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. Thus, studies will need to emphasize measures of substance-related problems in addition to reporting the degree of substance use (e.g., frequency, quantity). The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. 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.

Treatment

• 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).
• Links are drawn between cognitions, causal perceptions, and the binge/purge cycle in a reformulation of the abstinence violation effect with a special focus on attributions.
• In contrast to the holistic approach of harm reduction psychotherapy, 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.
• These data suggest that non-disordered drug use is possible, even for a substantial portion of individuals who use drugs such as heroin (about 45%).
• Multiple versions of harm reduction psychotherapy for alcohol and drug use have been described in detail but not yet studied empirically.
• Rather than undermining self-efficacy after a lapse, results indicate that longer periods of pre-lapse abstinence potentiated the effect of self-efficacy in protecting against subsequent progression.

This paper presents a narrative review of the literature and a call for increased research attention on the development of empirically supported nonabstinence treatments for SUD to engage and treat more people with SUD. 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. We first provide an overview of the development of abstinence and nonabstinence approaches within the historical context of SUD treatment in the U.S., followed by an evaluation of literature underlying the theoretical and empirical rationale for nonabstinence treatment approaches. Lastly, we review existing models of nonabstinence psychosocial treatment for SUD among adults, with a special focus on interventions for drug use, to identify gaps in the literature and directions for future research.

2.2. Relapse prevention

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). Together, this suggests a promising degree of alignment between goal selection and probability of success, and it highlights the potential utility of nonabstinence treatment as an “early intervention” approach to prevent SUD escalation.

Understanding the Abstinence Violation Effect and its role in Relapse Prevention Treatment

The most recent national survey assessing rates of illicit drug use and SUDs found that among individuals who report illicit drug use in the past year, approximately 15% meet criteria for one or more DUD (SAMHSA, 2019a). About 10% of individuals who report cannabis use in the past year meet criteria for a cannabis use disorder, while this proportion increases to 18%, 19%, 58%, and 65% of those with past year use of cocaine, opioids (misuse), methamphetamine, and heroin, respectively. These data suggest that non-disordered drug use is possible, even for a substantial portion of individuals who use drugs such as heroin (about 45%).

In addition to evaluating nonabstinence treatments specifically, researchers could help move the field forward by increased attention to nonabstinence goals more broadly. 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. 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. The harm reduction movement, and the wider shift toward addressing public health impacts of https://ecosoberhouse.com/ drug use, had both specific and diffuse effects on SUD treatment research.

Relapse dynamics during smoking cessation: Recurrent abstinence violation effects and lapse-relapse progression

We identify a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders and suggest that increased research attention on these interventions represents the logical next step for the field. Methodologically, our results illustrate the utility of analyzing highly detailed ecological data to represent and thereby understand the complexity inherent to the process of behavior change over time. Our use of EMA methods avoided reliance of retrospective data, and allowed for detailed, lapse-by-lapse prospective analyses of how lapse responses affect smokers’ subsequent course. Future studies that incorporate fine-grained, ecologically valid measures with dynamic longitudinal analysis techniques may reveal much more about the subtle processes the abstinence violation effect refers to that drive the link between lapse and relapse outcomes. For example, our data demonstrate that the lapse progression process is highly variable both between individual participants and across momentary circumstances.

3. Summary of the state of the literature

In sum, the current body of literature reflects multiple well-studied nonabstinence approaches for treating AUD and exceedingly little research testing nonabstinence treatments for drug use problems, representing a notable gap in the literature. Here we provide a brief review of existing models of nonabstinence psychosocial treatment, with the goal of summarizing the state of the literature and identifying notable gaps and directions for future research. Previous reviews have described nonabstinence pharmacological approaches (e.g., Connery, 2015; Palpacuer et al., 2018), which are outside the scope of the current review. While there are multiple such intervention approaches for treating AUD with strong empirical support, we highlight a dearth of research testing models Drug rehabilitation of harm reduction treatment for DUD. 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.