Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

doi:10.1016/j.cpr.2021.102110

Clinical Psychology Review

Volume 91, February 2022, 102110

https://doi.org/10.1016/j.cpr.2021.102110 Get rights and content

Highlights

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Abstinence-only treatment excludes most adults with substance use disorder.
•
Nonabstinence treatment may improve engagement, retention, and effectiveness.
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There is a gap in research examining nonabstinence psychosocial drug treatment.
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Future work is needed to test effectiveness of nonabstinence treatments for drug use.
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Addressing barriers to implementing nonabstinence treatment is also vital.

Abstract

Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD – especially drug use disorders – as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.

Section snippets

Background

Most adults with substance use disorders (SUDs) do not receive treatment in the United States (U.S.), contributing to immense individual and societal costs. Current estimates indicate that of the 20 million Americans with an SUD, only 11.8% receive treatment at a program specializing in SUD treatment (SAMHSA, 2019a). Most individuals with a current or past SUD report never utilizing treatment (Cohen, Feinn, Arias, & Kranzler, 2007; Compton, Thomas, Stinson, & Grant, 2007). For those who do

Historical context of nonabstinence approaches

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. We summarize historical factors relevant to nonabstinence treatment development to illuminate reasons these approaches are understudied.

Nonabstinence goals among people with SUD

Research suggests that a substantial portion of individuals with SUD have nonabstinence goals. These goals may include achieving moderation (definitions vary, but generally reflect low-risk use with few or no negative consequences), reductions in use, and/or decreasing problems associated with substance use (i.e., harm reduction).

There has been little research on the goals of non-treatment-seeking individuals; however, research suggests that nonabstinence goals are common even among individuals

Models of nonabstinence psychosocial treatment for SUD

Psychologists have been studying nonabstinence psychotherapy for AUD since the 1970s, but this area of research is still considerably underdeveloped with regard to DUDs. Research on nonabstinence DUD treatment has generally focused on medication for opioid use disorder (OUD), including the opioid agonist medications methadone and buprenorphine (Drucker, Anderson, & Haemmig, 2016), while very few studies have examined psychosocial DUD treatments. Although medication is the gold standard of care

Future directions for research

The current review highlights multiple important directions for future research related to nonabstinence SUD treatment. Overall, increased research attention on nonabstinence treatment is vital to filling gaps in knowledge. 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. In addition to evaluating nonabstinence treatments specifically,

Conclusions

There is a clear need for treatment approaches that can reduce individual and societal harms associated with problematic drug use. The current review examined evidence in support of nonabstinence treatment for SUD to engage and retain more individuals in treatment and to improve treatment effectiveness. Though decades of empirical evidence support nonabstinence interventions for AUD, there is a clear gap in research examining nonabstinence psychosocial treatment for DUDs. Existing harm

Role of funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Contributors

CP conceptualized the manuscript, conducted literature searches, synthesized the literature, and wrote the first draft of the manuscript. SD assisted with conceptualization of the review, and SD and KW both identified relevant literature for the review and provided critical review, commentary and revision. All authors contributed to and have approved the final manuscript.

Declaration of Competing Interest

The authors have no conflicts of interest to declare.

References (199)

S.T. Allen et al.
The evidence does not speak for itself: The role of research evidence in shaping policy change for the implementation of publicly funded syringe exchange programs in three US cities
International Journal of Drug Policy
(2015)
S.A. Ball et al.
Reasons for dropout from drug abuse treatment: Symptoms, personality, and motivation
Addictive Behaviors
(2006)
E. Barnett et al.
Motivational interviewing for adolescent substance use: A review of the literature
Addictive Behaviors
(2012)
C.L. Barry et al.
Arguments supporting and opposing legalization of safe consumption sites in the U.S
International Journal on Drug Policy
(2019)
P.G. Booth et al.
Problem drinkers' goal choice and treatment outcome: A preliminary study
Addictive Behaviors
(1984)
R.E. Booth et al.
Improving entry to methadone maintenance among out-of-treatment injection drug users
Journal of Substance Abuse Treatment
(2003)
H.H. Brorson et al.
Drop-out from addiction treatment: A systematic review of risk factors
Clinical Psychology Review
(2013)
E. Cohen et al.
Alcohol treatment utilization: Findings from the national epidemiologic survey on alcohol and related conditions
Drug and Alcohol Dependence
(2007)
M.M. Copenhaver et al.
Behavioral HIV risk reduction among people who inject drugs: Meta-analytic evidence of efficacy
Journal of Substance Abuse Treatment
(2006)
M.L. Dennis et al.
The duration and correlates of addiction and treatment careers
Journal of Substance Abuse Treatment
(2005)

R. Elvins et al.

The conceptualization and measurement of therapeutic alliance: An empirical review

Clinical Psychology Review

(2008)

J.L. Enggasser et al.

Drinking goal choice and outcomes in a web-based alcohol intervention: Results from vetchange

Addictive Behaviors

(2015)

S.R. Friedman et al.

Harm reduction - A historical view from the left

The International Journal of Drug Policy

(2001)

L.W. Gerson et al.

Medical care use by treated and untreated substance abusing medicaid patients

Journal of Substance Abuse Treatment

(2001)

M. Gossop et al.

Reductions in criminal convictions after addiction treatment: 5-year follow-up

Drug and Alcohol Dependence

(2005)

P.T. Harrell et al.

A latent class approach to treatment readiness corresponds to a transtheoretical ("stages of change") model

Journal of Substance Abuse Treatment

(2013)

D.C. Hodgins et al.

R.L. Hubbard et al.

Overview of 5-year followup outcomes in the Drug Abuse Treatment Outcome Studies (DATOS)

Journal of Substance Abuse Treatment

(2003)

A. Ivsins et al.

On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement

The International Journal of Drug Policy

(2019)

M. Järvinen

From wanting to willing – Controlled drug use as a treatment goal

Social Science and Medicine

(2017)

A.B. Laudet et al.

What could the program have done differently? A qualitative examination of reasons for leaving outpatient treatment

Journal of Substance Abuse Treatment

(2009)

S.J. Adamson et al.

Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes

Alcohol and Alcoholism

(2010)

C.E. Alderks

Trends in the use of methadone and buprenorphine at substance abuse treatment facilities: 2003 to 2011

Diagnostic and statistical manual of mental disorders

(2013)

D.J. Anderson et al.

The origins of the Minnesota model of addiction treatment–A first person account

Journal of Addictive Diseases

(1999)

W. Anderson

The New York needle trial: The politics of public health in the age of AIDS

American Journal of Public Health

(1991)

Alcoholics Anonymous

The twelve steps of Alcoholics Anonymous

E. Appiah-Brempong et al.

Motivational interviewing interventions and alcohol abuse among college students: A systematic review

American Journal of Health Promotion

(2014)

A. Baker et al.

Evaluation of a motivational interview for substance use within psychiatric in-patient services

Addiction

(2002)

L.S. Baker et al.

Community perceptions of comprehensive harm reduction programs and stigma towards people who inject drugs in rural Virginia

Journal of Community Health

(2020)

A. Bandura

Social foundations of thoughts and action: A social cognitive theory

(1986)

C. Bayles

Using mindfulness in a harm reduction approach to substance abuse treatment: A literature review

International Journal of Behavioral Consultation and Therapy

(2014)

N. Beckham

Motivational interviewing with hazardous drinkers

Journal of the American Academy of Nurse Practitioners

(2007)

K.J. Berglund et al.

Outcome in relation to drinking goals in alcohol-dependent individuals: A follow-up study 2.5 and 5 years after treatment entry

Alcohol and Alcoholism

(2019)

A.W. Blume

Seeking the middle way: G. Alan Marlatt and harm reduction

Addiction Research & Theory

(2012)

S. Bowen et al.

Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial

Substance Abuse

(2009)

S. Bowen et al.

Mindfulness-based relapse prevention for substance use disorders: A clinician’s guide

(2010)

S. Bowen et al.

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial

JAMA Psychiatry

(2014)

T.H. Brandon et al.

Relapse and relapse prevention

Annual Review of Clinical Psychology

(2007)

S. Bujarski et al.

The effects of drinking goal on treatment outcome for alcoholism

Journal of Consulting and Clinical Psychology

(2013)

B.L. Burke et al.

The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials

Journal of Consulting and Clinical Psychology

(2003)

P. Burkinshaw et al.

An evidence review of the outcomes that can be expected of drug misuse treatment in England (PHE publications gateway number: 2016489)

(2017)

K.M. Carroll et al.

A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy

The American Journal of Drug and Alcohol Abuse

(1991)

K. Charlet et al.

Harm reduction -A systematic review on effects of alcohol reduction on physical and mental symptoms

Addiction Biology

(2017)

L.-Y. Chen et al.

Gender differences in substance abuse treatment and barriers to care among persons with substance use disorders with and without comorbid major depression

Journal of Addiction Medicine

(2013)

S.E. Collins et al.

Project-based housing first for chronically homeless individuals with alcohol problems: Within-subjects analyses of 2-year alcohol trajectories

American Journal of Public Health

(2012)

W.M. Compton et al.

Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States

Archives of General Psychiatry

(2007)

H.S. Connery

Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions

Harvard Review of Psychiatry

(2015)

E.L. Deci

Intrinsic motivation

(1975)

D. Denis-Lalonde et al.

Beyond the buzzword: A concept analysis of harm reduction

Research and Theory for Nursing Practice

(2019)

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ReviewExpanding the continuum of substance use disorder treatment: Nonabstinence approaches

Highlights

Abstract

Section snippets

Background

Historical context of nonabstinence approaches

Nonabstinence goals among people with SUD

Models of nonabstinence psychosocial treatment for SUD

Future directions for research

Conclusions

Role of funding source

Contributors

Declaration of Competing Interest

International Journal of Drug Policy

Addictive Behaviors

Addictive Behaviors

International Journal on Drug Policy

Addictive Behaviors

Journal of Substance Abuse Treatment

Clinical Psychology Review

Drug and Alcohol Dependence

Journal of Substance Abuse Treatment

Journal of Substance Abuse Treatment

Clinical Psychology Review

Addictive Behaviors

The International Journal of Drug Policy

Journal of Substance Abuse Treatment

Drug and Alcohol Dependence

Journal of Substance Abuse Treatment

Journal of Substance Abuse Treatment

The International Journal of Drug Policy

Social Science and Medicine

Journal of Substance Abuse Treatment

Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes

Alcohol and Alcoholism

Trends in the use of methadone and buprenorphine at substance abuse treatment facilities: 2003 to 2011

Diagnostic and statistical manual of mental disorders

The origins of the Minnesota model of addiction treatment–A first person account

Journal of Addictive Diseases

The New York needle trial: The politics of public health in the age of AIDS

American Journal of Public Health

The twelve steps of Alcoholics Anonymous

Motivational interviewing interventions and alcohol abuse among college students: A systematic review

American Journal of Health Promotion

Evaluation of a motivational interview for substance use within psychiatric in-patient services

Addiction

Community perceptions of comprehensive harm reduction programs and stigma towards people who inject drugs in rural Virginia

Journal of Community Health

Social foundations of thoughts and action: A social cognitive theory

Using mindfulness in a harm reduction approach to substance abuse treatment: A literature review

International Journal of Behavioral Consultation and Therapy

Motivational interviewing with hazardous drinkers

Journal of the American Academy of Nurse Practitioners

Outcome in relation to drinking goals in alcohol-dependent individuals: A follow-up study 2.5 and 5 years after treatment entry

Alcohol and Alcoholism

Seeking the middle way: G. Alan Marlatt and harm reduction

Addiction Research & Theory

Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial

Substance Abuse

Mindfulness-based relapse prevention for substance use disorders: A clinician’s guide

Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial

JAMA Psychiatry

Relapse and relapse prevention

Annual Review of Clinical Psychology

The effects of drinking goal on treatment outcome for alcoholism

Journal of Consulting and Clinical Psychology

The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials

Journal of Consulting and Clinical Psychology

An evidence review of the outcomes that can be expected of drug misuse treatment in England (PHE publications gateway number: 2016489)

A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse prevention and interpersonal psychotherapy

The American Journal of Drug and Alcohol Abuse

Harm reduction -A systematic review on effects of alcohol reduction on physical and mental symptoms

Addiction Biology

Gender differences in substance abuse treatment and barriers to care among persons with substance use disorders with and without comorbid major depression

Journal of Addiction Medicine

Project-based housing first for chronically homeless individuals with alcohol problems: Within-subjects analyses of 2-year alcohol trajectories

American Journal of Public Health

Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States

Archives of General Psychiatry

Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions

Review
Expanding the continuum of substance use disorder treatment: Nonabstinence approaches