Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review. We first describe treatment models with an explicit harm reduction or nonabstinence focus. While there are multiple such intervention approaches for treating AUD with strong empirical support, we highlight a dearth of research testing models of harm reduction treatment for DUD. Next, we review other established SUD treatment models that are compatible with non-abstinence goals. We focus our review on two well-studied approaches that were initially conceptualized – and have been frequently discussed in the empirical literature – as client-centered alternatives to abstinence-based treatment.
2. Controlled drinking
By 1989, treatment center referrals accounted for 40% of new AA memberships (Mäkelä et al., 1996). This standard persisted in SUD treatment even as strong evidence emerged that a minority of individuals who receive 12-Step treatment achieve and maintain long-term abstinence (e.g., Project MATCH Research Group, 1998). Along with the client, the therapist needs to explore past circumstances and triggers of relapse.
Outcome Studies for Relapse Prevention
Even among those who do perceive a need for treatment, less than half (40%) make any effort to get it (SAMHSA, 2019a). 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.
Treatment strategies in the relapse prevention
Also, therapists can provide positive feedback of achievements that the client has been able to make in other facets of life6. Additionally, the support of a solid social network and professional help can play a pivotal role. Encouragement and understanding from friends, family, or support groups can help individuals overcome the negative emotional aftermath of the AVE. In the 12-step world, members who have maintained continuous abstinence for many years are revered—the longer their time away from alcohol and other drugs, the higher their status tends to be.
These interventions integrate both cognitive behavioural and mindfulness based strategies. The greatest strength of cognitive behavioural programmes is that they are individualized, and have a wide applicability. The neurobiological basis of mindfulness in substance use and craving have also been described in recent literature40.
- Specific training steps to suit patients in the Indian setting have been described16,17.
- 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.
- 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).
- Mindfulness, is drawn from Zen Buddhist teachings and refers to viewing things in a special way.
- Motivational Interviewing (MI) and motivational enhancement therapy (MET) are approaches that target motivation and decisional balance of the patient.
- A psycho-educational self-management approach is adopted in this program and the client is trained in a variety of coping skills and responses.
- Cognitive restructuring can be used to tackle cognitive errors such as the abstinence violation effect.
Among the psychosocial interventions, the Relapse Prevention (RP), cognitive-behavioural approach, is a strategy for reducing the likelihood and severity of relapse following the cessation or reduction of problematic behaviours. Here the assessment and management of both the intrapersonal and interpersonal determinants of relapse are undertaken. This article discusses the concepts of relapse prevention, relapse determinants and the specific interventional strategies.
2. Established treatment models compatible with nonabstinence goals
These are presented repeatedly without the previously learned pattern of drinking so as to lead to extinction. Despite work on cue reactivity, there is limited empirical support for the efficacy of cue exposure in recent literature14. As seen in Rajiv’s case illustration, internal (social anxiety, craving) and external cues (drinking partner, a favourite brand of drink) were identified as triggers for his craving. Subsequently inadequate coping and lack of assertiveness and low self-efficacy maintained his drinking. The following section presents a brief overview of some of the major approaches to managing addictive behaviours. An individual progresses through various stages of changes and the movement is influenced by several factors.
- For example, despite being widely cited as a primary rationale for nonabstinence treatment, the extent to which offering nonabstinence options increases treatment utilization (or retention) is unknown.
- With regard to addictive behaviours Cognitive Therapy emphasizes psychoeducation and relapse prevention.
- Matching interventions to the stage of change at which an individual is, can maximize outcome.
- 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).
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). It has also been used to advocate for managed alcohol and housing first programs, which represent a harm reduction approach to high-risk drinking among people with severe AUD (Collins et al., 2012; Ivsins et al., 2019). Advocates of managed alcohol programs also note that individuals with severe the abstinence violation effect refers to AUD and structural vulnerabilities often have low interest in and utilization of abstinence-oriented treatment, and that these treatments are less effective for this population (Ivsins et al., 2019), though there is limited research examining these claims. Despite various treatment programmes for substance use disorders, helping individuals remain abstinent remains a clinical challenge. Cognitive behavioural therapies are empirically supported interventions in the management of addictive behaviours.
The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research. 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).
Relapse road maps
Positive social support is highly predictive of long-term abstinence rates across several addictive behaviours. Among social variables, the degree of social support available from the most supportive person in the network may be the best predictor of reducing drinking, and the number of supportive relationships also strongly predicts abstinence. Further, the more non-drinking friends a person with an AUD has, the better outcomes tend to be. Negative social support in the form of interpersonal conflict and social pressure to use substances has been related to an increased risk for 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.