The abstinence violation effect (AVE) has been described as the “eff-it” phenomenon. It’s the “I already ate half a box of cookies, so I might as well eat them all” reaction that a person on a diet is prone to. It’s the “I already had a drink tonight, so I might as well black out” thought process that a person trying to address their substance use disorder might engage in.
To be even clearer, the AVE leads to:
– More extreme behavior during a relapse
– More negativity and pessimism about the meaning of a relapse
First characterized as an important ingredient in the relapse process in the mid-1980s, the AVE has profound relevance for addiction professionals today. In our era of heightened overdose risk, the AVE is more likely than ever to have tragic effects.
Furthermore, the AVE is something we become vulnerable to when we begin to address unhealthy behaviors–in other words, when we seek treatment and support. Therefore, treatment providers have an ethical obligation to try to mitigate the possible harms of the AVE because it is associated with the care they are providing.
Does 12-Step Contribute to the AVE?
Twelve-step can certainly contribute to extreme and negative reactions to drug or alcohol use. This does not mean that 12-step is an ineffective or counterproductive source of recovery support, but that clinicians should be aware that 12-step participation may make a client’s AVE more pronounced.
There are several ways that 12-step that can contribute to the AVE. Most importantly, 12-step programs tend to be abstinence-based, emphasizing that an authentic or high-quality recovery depends on abstaining completely from drugs and alcohol. Furthermore, 12-step programs often celebrate abstinence milestones and encourage participants to count abstinent days, leading to a perception that someone who resumes substance use is “going back to the beginning” and has not made progress in recovery.
As with all things 12-step, the emphasis on accumulating “time” and community reaction to a lapse varies profoundly from group to group, which makes generalizations somewhat unhelpful. However, broadly speaking, there are clear features of 12-step programs that can contribute to the AVE.
Although the benefits of 12-step participation may (and quite often do) outweigh the added AVE risk, clinicians should be aware of this particular risk and take steps to counteract it.
What Can Clinicians Do To Counteract the AVE?
Discuss the AVE with clients. Dr. Heather Fulton, a psychologist who presented a webinar on Cognitive Behavioral Therapy for substance use disorders (full recording available here) emphasized the importance of educating clients about AVE. She said that AVE can contribute to a stronger perceived effect of the substance during a relapse. This, in turn, can reinforce the client’s old ideas that “cocaine makes me fun” or “marijuana relaxes me” or “alcohol helps me cope.”
Before any substance use even occurs, clinicians can talk to clients about the AVE and the cognitive distortions that can accompany it. This preparation can empower a client to avoid relapse altogether or to lessen the impact of relapse if it occurs.
Reframe relapse when and if it occurs. Here are several ways that clinicians can respond to a client’s substance use, particularly if the client seems to be experiencing a particularly intense AVE:
You used last night, but you had been sober for 30 days before. So in the past 31 days, you have been sober for 30. That’s more sobriety than you have experienced in many years.
Learning to get sober is like riding a bicycle. Mistakes will be made. It’s important to get back up and keep trying.
Most people who eventually get sober do have relapses along the way. You are not unique in having suffered a relapse and it’s not the end of the world.
Note that these script ideas were pulled from a UN training on cognitive behavioral therapy that is available online.
Provide naloxone and overdose prevention training to all clients. One of the biggest problems with the AVE is that periods of abstinence from opioids increase a person’s risk of overdose and today’s heroin is often tainted with super-potent fentanyl analogs. As a result, the AVE can be profoundly dangerous in today’s drug market. Because of heightened overdose risk, treatment providers can offer naloxone and overdose prevention training to all clients, even those whose “drug of choice” does not include opioids. Rather than communicating pessimism about a client’s potential to recover, these overdose prevention measures acknowledge the existence of the AVE and communicate that safety is more important than maintaining perfect abstinence. More information on overdose prevention strategies in treatment settings is available here.
Avoid harsh sanctions for continued substance use. More and more, behavioral health organizations are moving away from “kicking people out of treatment” if they return to substance use. This type of policy is increasingly recognized as scientifically un-sound, given that continued substance use despite consequences is a hallmark symptom of the disease of addiction. Although it may be helpful for treatment centers to incorporate small penalties or rewards for specific client behaviors (for example, as part of a contingency management program), enforcing harsh consequences when clients do not maintain total abstinence will only exacerbate the AVE. As a reminder, in an era of very potent opioids, this can lead to fatal results.
Support all paths to recovery. Although abstinence from all substances is an excellent recovery goal for some, research consistently shows that many people who resolve alcohol and drug problems follow a path of moderation. Furthermore, the use of FDA-approved medications (which not all clients will view as “abstinence”) has been shown to produce the best health and recovery outcomes for people with opioid use disorders. Although there may be practical reasons for your client to choose abstinence as a goal (e.g., being on probation), it is inaccurate to characterize abstinence-based recovery as the only path to wellness. Celebrate recovery in all its forms.