Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

In a 2017 survey, only about half of LMICs surveyed reported cessation services were available in hospitals 13. In India, the absence of tobacco cessation services in secondary and tertiary care and private healthcare is highlighted as a challenge in the search for cessation solutions 14. Individuals with fewer years of addiction and lower severity SUDs generally have the highest likelihood of achieving moderate, low-consequence substance use after treatment (Öjehagen & Berglund, 1989; Witkiewitz, 2008). Notably, these individuals are also most likely to endorse nonabstinence goals (Berglund et al., 2019; Dunn & Strain, 2013; Lozano et al., 2006; Lozano et al., 2015; Mowbray et al., 2013). In contrast, individuals with greater SUD severity, who are more likely to have abstinence goals, generally have the best outcomes when working toward abstinence (Witkiewitz, 2008).

• Changing bad habits of any kind takes time, and thinking about success and failure as all-or-nothing is counterproductive.
• However, most of the evidence supporting the effectiveness of hospital-initiated cessation services was produced in high-income countries 7.
• The longer someone neglects self-care, the more that inner tension builds to the point of discomfort and discontent.
• She supports individuals who long for a better relationship with alcohol, helping them learn to drink less without living less.

The effect of brief exercise cessation on pain, fatigue, and mood symptom development in healthy, fit individuals

Yet smoking is only theorized to elicit an abstinence violation effect when it disrupts ongoing abstinence. Even when it remains below the level of full-blown relapse, smoking that is part of a routine pattern of daily use may not produce an AVE, because there is no abstinence to violate. To avoid data from periods when smoking had become routine, we limited the analysis to lapses that occurred before the onset of routine daily smoking.

Outcomes

Recurrent lapses and AVE responses were thus expected to synergistically drive one another toward relapse, and our analysis attempts to capture and elucidate this cascading downward spiral driven by cognitive and affective responses to recurrent lapses during self-imposed abstinence. Lack of consensus around target outcomes also presents a challenge to evaluating the effectiveness of nonabstinence treatment. Experts generally recommend that SUD treatment studies report substance use as well as related consequences, and select primary outcomes based on the study sample and goals (Donovan et al., 2012; Kiluk et al., 2019). 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.

Ecological momentary assessment in the investigation of craving and substance use in daily life: A systematic review

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). Nonabstinence goals have become more widely accepted in SUD treatment in much of Europe, and evidence suggests that acceptance of controlled drinking has increased among U.S. treatment providers since the 1980s and 1990s (Rosenberg, Grant, & Davis, 2020). 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). Many advocates of harm reduction believe the SUD treatment field is at a turning point in acceptance of nonabstinence approaches.

2. Addressing barriers to implementation

The relapse prevention model (RPM) developed by Marlatt was the first to establish an integrative framework for understanding the cognitive-behavioral processes that drive progression from lapses to relapse (Marlatt & Gordon, 1985), and has been prominent in clinical thinking about relapse. Nearly all other prominent models of addiction and relapse focus on the psychophysiological determinants of drug priming and reinforcement (e.g., Baker et al., 1986; Kalivas & Volkow, 2005; Koob & Le Moal, 1997; Robinson & Berridge, 2003). According to the RPM (Marlatt & Gordon, 1985; Witkiewitz & Marlatt, 2004), the primary determinants of whether an individual who has lapsed will progress towards relapse or towards reestablishing abstinence are that person’s explicit (i.e., subject to conscious awareness) cognitive and emotional responses to lapsing. Specifically, relapse is predicted to be more likely when lapses produce an abstinence violation effect (AVE), characterized by internal attribution of blame, reduced abstinence self-efficacy, and feelings of guilt.

In the case of minors (i.e., year-olds), written informed consent from a parent or guardian plus written assent from the minor were obtained prior to taking part in the research. Finally, you convince yourself, “One drink can’t hurt,” and you wave to the waiter. Before you know it, you’re back in the old pattern—hangovers, drunk arguments, the endless obsession around the wine o’clock. One way of ensuring recovery from addiction is to remember the acronym DEADS, shorthand for an array of skills to deploy when faced with a difficult situation—delay, escape, avoid, distract, and substitute.

Fear of missing out (FoMO) and internet use: A comprehensive systematic review and meta-analysis

Perhaps the most notable gap identified by this review is the dearth of research empirically evaluating the effectiveness of nonabstinence approaches abstinence violation effect for DUD treatment. Given low treatment engagement and high rates of health-related harms among individuals who use drugs, combined with evidence of nonabstinence goals among a substantial portion of treatment-seekers, testing nonabstinence treatment for drug use is a clear next step for the field. Ultimately, nonabstinence treatments may overlap significantly with abstinence-focused treatment models. 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.