Most U.S. treatment providers still utilize abstinence-focused approaches such as 12 Step Facilitation and AA/NA groups as a mandatory aspect of treatment (SAMHSA, 2017), and while providers demonstrate growing acceptance of controlled drinking, acceptance of nonabstinence outcomes for drug use remains very low (Rosenberg et al., 2020). 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). Models of nonabstinence psychosocial treatment for drug use have been developed and promoted by practitioners, but little empirical research has tested their effectiveness.

4.3. Reduction in treatment effectiveness

• Unfortunately, few quantitative, survey-based studies have included substance use during treatment as a potential reason for treatment noncompletion, representing a significant gap in this body of literature (for a review, see Brorson, Ajo Arnevik, Rand-Hendriksen, & Duckert, 2013).
• We also observed that the effects of active patch assignment on progression were moderated by lapse-related guilt, such that elevated guilt accelerated progression among those on active patch, while it was protective among those on placebo.
• A corresponding extension of this approach would be to identify subgroups of subjects who followed similar AVE response trajectories; e.g., using latent mixture models to identify different trajectories towards relapse versus recovery.
• 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).

Rather than focusing on binary and distal relapse outcomes, our analyses aimed to advance understanding of factors that influence the dynamic process of recurrent lapse episodes recorded as participants attempted to maintain abstinence from smoking. The analysis evaluated the way emotional and cognitive responses to smoking lapses prospectively affect subsequent lapse progression. We assessed the implications of Marlatt’s AVE concept, which holds that each lapse – not just the first – represents a pivotal situation after which the lapser will either become increasingly demoralized or remain confident and committed to cessation. Researchers have long posited that offering goal choice (i.e., non-abstinence and abstinence treatment options) may be key to engaging more individuals in SUD treatment, including those earlier in their addictions (Bujarski et al., 2013; Mann et al., 2017; Marlatt, Blume, & Parks, 2001; Sobell & Sobell, 1995). Advocates of nonabstinence approaches often point to indirect evidence, including research examining reasons people with SUD do and do not enter treatment.

Lapse timing

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). Drawing from Intrinsic Motivation Theory (Deci, 1975) and the controlled drinking literature, Miller (1985) argued that clients benefit most when offered choices, both for drinking goals and intervention approaches. 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). AA was established in 1935 as a nonprofessional mutual aid group for people who desire abstinence from alcohol, and its 12 Steps became integrated in SUD treatment programs in the 1940s and 1950s with the emergence of the Minnesota Model of treatment (White & Kurtz, 2008). The Minnesota Model involved inpatient SUD treatment incorporating principles of AA, with a mix of professional and peer support staff (many of whom were members of AA), and a requirement that patients attend AA or NA meetings as part of their treatment (Anderson, McGovern, & DuPont, 1999; McElrath, 1997). This model both accelerated the spread of AA and NA and helped establish the abstinence-focused 12-Step program at the core of mainstream addiction treatment.

Theoretical and empirical rationale for nonabstinence treatment

A number of studies have examined psychosocial risk reduction interventions for individuals with high-risk drug use, especially people who inject drugs. In contrast to the holistic approach of harm reduction psychotherapy, the abstinence violation effect refers to 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. However, these interventions also typically lack an abstinence focus and sometimes result in reductions in drug use.

1. Nonabstinence treatment effectiveness

In contrast, recurrent events survival analyses assess the hazard of events that can occur multiple times (e.g., lapses). Recurrent models incorporating both the timing and sequence of lapses made it possible to systematically examine the extent to which each successive AVE response prospectively accelerated lapses across the series, driving the process downward toward relapse. Any smoking after initial cessation, ranging from a single puff to multiple cigarettes, can be considered a lapse (Brownell et al., 1986; Shiffman et al., 1986). Yet smoking is only theorized to elicit an abstinence violation effect when it disrupts ongoing abstinence.

4.2. Negative impact on treatment retention and completion

Harm reduction may also be well-suited for people with high-risk drug use and severe, treatment-resistant SUDs (Finney & Moos, 2006; Ivsins, Pauly, Brown, & Evans, 2019). These individuals are considered good candidates for harm reduction interventions because of the severity of substance-related negative consequences, and thus the urgency of reducing these harms. Indeed, this argument has been central to advocacy around harm reduction interventions for people who inject drugs, such as SSPs and safe injection facilities (Barry et al., 2019; Kulikowski & Linder, 2018).

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. In the multifaceted journey of overcoming addiction and living a healthier life, individuals often encounter a psychological phenomenon known as the abstinence violation effect (AVE). It sheds light on the challenges individuals face when attempting to maintain abstinence and how a single lapse can trigger a surge of negative emotions, potentially leading to a full relapse Halfway house or a return to unhealthy living (Collins & Witkiewitz, 2013; Larimer, Palmer, & Marlatt, 1999).

Lapse and relapse outcomes

Treatment components stemming from the RPM have been incorporated into behavioral interventions for relapse prevention (Brandon, Vidrine, & Litvin, 2007), not only for smoking cessation (Abrams et al., 2003), but also for other addictions and health-related behavior change targets (Marlatt & Donovan, 2005). A focus of relapse-prevention treatment has been on helping those who lapse manage the AVE and maintain or reestablish abstinence from the undesired behavior. The current review highlights a notable gap in research empirically evaluating the effectiveness of nonabstinence approaches for DUD treatment. 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).

Harm reduction therapy has also been applied in group format, mirroring the approach and components of individual harm reduction psychotherapy but with added focus on building social support and receiving feedback and advice from peers (Little, 2006; Little & Franskoviak, 2010). 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). Additionally, some groups target individuals with co-occurring psychiatric disorders (Little, Hodari, Lavender, & Berg, 2008). Important features common to these groups include low program barriers (e.g., drop-in groups, few rules) and inclusiveness of clients with difficult presentations (Little & Franskoviak, 2010). It is important to highlight that most of the studies cited above did not provide goal-matched treatment; thus, these outcomes generally reflect differences between individuals with abstinence vs. non-abstinence goals who participated in abstinence-based https://ecosoberhouse.com/ AUD treatment.

• “Frailty effects” account for such individual differences in vulnerability, as distinct from factors that influence survival for each individual episode.
• EMA captured the timing of lapses, the amount smoked during each lapse episode, and participants’ immediate AVE responses.
• The amount of abstinence time preceding each lapse was used to evaluate the extent to which lapses occurring after longer periods of time were more or less likely to trigger AVE reactions.
• Analyses suggested that cognitive states (e.g., AVE and guilt) evoked by particular events were better predictors of how quickly binging repeats than were stable differences in attributional style.
• Clinical outcomes have been reported elsewhere (Shiffman, Ferguson, & Gwaltney, 2006; Shiffman, Scharf, et al., 2006).

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).