Relapse Prevention PMC

The myths related to substance use can be elicited by exploring the outcome expectancies as well as the cultural background of the client. Following this a decisional matrix can be drawn where pros and cons of continuing or abstaining from substance are elicited and clients’ beliefs may be questioned6. In RP client and therapist are equal partners and the client is encouraged to actively contribute solutions for the problem. Client is taught that overcoming the problem behaviour is not about will power rather it has to do with skills acquisition. Another technique is that the road to abstinence is broken down to smaller achievable targets so that client can easily master the task enhancing self-efficacy.

Cognitive Behavioural model of relapse

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. One of the most critical predictors of relapse is the individual’s ability to utilize effective coping strategies in dealing with high-risk situations. Coping is defined as the thoughts and behaviours used to manage the internal and external demands of situations that are appraised as stressful.

Marlatt’s relapse prevention model: Historical foundations and overview

The abstinence violation effect, along with positive outcome expectancies, can increase the probability of a relapse. It was also hypothesized that, given naltrexone’s effect on hedonic response to alcohol (King et al., 1997; McCaul et al., 2001; Ray et al., 2010), naltrexone would be more effective among those with a controlled drinking goal versus those with an abstinence oriented goal. This hypothesis was not supported by the data in that there abstinence violation effect was no significant drinking goal × naltrexone interaction in any of the outcome measures. This may be due to the fact that the vast majority of participants (78%) consumed alcohol during the trial, such that the drinking mediated effects of naltrexone were not restricted to patients with controlled drinking goals. As a data check, all outcomes presented in the primary COMBINE manuscript were replicated prior to any model testing for this study.

Study selection

• Even when alcohol’s perceived positive effects are based on actual drug effects, often only the immediate effects are positive (e.g., euphoria), whereas the delayed effects are negative (e.g., sleepiness), particularly at higher alcohol doses.
• One of the most critical predictors of relapse is the individual’s ability to utilize effective coping strategies in dealing with high-risk situations.
• From this standpoint, an initial return to the target behavior after a period of volitional abstinence (a lapse) is seen not as a dead end, but as a fork in the road.
• Both negative and positive expectancies are related to relapse, with negative expectancies being protective against relapse and positive expectancies being a risk factor for relapse4.

This article discusses the concepts of relapse prevention, relapse determinants and the specific interventional strategies. Relapse Prevention (RP) is another well-studied model used in both AUD and DUD treatment (Marlatt & Gordon, 1985). In its original form, RP aims to reduce risk of relapse by teaching participants cognitive and behavioral skills for coping in high-risk situations (Marlatt & Gordon, 1985). More recent versions of RP have included mindfulness-based techniques (Bowen, Chawla, & Marlatt, 2010; Witkiewitz et al., 2014). The RP model has been studied among individuals with both AUD and DUD (especially Cocaine Use Disorder, e.g., Carroll, Rounsaville, & Gawin, 1991); with the largest effect sizes identified in the treatment of AUD (Irvin, Bowers, Dunn, & Wang, 1999).

Overview of the RP Model

While there is evidence that a subset of individuals who use drugs engage in low-frequency, non-dependent drug use, there is insufficient research on this population to determine the proportion for whom moderation is a feasible treatment goal. However, among individuals with severe SUD and high-risk drug or alcohol use, the urgency of reducing substance-related harms presents a compelling argument for engaging these individuals in harm reduction-oriented treatment and interventions. 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.

• Definitions of relapse are varied, ranging from a dichotomous treatment outcome to an ongoing, transitional process [8,12,13].
• An important part of RP is the notion of Abstinence violation effect (AVE), which refers to an individual’s response to a relapse where often the client blames himself/herself, with a subsequent loss of perceived control4.
• Abstinence continues to be the dominant approach to alcohol treatment in the United States, while non-abstinent approaches tend to be more acceptable abroad (Klingemann & Rosenberg, 2009; Luquiens, Reynaud, & Aubin, 2011).
• 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).
• None of the studies included a waitlist control; thus, AA/TSF was always compared to some kind of active treatment.
• Despite AA’s international popularity, there had been confusion about its clinical and public health utility and whether it can be subjected to the rigorous evaluation.

Given its focus on long-term maintenance of treatment gains, RP is a behavioral intervention that is particularly well suited for implementation in continuing care contexts. However, it is imperative that insurance providers and funding entities support these efforts by providing financial support for aftercare services. It is also important that policy makers and funding entities support initiatives to evaluate RP and other established interventions in the context of continuing care models. In general, more research on the acquisition and long-term retention of specific RP skills is necessary to better understand which RP skills will be most useful in long-term and aftercare treatments for addictions.

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. 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. Of note, other SUD treatment approaches that could be adapted to target nonabstinence goals (e.g., contingency management, behavioral activation) are excluded from the current review due to lack of relevant empirical evidence.

• Findings concerning possible genetic moderators of response to acamprosate have been reported [99], but are preliminary.
• Expectancies are the result of both direct and indirect (e.g. perception of the drug from peers and media) experiences3.
• Despite the growth of the harm reduction movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged.

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. Cognitive behavioral therapy (CBT) for alcoholism has received empirical support since the 1980s (Marlatt & Gordon, 1985). CBT for alcohol use disorders is grounded in social-cognitive theory (Bandura, 1986) and employs skills training in order to help patients cope more effectively with substance use triggers, including life stressors (Longabaugh & Morgenstern, 1999; Morgenstern & Longabaugh, 2000). The ultimate goal of CBT is to provide the skills that can prevent a relapse and maintain drinking goals, whether they be abstinence or controlled drinking (Marlatt & Gordon, 1985; Marlatt & Witkiewitz, 2005). A recent meta-analysis of CBT for substance use disorders found support for a modest benefit of CBT over treatment as usual (Magill & Ray, 2009). Furthermore, one report using a trajectory analysis of the COMBINE study data found the Combined Behavioral Intervention (CBI), which is principally grounded in CBT, to reduce the risk of being in an “increasing to nearly daily drinking” trajectory.