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The abstinence violation effect (AVE) occurs when an individual, having made a personal commitment to abstain from using a substance or to cease engaging in some other unwanted behavior, has an initial lapse whereby the substance or behavior is engaged in at least once. The AVE occurs when the person attributes the cause of the initial lapse (the first violation of abstinence) to internal, stable, and global factors within (e.g., lack of willpower or the underlying addiction or disease). To account for correlated observations due to repeated measures within subjects (i.e., recurrent lapse events), we used parametric shared-frailty models, the survival-data analog to mixed-effects (i.e., multilevel or hierarchical linear) regression models (Hougaard, 1999; Hosmer, Lemeshow, & May, 2008).

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). Participant recruitment and data collection occurred between October 1997 and February 2000. Training in assertiveness involves two steps, a minimal effective response and escalation. When the minimal effective response (such as informing friends that “I do not drink”) is not sufficient to bring about change, the individual is instructed to escalate to a stronger response, such as warning, threat, involving others’ support. Role play, behavioural rehearsal and modeling are used to train patients in assertiveness.

Celibacy vs. Abstinence

The “dynamic model of relapse” builds on several previous studies of relapse risk factors by incorporating the characterization of distal and proximal risk factors. Distal risks, which are thought to increase the probability of relapse, include background variables (e.g. severity of alcohol dependence) and relatively stable pretreatment characteristics (e.g. expectancies). Proximal risks actualize, or complete, the distal predispositions and include transient lapse precipitants (e.g. stressful situations) and dynamic individual characteristics (e.g. negative affect, self-efficacy).

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).

Cognitive Factors in Addictive Processes

The therapist also can use examples from the client’s own experience to dispel myths and encourage the client to consider both the immediate and the delayed consequences of drinking. Although high-risk situations can be conceptualized as the immediate determinants of relapse episodes, a number of less obvious factors also influence the relapse process. These covert antecedents include lifestyle factors, such as overall stress level, as well as cognitive factors that may serve to “set up” a relapse, such as rationalization, denial, and a desire for immediate gratification (i.e., urges and cravings) (see figure 2). These factors can increase a person’s vulnerability to relapse both by increasing his or her exposure to high-risk situations and by decreasing motivation to resist drinking in high-risk situations. In a meta-analysis by Carroll, more than 24 RCT’s have been evaluated for the effectiveness of RP on substance use outcomes.

According to this metaphor, learning to anticipate and plan for high-risk situations during recovery from alcoholism is equivalent to having a good road map, a well-equipped tool box, a full tank of gas, and a spare tire in good condition for the journey. Despite the growth of the harm reduction abstinence violation effect definition movement globally, research and implementation of nonabstinence treatment in the U.S. has lagged. Furthermore, abstinence remains a gold standard treatment outcome in pharmacotherapy research for drug use disorders, even after numerous calls for alternative metrics of success (Volkow, 2020).

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