Relapse Prevention PMC

The debate between abstinence and non-abstinence approaches, specifically controlled drinking (CD), has remained a controversial topic in the alcoholism field since the 1960s (Davies, 1962; Miller & Caddy, 1977). As far as treatment outcomes are considered, there is no universally accepted definition of what constitutes successful CD. It has been suggested that CD, and more specifically a reduction in heavy drinking, has a number of clinical benefits that should be taken into consideration when discussing drinking goals (Gastfriend, Garbutt, Pettinati, & Forman, 2007).

Critiques of the RP Model

Additionally, we review the nascent but rapidly growing literature on genetic predictors of relapse following substance use interventions. In focusing exclusively on addictive behaviors (for which the RP model was initially conceived) we forego a discussion of RP as it relates to various other behavioral domains (e.g., sexual offending, depression, diet and exercise) and refer readers to other sources for updates on the growing range of RP applications [8,11]. While there have been calls for abstinence-focused treatment settings to relax punitive policies around substance use during treatment (Marlatt et al., 2001; White et al., 2005), there may also be specific benefits provided by nonabstinence treatment in retaining individuals who continue to use (or return to use) during treatment. 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. This suggests that individuals with non-abstinence goals are retained as well as, if not better than, those working toward abstinence, though additional research is needed to confirm these results and examine the effect of goal-matching on retention. 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.

Financial support and sponsorship

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. AVE occurs when someone who is striving for abstinence from a particular behavior or substance experiences a setback, such as a lapse or relapse. 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).

Relapse prevention, recovery management, recovery transcendence

It is well known to both clinicians and researchers in the addiction field that patients in alcoholism treatment vary dramatically with respect to their alcohol use goals. Patients differ on the continuum between not wanting to change their drinking at all to seeking complete and long-term abstinence from alcohol. While drinking goal represents an important clinical variable, the literature is relatively limited as to the specific influence of drinking goal on treatment outcomes for alcoholism.

Helping clients develop positive addictions or substitute indulgences (e.g. jogging, meditation, relaxation, exercise, hobbies, or creative tasks) also help to balance their lifestyle6. 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. 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.

Specific Intervention Strategies

• Tonic processes include distal risks–stable background factors that determine an individual’s “set point” or initial threshold for relapse [8,31].
• Additionally, the revised model has generated enthusiasm among researchers and clinicians who have observed these processes in their data and their clients [122,123].
• In these situations, the drinker focuses primarily on the anticipation of immediate gratification, such as stress reduction, neglecting possible delayed negative consequences.
• Compared to a control group, those who practiced self-control showed significantly longer time until relapse in the following month.
• Lifestyle factors have been proposed as the covert antecedents most strongly related to the risk of relapse.

(Moderating effects of OPRM1 were specific to participants receiving medication management without the cognitive-behavioral intervention [CBI] and were not evident in participants receiving NTX and CBI). A smaller placebo controlled study has also found evidence for better responses to NTX among Asp40 carriers [94]. One study found that the Asp40 allele predicted cue-elicited craving among individuals low in baseline craving but not those high in initial craving, suggesting that tonic craving could interact with genotype to predict phasic responses to drug cues [97]. In summary, these analyses of the COMBINE study provide strong evidence that drinking goal represents an important clinical predictor of treatment outcomes and thus should be an integral part of the clinical assessment of problem drinkers. Further, results from this study suggest that drinking goal may be useful in selecting a treatment approach. In particular, medically oriented treatments emphasizing abstinence appear to be an effective and cost efficient treatment modality for patients whose goals are oriented toward complete abstinence.

These results suggest that researchers should strive to consider alternative mechanisms, improve assessment methods and/or revise theories about how CBT-based interventions work [77,130]. The dynamic model of relapse assumes that relapse can take the form of sudden and unexpected returns to the target behavior. This concurs not only with clinical observations, but also with contemporary learning models stipulating that recently modified behavior is inherently unstable and easily swayed by context [32]. While maintaining its footing in cognitive-behavioral theory, the revised model also draws from nonlinear dynamical systems theory (NDST) and catastrophe theory, both approaches for understanding the operation of complex systems [10,33]. Detailed discussions of relapse in relation to NDST and catastrophe theory are available elsewhere [10,31,34].

• This collaborative research project evaluated the reliability of raters’ categorizations of high-risk situations using Marlatt’s taxonomy and assessed whether a prior situation could predict future lapse episodes.
• A person whose life is full of demands may experience a constant sense of stress, which not only can generate negative emotional states, thereby creating high-risk situations, but also enhances the person’s desire for pleasure and his or her rationalization that indulgence is justified (“I owe myself a drink”).
• Thirty-two states now have legally authorized SSPs, a number which has doubled since 2014 (Fernández-Viña et al., 2020).
• Given the widespread recognition of individual differences in drinking goals for alcoholism treatment, as well as the accessible nature of this clinical variable to treatment providers, the potential clinical utility of such findings is high.
• For example, a recent study found that patients stating a preference for abstinence had better treatment outcome than those stating a preference for non-abstinence (Adamson, Heather, Morton, & Raistrick, 2010).

Outcome expectancies

Also, therapists can provide positive feedback of achievements that the client has been able to make in other facets of life6. Interpersonal relationships and support systems are highly influenced by intrapersonal processes such as emotion, coping, and expectancies18. Approach coping may involve attempts to accept, confront, or reframe as a means of coping, whereas avoidance coping may include distraction from cues or engaging in other activities. Approach oriented participants may see themselves as more responsible for their actions, including lapse, while avoidance-based coping may focus more on their environment than on their own actions14. Nonabstinence approaches to SUD treatment have a complex and contentious history, and significant social and political barriers have impeded research and implementation of alternatives to abstinence-focused treatment.

1. Review aims

Second, the likelihood of abstinence following a behavioral or pharmacological intervention can be moderated by genetic influences on metabolic processes, receptor activity/expression, and/or incentive value specific to the addictive substance in question. Third, variants implicated in broad traits relevant for addictive behaviors–for instance, executive cognitive functioning (e.g., COMT) or externalizing traits (e.g., GABRA2, DRD4)–could influence relapse proneness via general neurobehavioral mechanisms, irrespective of drug class or treatment modality. A basic assumption is that relapse events are immediately preceded by a high-risk situation, broadly defined as any context that confers vulnerability for engaging in the target behavior. Examples of high-risk contexts include emotional or cognitive states (e.g., negative affect, diminished self-efficacy), environmental contingencies (e.g., conditioned drug cues), or physiological states (e.g., acute withdrawal).

While CBI should theoretically reduce the impact of the abstinence violation effect by providing the opportunity to accurately process a lapse, the results presented herein did not support this effect (i.e., no goal × CBI interaction was observed). Ultimately, individuals who are struggling with behavior change often abstinence violation effect find that making the initial change is not as difficult as maintaining behavior changes over time. Many therapies (both behavioral and pharmacological) have been developed to help individuals cease or reduce addictive behaviors and it is critical to refine strategies for helping individuals maintain treatment goals.