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). Little attention was given to whether people in abstinence-focused treatments endorsed abstinence goals themselves, or whether treatment could help reduce substance use and related problems for those who did not desire (or were not ready for) abstinence. AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse. Instead of viewing the incident as a temporary setback, the individual perceives it as evidence of personal failure, leading to increased feelings of guilt, shame, and hopelessness (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999). 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.
Harm reduction psychotherapies, for example, incorporate multiple modalities that have been most extensively studied as abstinence-focused SUD treatments (e.g., cognitive-behavioral therapy; mindfulness). 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. 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.
These negative emotions abstinence violation effect are, unfortunately, often temporarily placated by a renewed pattern of substance abuse. Lapses are, however, a major risk factor for relapse as well as overdose and other potential social, personal, and legal consequences of drug or alcohol abuse. This can include abstinence from substance abuse, overeating, gambling, smoking, or other behaviors a person has been working to avoid. Nevertheless, 40 to 60% of people who once were addicted to a substance and achieved sobriety relapse at some point, based on estimates from the National Institute on Drug Abuse (NIDA). It was written based on peer-reviewed medical research, reviewed by medical and/or clinical experts, and provides objective information on the disease and treatment of addiction (substance use disorders).
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