Although reducing practical barriers to treatment is essential, evidence suggests that these barriers do not fully account for low rates of treatment utilization. Instead, the literature indicates that most people with SUD do not want or need – or are not ready for – what the current treatment system is offering. Regarding setbacks as a normal part of progress enables individuals to broaden their array of coping skills, to engage in planning for problematic situations, and to devise strategies in advance for dealing with predictable difficulties. Among the most important coping skills needed are strategies of distraction that can be quickly engaged when cravings occur. Mindfulness training, for example, can modify the neural mechanisms of craving and open pathways for executive control over them. Relapse is most likely in the first 90 days after embarking on recovery, but in general it typically happens within the first year.
- 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.
- Broadly speaking, there are at least three primary contexts in which genetic variation could influence liability for relapse during or following treatment.
- It skills training such as behavioural rehearsal, assertiveness training, communication skills to cope with social pressures and interpersonal problem solving to reduce impact of conflicts, arousal reduction strategies such as relaxation training to manage pain or anxiety as risk for relapse.
- Most importantly, 12-step programs tend to be abstinence-based, emphasizing that an authentic or high-quality recovery depends on abstaining completely from drugs and alcohol.
Overview of the RP Model
Global self-management strategy involves encouraging clients to pursue again those previously satisfying, nondrinking recreational activities. In addition, relaxation training, time management, and having a daily schedule can be used to help clients achieve greater lifestyle balance. Lapse management includes drawing a contract with the client to limit use, to contact the therapist as soon as possible, and to evaluate the situation for factors that triggered the lapse6. The myths related to substance use can be elicited https://thebostondigest.com/top-5-advantages-of-staying-in-a-sober-living-house/ by exploring the outcome expectancies as well as the cultural background of the client. Following this a decisional matrix can be drawn where pros and cons of continuing or abstaining from substance are elicited and clients’ beliefs may be questioned6. Critical for craving and relapse is the process of associative learning, whereby environmental stimuli repeatedly paired with drug consumption acquire incentive-motivational value, evoking expectation of drug availability and memories of past drug euphoria15.
1. Nonabstinence psychosocial treatment models
Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020). 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. Indeed, a prominent harm reduction psychotherapist and researcher, Rothschild, argues that the harm reduction approach represents a “third wave of addiction treatment” which follows, and is replacing, the moral and disease models (Rothschild, 2015a).
- A better understanding of one’s motives, one’s vulnerabilities, and one’s strengths helps to overcome addiction.
- Although many researchers and clinicians consider urges and cravings primarily physiological states, the RP model proposes that both urges and cravings are precipitated by psychological or environmental stimuli.
- The power to resist cravings rests on the ability to summon and interpose judgment between a craving and its intense motivational command to seek the substance.
- For example, if the client understands that using alcohol in the day time triggers a binge, agreeing for a meeting in the afternoon in a restaurant that serves alcohol would be a SID5.
- This taxonomy includes both immediate relapse determinants and covert antecedents, which indirectly increase a person’s vulnerability to relapse.
Models of nonabstinence psychosocial treatment for SUD
A key feature of the dynamic model is its emphasis on the complex interplay between tonic and phasic processes. As indicated in Figure Figure2,2, distal risks may influence relapse either directly or indirectly (via phasic processes). For instance, the return to substance use can have reciprocal effects on the same cognitive or affective factors (motivation, mood, self-efficacy) that contributed to the lapse.
- However, broadly speaking, there are clear features of 12-step programs that can contribute to the AVE.
- He adopted the language and framework of harm reduction in his own research, and in 1998 published a seminal book on harm reduction strategies for a range of substances and behaviors (Marlatt, 1998).
- 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.
- Shiffman and colleagues describe stress coping where substance use is viewed as a coping response to life stress that can function to reduce negative affect or increase positive affect.
Although withdrawal is usually viewed as a physiological process, recent theory emphasizes the importance of behavioral withdrawal processes [66]. Current theory and research indicate that physiological components of drug withdrawal may be motivationally inert, with the core motivational constituent of withdrawal being negative affect [25,66]. Thus, examining withdrawal in relation to relapse may only prove useful to the extent that negative affect is assessed adequately [64]. Relapse poses a fundamental barrier to the treatment of addictive behaviors by representing the modal outcome of behavior change efforts [1-3]. 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].
Elucidating the “active ingredients” of CBT treatments remains an important and challenging goal, Also, integration of neurocognitive parameters in relapse models as well as neural (such as functional circuitry involved in relapse) and genetic markers of relapse will be major challenges moving ahead19. In addition to shaping mainstream addiction treatment, the abstinence-only 12-Step model also had an indelible effect on the field of SUD treatment research. Most scientists who studied SUD treatment believed that abstinence was the only acceptable treatment goal until at least the 1980s (Des Jarlais, 2017). 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.
2. Established treatment models compatible with nonabstinence goals
Conversely, a return to the target behavior can undermine self-efficacy, increasing the risk of future lapses. Outcome expectancies (anticipated effects of substance use; [27]) also figure prominently in the RP model. Additionally, Top 5 Advantages of Staying in a Sober Living House attitudes or beliefs about the causes and meaning of a lapse may influence whether a full relapse ensues. Viewing a lapse as a personal failure may lead to feelings of guilt and abandonment of the behavior change goal [24].
Outcome Studies for Relapse Prevention
- 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.
- When an urge to use hits, it can be helpful to engage the brain’s reward pathway in an alternative direction by quickly substituting a thought or activity that’s more beneficial or fun— taking a walk, listening to a favorite piece of music.
- Thus, instead of focusing on a distant end goal (e.g., maintaining lifelong abstinence), the client is encouraged to set smaller, more manageable goals, such as coping with an upcoming high-risk situation or making it through the day without a lapse.
- He reported difficulty sleeping if he did not drink, could not get past the day without drinking or thinking about his next drink (establishment of a dependence pattern).
- The RP model developed by Marlatt [7,16] provides both a conceptual framework for understanding relapse and a set of treatment strategies designed to limit relapse likelihood and severity.
At the start of treatment, Rajiv was not keen engage to in the process of recovery, having failed at multiple attempts over the years (motivation to change, influence of past learning experiences with abstinence). Results of a preliminary nonrandomized trial supported the potential utility of MBRP for reducing substance use. In this study incarcerated individuals were offered the chance to participate in an intensive 10-day course in Vipassana meditation (VM). Those participating in VM were compared to a treatment as usual (TAU) group on measures of post-incarceration substance use and psychosocial functioning. 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 [116].