Expanding the continuum of substance use disorder treatment: Nonabstinence approaches PMC

It is well known to clinicians and researchers in the field of alcoholism that patients vary with respect to drinking goal. The objective of this study is to elucidate the contribution of drinking goal to treatment outcome in the context of specific behavioral and pharmacological interventions. Although abstinence from all substances is an excellent recovery goal for some, research consistently shows that many people who resolve alcohol and drug problems follow a path of moderation. Furthermore, the use of FDA-approved medications (which not all clients will view as “abstinence”) has been shown to produce the best health and recovery outcomes for people with opioid use disorders. Although there may be practical reasons for your client to choose abstinence as a goal (e.g., being on probation), it is inaccurate to characterize abstinence-based recovery as the only path to wellness. Along with the client, the therapist needs to explore past circumstances and triggers of relapse.

• Social pressure may be experienced directly, such as peers trying to convince a person to use, or indirectly through modelling (e.g. a friend ordering a drink at dinner) and/or cue exposure.
• Marlatt, based on clinical data, describes categories of relapse determinants which help in developing a detailed taxonomy of high-risk situations.
• Importantly, clinical assessment of drinking goal is a readily accessible clinical variable which, given the results presented herein, is potentially critical to treatment planning and prognosis.

2. Controlled drinking

Helping clients develop positive addictions or substitute indulgences (e.g. jogging, meditation, relaxation, exercise, hobbies, or creative tasks) also help to balance their lifestyle6. Global self-management strategy involves encouraging clients to pursue again those previously satisfying, nondrinking recreational abstinence violation effect activities. In addition, relaxation training, time management, and having a daily schedule can be used to help clients achieve greater lifestyle balance. The myths related to substance use can be elicited by exploring the outcome expectancies as well as the cultural background of the client.

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There is also a need for updated research examining standards of practice in community SUD treatment, including acceptance of non-abstinence goals and facility policies such as administrative discharge. For example, in AUD treatment, individuals with both goal choices demonstrate significant improvements in drinking-related outcomes (e.g., lower percent drinking days, fewer heavy drinking days), alcohol-related problems, and psychosocial functioning (Dunn & Strain, 2013). Additionally, individuals are most likely to achieve the outcomes that are consistent with their goals (i.e., moderation vs. abstinence), based on studies of both controlled drinking and drug use (Adamson, Heather, Morton, & Raistrick, 2010; Booth, Dale, & Ansari, 1984; Lozano et al., 2006; Schippers & Nelissen, 2006). Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. 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).

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Note that these script ideas were pulled from a UN training on cognitive behavioral therapy that is available online. Fortunately, professional treatment for addiction can improve outcomes for people experiencing the Abstinence Violation Effect. Some examples of proven coping skills include practicing mindfulness, engaging in exercise, or pursuing activities that bring you fulfillment. Our addiction treatment network offers comprehensive care for alcohol addiction, opioid addiction, and all other forms of drug addiction. Our treatment options include detox, inpatient treatment, outpatient treatment, medication-assisted treatment options, and more.

Also, the client is asked to keep a current record where s/he can self-monitor thoughts, emotions or behaviours prior to a binge. One is to help clients identify warning signs such as on-going stress, seemingly irrelevant decisions and significant positive outcome expectancies with the substance so that they can avoid the high-risk situation. The second is assessing coping skills of the client and imparting general skills such as relaxation, meditation or positive self-talk or dealing with the situation using drink refusal skills in social contexts when under peer pressure through assertive communication6. Positive social support is highly predictive of long-term abstinence rates across several addictive behaviours.

• However, this approach is consistent with the goal of increasing treatment utilization by reaching those who may not otherwise present to treatment.
• For example, all studies with SUD populations could include brief questionnaires assessing short-and long-term substance use goals, and treatment researchers could report the extent to which nonabstinence goals are honored or permitted in their study interventions and contexts, regardless of treatment type.
• The term relapse may be used to describe a prolonged return to substance use, whereas lapsemay be used to describe discrete, circumscribed…
• The harm reduction movement, and the wider shift toward addressing public health impacts of drug use, had both specific and diffuse effects on SUD treatment research.
• 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).

It was hypothesized that patients whose drinking goals were oriented towards complete abstinence would have better treatment outcomes as indexed by a greater percentage of days abstinent, longer period until relapse, and an overall higher global clinical outcome. These hypotheses were supported by the present study, such that participants with a self-reported goal of complete abstinence had better overall clinical outcomes following 16 weeks of alcohol dependence treatment. Participants with a goal of controlled drinking had the worst drinking outcomes, whereas those with a conditional abstinence goal comprise an intermediate group between complete abstinence and controlled drinking.

As a newer iteration of RP, Mindfulness-Based Relapse Prevention (MBRP) has a less extensive research base, though it has been tested in samples with a range of SUDs (e.g., Bowen et al., 2009; Bowen et al., 2014; Witkiewitz et al., 2014). The results of the Sobell’s studies challenged the prevailing understanding of abstinence as the only acceptable outcome for SUD treatment and raised a number of conceptual and methodological issues (e.g., the Sobell’s liberal definition of controlled drinking; see McCrady, 1985). A “controlled drinking controversy” followed, in which the Sobells as well as those who supported them were publicly criticized due to their claims about controlled drinking, and the validity of their research called into question (Blume, 2012; Pendery, Maltzman, & West, 1982). Despite the intense controversy, the Sobell’s high-profile research paved the way for additional studies of nonabstinence treatment for AUD in the 1980s and later (Blume, 2012; Sobell & Sobell, 1995). Marlatt, in particular, became well known for developing nonabstinence treatments, such as BASICS for college drinking (Marlatt et al., 1998) and Relapse Prevention (Marlatt & Gordon, 1985).

How The Abstinence Violation Effect Impacts Long-Term Recovery

Drinking Goals in Alcoholism Treatment