Prevention of Substance Abuse

Substance use disorders (SUDs) causes copious and serious systemic problems within our society. There has been an ongoing increase in the frequency and the complicity of the widespread problems of substance use disorders. It impacts all areas of life. Families are broken and disrupted; it bankrupts a person’s spirituality; people are psychologically and emotionally traumatized; and the financial cost for the crimes committed by substance abusers along with the cost for prevention and treatment has escalated exponentially. The totality of the overall negative effects on our families, especially children has still not been fully realized and recognized. Families are breaking up and breaking down; children are experiencing low academic success and numerous behavioral problems in school, school dropout rates are at an all time high, low or no self-esteem, and suicides are more frequent along with children killing each other (Dailey and Feit, 2013).

According to the National Institute on Drug Abuse (NIDA) 2011, the United States of America spends over $600 billion each year. This cost includes imprisonment of offenders, therapeutic treatment programs, and decline in production and efficiency, hospital and doctors expenses. The National Center on Addiction and Substance Abuse (NCASA) states that over 70 percent of the budget is spent in the area of health care and medical expenses related to Substance Use Disorders. These costs are escalating at an all time high and will probably exceed the trillion dollar mark if things keep going in this direction.

In spite of these astronomical cost and the money involved in drug education, treatment and prevention the relapse rate for individuals who have sought professional help is still between 60-90 percent within the first year. This means that for every 10 people who go through treatment, at least 7 of them end up returning to their substance of choice. Many studies have been conducted to analyze and evaluate the effectiveness of the many relapse prevention treatment models. In this paper we will look at the three most prominent models and make an assessment based on the most current research of which one has proven to get the best results. The three treatment models are Relapse Prevention (RP), Treatment as Usual (TAU or 12-Step), and Mindfulness-based Relapse Prevention Model.

Substance Use Disorder

The DSM-5 has reclassified the two separate categories for substance dependence and substance abuse and made one category which is called a “substance use disorder” (APA, 2010). “In the DSM-IV-TR, an individual must meet at least three of seven dependence symptoms: tolerance; withdrawal; using larger amounts than intended; unsuccessful attempts to stop or control substance use; spending a great deal of time obtaining, using, or recovering from the effects of the substance; important activities given up or reduced because of substance use; and continued use despite substance-related physical or psychological problems.

In contrast, the diagnosis of substance abuse is given to someone who might use a substance and suffer adverse consequences, yet does not show dependence. The focus is primarily on the adverse social consequences of substance use. Diagnostically, the individual must meet at least one of the following symptoms: failure to fulfill major role obligations at work, home, or school; use in Physically hazardous situations (e.g., drunk driving); substance-related legal problems; and continued use despite recurrent substance-related social or interpersonal problems (APA, 2000).”

Relapse

Relapse is defined in several different ways. Marlatt “defines relapse as a breakdown or setback in a person’s attempt to change or modify a target behavior.” Moore defines relapse as a “return to any use of substance” (Moore et al., 2014, p. 619). Another word to consider in regards to substance use disorders is “lapse.” The initial return to substance use following a period where a person has not been using is called a “lapse” which could just be a onetime event. But, a continual or ongoing repetition of this substance use behavior is considered a relapse.

According to the current research, relapse is a fearsome challenge facing those persons who are afflicted with substance use disorders. As they attempt to change their self-destructive lifestyles they have to face the almost irresistible cravings, physical and emotional triggers that doesn’t disappear overnight. This has led several authors to describe relapse as “complex, dynamic, and unpredictable (Burhringer, 2000; Donovan, 1996; Marlatt, 1996; Shiffman, 1989).” Substance use behavior is complex and extremely unpredictable. Hendershot and Witkiewitz state that the relapse for alcohol or tobacco is as high as 80-90%. Relapse is exceedingly common following substance use disorder treatment and necessitates the need for greater follow-up and better aftercare interventions.

Relapse Prevention Model

The Relapse Prevention (RP) model has been a foundation of substance use theory and treatment for over thirty years. The unrelenting influence of RP is supported by its assimilation in most cognitive-behavioral substance use interventions. On the other hand, the inclination to consider RP inside other treatment models has created a obstacle to methodical assessment of the RP model. In general, RP is still a prominent cognitive-behavioral structure that can enlighten the academic and scientific approaches to understanding and promoting change in a person’s conduct. Relapse prevention (RP) is an intervention strategy for decreasing the odds and severity of relapse following the termination or decline of challenging conduct. Thirty years from the time when it was first presented, the RP model is still one of the prominent cognitive-behavioral approach in the treatment and study of addictions.

Today, many of the psychosocial treatments uses concepts from the Relapse Prevention model even though the original intent for “relapse prevention” was primarily designed to stand for a definite scientific intervention. Relapse Prevention strategies are now essential to most psychosocial treatments for substance use, including many of the most widely disseminated interventions. Currently, Relapse Prevention has in many ways been transformed into a comprehensive term covering the majority of the skill-based treatments that call attention to cognitive-behavioral skills building and coping responses. Despite the fact that attesting to the extensive influence of the Relapse Prevention model, the widespread use Relapse Prevention approaches furthermore tends to cause difficulties in efforts to define Relapse Prevention-based treatments and assess their overall effectiveness.

This Relapse Prevention model proposed by Marlatt establishes both a theoretical structure for understanding relapse and a set of treatment strategies intended to minimize the possibility of a person returning back to their substance use and abuse. As a result of this cognitive-behavioral model of relapse, Relapse Prevention was originally formulated due to an expansion of a long-established behavioral approach to study and treatment of people who were addicted to substances. The development of this cognitive-behavioral theory of substance use bring noteworthy advancements in the understanding of the process of relapse, several of these came out of the conventional (e.g., disease-based) models of addiction. Case in point, the conventional models often contribute relapse to factors like cravings or withdrawal.

Cognitive-behavioral theorists also rejected the disease model of addiction and did not accept the beliefs that relapse were a dichotomous outcome. Rather than being viewed as a state or endpoint signaling treatment failure, relapse was considered as an unpredictable development that starts before and goes further than the return to the target behavior. Based on this viewpoint, when a person reverts back to substance use after they have had a significant time of abstinence, it is not considered a failure but a lapse. This lapse could result in a total relapse, but not necessarily so. The person could identify and correct the negative and undesirable behavior before it becomes worst.

An important implication is that rather than viewing this as a complete failure in the behavior change process, this lapse could be considered a temporary setback and an opportunity for the person to learn from the circumstances. In looking at relapse as a ordinary (although unwanted) experience, emphasizing related background over internal causes, and distinguishing relapse from treatment failure, the Relapse Prevention model introduced a complete, flexible and positive option to conventional approaches. Marlatt's original Relapse Prevention model is outlined in Figure 1. A basic belief is that relapse actions are followed by a high-risk situation, which is generally defined as any environment that makes a person susceptible to engaging in the risky behavior.

Original cognitive-behavioral model of relapse 

According to the APA Dictionary of Psychology (VandenBos, 2007), potential benefits of self-help groups that professionals may not be able to provide include camaraderie, emotional support, practical awareness, individuality, important roles, and a sense of community. Alcoholics Anonymous was founded in 1935 by Dr. Robert Holbrook Smith an Akron, Ohio surgeon and William Griffith Wilson, a New York stockbroker. Alcoholics Anonymous was the first 12-step group. The AA agenda was based on the belief that only someone with the “combined experience” of alcoholism could help another alcoholic in the healing process (Wilson, 1939). On the other hand, this does not mean that AA believe that people who are not alcoholics cannot assist or support an alcoholic in his or her journey to become sober.

One of the authors of the Big Book, Bill Wilson, acknowledged that in the majority of the times, just doing the 12-steps alone would not be sufficient to bring a person back to full mental strength. He encouraged those members of AA to not hesitate to consult with outside help when necessary. When Alcoholics Anonymous first began, most of the people who initially attended the meetings had more than just alcohol use disorder; they had other substance use disorders. But, AA had emerged into a “singleness of purpose” fellowship in which “the only requirement for membership was a desire to stop drinking” (NA Foundation Group, 2013).

Alcoholics Anonymous program has been described as a spiritual recovery movement in a social system that promotes new and transcendent meaning in the lives of their recruits (Galanter, 2007). Spirituality has been defined as that which gives significance and purpose in life (Puchalski 2003) as well as a sense of personal identity and transcendence that motivate individuals beyond the practicalities of daily living (Galanter et al. 2011). Spirituality is fundamental to Alcoholics Anonymous (AA) as demonstrated in the 12 steps that members apply in working the program as well as in the Twelve Traditions that relate to the function of the AA groups. The origin of AA can be traced to the influence of the Oxford Group, a Christian evangelical group that promotes self-inventory admission of personality flaws, repayment for damage done, and sharing with others.

Alcoholics Anonymous as a spiritual recovery movement sees addiction as a disease of the mind, body, and spirit, and requires a pledge to abstinence, and a working of the 12 steps. The primary focus of the 12-steps is to bring a greater consciousness and understanding of one’s own individual point of reference with God. The first step involves acceptance followed by total submission, acknowledgement of mistakes, a desire to have God eradicate character flaws, and a commitment to maintaining a lifestyle of abstinence and growth in spirituality by prayer and meditation. As a person works through the first 11 steps, he will experience a spiritual consciousness which can lead to greater confidence and trust in God. The Twelve Traditions which exemplify the camaraderie of sharing and support are values important to the functioning of AA groups. The traditions are designed to provide guiding principles for AA groups to endure conflict and to function efficiently in the absence of a formal structured governing organization (Detar 2011).

Mindfulness-Based Relapse Prevention Model

Mindfulness-Based relapse Prevention (MBRP) is a group-based psychosocial aftercare intervention which integrates evidence-based practices from mindfulness-based interventions and cognitive-behavioral Relapse Prevention interventions. The goal is to access the efficacy of Mindfulness-based Relapse Prevention model in comparison with the Relapse Prevention model, and the Treatment As Usual (TAU or the 12-Step) model. A research study was conducted with 286 participants from October 2009 to July 2012. All participants successfully finished a substance use disorder treatment held at a private nonprofit treatment facility. Each person was randomly selected and placed in one of the three aftercare program, the MBRP, the RP, or the TAU one year for observation. During the one year treatment period, individuals were randomly placed into eight weekly group sessions of MBRP, RP, or TAU. 4

In my opinion what made this treatment most effective were the follow-up assessments that were conducted at the third, sixth, and twelve month time periods. The participants did self-reporting and drug and alcohol urine screenings periodically throughout the twelve month time period. In the findings those who were assigned to the RP and MBRP groups had a significantly lower risk of relapse to substance use and heavy drinking. At the twelve month follow-up assessment, the MBRP participants reported a significantly fewer days of substance use and a substantial decrease in heavy drinking compared with other two groups. In conclusion, because of these results I believe that Mindfulness-based Relapse is more beneficial to individuals undergoing substance use disorder treatments.

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