Approximately 10.6% of individuals with Substance Use Disorders (SUD) in the US seek treatment, with 40-60% relapsing within a year (Dept of Health and Human Services, 2008; McLellan et al, 2000). This highlights a real need for substance abuse treatment that focuses on relapse prevention.

This blog summarises a recent RCT from JAMA Psychiatry on the relative efficacy of mindfulness-based relapse prevention (MBRP), standard relapse prevention (RP), and treatment as usual (TAU) for SUD  (Bowen et al, 2014).

The researchers tested mindfulness-based treatment, which has previously been proven effective in:

• Anxiety (Kabat-Zinn et a,l 1992)
• Eating disorders (Kristeller & Hallett, 1999)
• Depression  (Ma & Teasdale, 2004)

Mindfulness practices help an individual to become more aware of specific external stimuli, which may cause cravings and subsequently relapse (Marlatt, 2002).

Methods

Participants

Participants were recruited from a private rehabilitation centre. Study eligibility was 18+ years of age, medical clearance, ability to attend sessions, agreement to random allocation, and initial completion of inpatient or outpatient care. Those diagnosed with psychotic disorders, dementia, risk of suicide, being a danger to others, or who had previously participated in an MBRP trial were excluded.

Treatment Interventions

All interventions began 2 weeks after baseline assessment. The TAU group remained in standard aftercare alongside individuals not enrolled in the study, while the MBRP and RP groups were removed from primary care and returned on completion. All assessments were conducted with research staff, however participants whom couldn’t attend could complete these online or on the phone. Individuals who relapsed were allowed to remain in their intervention and receive additional help.

Treatment as usual (TAU):

• Was based on the 12 step Alcoholics/Narcotic Anonymous programme
• Participants (n=95) attended weekly open-discussion sessions lasting 1.5 hours with topics facilitated around recovery (Alcoholics Anonymous World Services, 1952)

Mindfulness-Based Relapse Prevention (MBRP):

• Consisted of 8 weekly 2-hour sessions lead by 2 therapists with 6-10 participants (n=103)
• The first few weeks focused on awareness of cognitive, physical and emotional phenomena, while subsequent sessions focused on mindfulness practices in relapse prevention and a balanced lifestyle
• Each session included a 20-30 minute guided meditation, experiential skills based practices, and discussion of practical application (44)
• On conclusion of the sessions, participants received hand-outs and audio-recordings of mindfulness exercises for homework and tracking sheets to record mood and cravings

Relapse Prevention (RP):

• Was similar to the MBRP in length, size, location, format, and homework
• The main objectives were to assess high-risk situations, coping skills, goal setting, problem solving, and social support
• Participants (n=88) also monitored their daily craving and mood (Daley & Marlatt, 2006)

Results

Descriptive Analysis

• On completion, 100% of RP participants and 88.3% of MBRP participants reported using the skills taught at least once a week
• 12 months follow up, 100% of RP participants and 67.6% MBRP participants still reported weekly use of the skills taught

Analysis

Regression models were used to estimate ratios for relapse to drinking and drug use during the 12 month follow up using treatment groups, age, treatment site, treatment history, treatment house, and baseline severity as covariates.

• Compared to TAU, the MBRP and RP groups showed a 54% decreased risk of relapse to drug and 59% decreased risk of relapse to heavy drinking
• Compared with RP, the MBRP groups showed a 21% increase in relapse risk to first drug use
• RP and MBRP did not differ on time to first heavy drinking day

Three months

• There was no difference between drug use or drinking between treatment groups

Six Months

• Among those whom reported drinking heavily, RP and MBRP reported 31% fewer days than TAU participants
• Compared to TAU participant, RP and MBRP had a higher probability of abstinence from drug use and not engaging in drinking
• There was no difference between RP and MBRP at 6 months

Twelve Months

• Among those whom reported substance use, MBRP participants reported 31% fewer drug days and a higher probability of not engaging in heavy drinking compared to the RP participants

Discussion

Bowen et al (2014) provide evidence that MBRP and RP are more beneficial aftercare options compared to the traditional 12-step course of treatment. While there were no differences between the treatment conditions at 3 months, at 6 months RP and MBRP displayed a reduced risk for heavy drinking lapse to drug use compared to treatment as usual. At 12 months, MBRP participants displayed less drinking and drug days compared to RP, suggesting this intervention provides long-term sustainability for those with substance abuse disorders.

The longer lasting effects displayed in MBRP may be due to an individual’s increased awareness of cravings and other low moods which accompany these cravings (Witkiewitz & Bowen, 2010). Individuals treated with MBRP have experience in recognising their cravings, and are able to continually practice, thus modifying their responses more positively over time.

However, it should be noted that in all three treatment conditions, the rates of abuse were lower than similar studies on substance abuse disorders (Laudet et al, 2007). Although, the rates are concurrent with other research conducted within the same agency (Bowen et al, 2009), which may be a result of drug screening and participation in on-going aftercare.

Links 

Bowen S, Witkiewitz K, Clifasefi SL, 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; (Published online March 19, 2014):. doi:10.1001/jamapsychiatry.2013.4546. [Abstract]

Substance Abuse and Mental Health Services Administration. Treatment Episode Data Set (TEDS): 2005: Discharges From Substance Abuse Treatment Services: DASIS Series: S-41. Rockville, MD: Dept of Health & Human Services; 2008. Dept of Health & Human Services publication No. (SMA) 08-4314.

McLellan  AT, Lewis  DC, O’Brien  CP, Kleber  HD.  Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689-1695. [PubMed abstract]

Kabat-Zinn  J, Massion  AO, Kristeller  JL,  et al.  Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am J Psychiatry. 1992;149(7):936-943. [PubMed abstract]

Kristeller  JL, Hallett  CB.  An exploratory study of a meditation-based intervention for binge eating disorder. J Health Psychol. 1999;4(3):357-363. [PubMed abstract]

Ma  SH, Teasdale  JD.  Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. J Consult Clin Psychol. 2004;72(1):31-40. [PubMed abstract]

Marlatt  GA.  Buddhist philosophy and the treatment of addictive behavior. Cognit Behav Pract. 2002;9(1):44-49. [Abstract]

Alcoholics Anonymous. Twelve Steps and Twelve Traditions (PDF). New York, NY: Alcoholics Anonymous World Services; 1952.

Daley DC, Marlatt GA. Overcoming Your Alcohol or Drug Problem: Effective Recovery Strategies: Therapist Guide.2nd ed. New York, NY: Oxford University Press; 2006.

Witkiewitz  K, Bowen  S.  Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. J Consult Clin Psychol. 2010;78(3):362-374. [Abstract]

Laudet  A, Stanick  V, Sands  B.  An exploration of the effect of on-site 12-step meetings on post-treatment outcomes among polysubstance-dependent outpatient clients. Eval Rev. 2007;31(6):613-646. [PubMed abstract]

Bowen  S, Chawla  N, Collins  SE,  et al.  Mindfulness-based relapse prevention for substance use disorders: a pilot efficacy trial. Subst Abus. 2009;30(4):295-305. [Abstract]