Additional hours of prospective abstinence time across each 1-unit change in post-lapse internal attribution of blame, plotted as a function of abstinence duration (days) preceding the lapse. The analysis was based on data from a randomized, double-blind, placebo-controlled clinical trial of high-dose nicotine patch for smoking cessation. Clinical outcomes have been reported elsewhere (Shiffman, Ferguson, & Gwaltney, 2006; Shiffman, Scharf, et al., 2006). A common pattern of self-regulation failure occurs for addicts and chronic dieters when they ‘fall off the wagon’ by consuming the addictive substance or violating their diets 5.
How The Abstinence Violation Effect Impacts Long-Term Recovery
- For example, offering nonabstinence treatment may provide a clearer path forward for those who are ambivalent about or unable to achieve abstinence, while such individuals would be more likely to drop out of abstinence-focused treatment.
- Based on the current findings, as well as the findings from Hufford and colleagues (2003), it appears that a higher level of distal risk at intake to treatment increases a client’s susceptibility to drastic differences in drinking behavior following treatment.
- It is hypothesized that including non-drinkers creates a mode of zeros and under these circumstances the complexity and variation in drinking behavior is not actualized by the proposed risk factors.
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%). However, they do not elucidate patterns of non-disordered use over time, nor the likelihood of maintaining drug use without developing a DUD. 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).
The Abstinence Violation Approach
The divergence of linear response and critical slowing down catastrophe flags require data that includes a perturbation of the system. Evidence of divergence of linear response was abstinence violation effect demonstrated by Boker and Graham (1998) who investigated dynamic instability and self-regulation in the development of adolescent substance abuse showing relatively small changes feedback into the system and lead to large changes in substance abuse over a relatively short period of time. Critical slowing down can be demonstrated by looking at the pattern of changes in drinking behavior following treatment.
- Witkiewitz (2004, 2005) used a type of person-centered analysis called latent growth mixture modeling to assess the within-person variability in drinking behavior during the 12-months following treatment.
- Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
- This finding demonstrates that models of the relapse process will not provide a complete description of the nonlinear dynamical process of post-treatment dinking if relapse is defined as a dichotomous event (e.g., drinking or abstaining).
- It occurs when individuals who have set strict rules for themselves regarding certain behaviors or habits (e.g., alcohol consumption, smoking, or eating certain foods) engage in the prohibited behavior, leading to feelings of guilt, shame, and loss of control.
- There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals presenting to SUD treatment.
- In the 1980s and 1990s, the HIV/AIDS epidemic prompted recognition of the role of drug use in disease transmission, generating new urgency around the adoption of a public health-focused approach to researching and treating drug use problems (Sobell & Sobell, 1995).
Relapse Risk Factors: The Potholes
The Abstinence Violation Effect is a concept originally introduced by psychologist Alan Marlatt in the context of treating substance abuse. It stems from the belief that individuals who establish strict rules of abstinence may be more vulnerable to relapse when faced with a violation of those rules. There is less research examining the extent to which moderation/controlled use goals are feasible for individuals with DUDs. 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).
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On the other hand, if individuals perceive the Abstinence Violation Effect as a sign of personal failure or lack of self-control, it may diminish their self-efficacy and motivation to continue pursuing behavior change. 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 1990, Marlatt was introduced to the philosophy of harm reduction during a trip to the Netherlands (Marlatt, 1998). 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). Marlatt’s work inspired the development of multiple nonabstinence treatment models, including harm reduction psychotherapy (Blume, 2012; Denning, 2000; Tatarsky, 2002). Additionally, while early studies of SUD treatment used abstinence as the single measure of treatment effectiveness, by the late 1980s and early 1990s researchers were increasingly incorporating psychosocial, health, and quality of life measures (Miller, 1994).
- Taylor uses an app to watch her intake of calorie limit and does see positive outcomes to her new lifestyle.
- The past 20 years has seen growing acceptance of harm reduction, evidenced in U.S. public health policy as well as SUD treatment research.
- The relapse prevention model (RPM) developed by Marlatt was the first to establish an integrative framework for understanding the cognitive-behavioral processes that drive progression from lapses to relapse (Marlatt & Gordon, 1985), and has been prominent in clinical thinking about relapse.
- In contrast, high self-efficacy following a very short period of abstinence may be less realistic and more brittle in the face of challenge, and hence have a weaker association with subsequent behavior.
Unfortunately, the lack of collateral informants did not allow the MATCH researchers to examine the reliability of participant responses. Hysteresis may occur when a sudden jump in the dependent variable corresponds with different values of the independent variable, depending on the direction of the change in the value of the independent variable. Furthermore, the timing of depressive episodes in individuals with major depression has been shown to predict relapse following treatment for substance dependence (Hasin, Liu, Nunes, McCloud, Samet, & Endicott, 2002). The strengths of the study lie in its use of near-real-time EMA reports of AVE responses, recorded soon after each lapse, and the ability to use a stream of EMA reports over many lapses to characterize the prospective influence of AVE responses on progression to subsequent lapses.
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Analyses of these data revealed a periodic cycle in which the drinking trajectory changed in consistent, albeit discontinuous, ways. 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.