Relapse Guide

Anyone who has ever overcome a substance abuse problem can look you in the eye and tell you that it was not easy process.

Addiction sinks its claws very deep into a person’s mind and life, and escaping its clutches is not always a clean process.

That’s why every recovery program stresses the importance of accounting for relapsing.

Guiding a patient through the knowledge of why people relapse, and how they can anticipate the signs of relapse, can make all the difference between an isolated slip and completely falling off the wagon.

What a Relapse Is and What It Isn’t

To begin with, it’s important to know the difference between a “slip” and a “relapse.” Broadly speaking, both terms refer to the patient indulging in their addictive behavior after completing treatment. A slip, however, has a couple of characteristics that distinguish it from a relapse:

  • A slip is one-off event; it is not necessarily the renunciation of the progress made in treatment.
  • The patient is still committed to the treatment program and ethic, notwithstanding the brief foray into their addictive behavior.

On the other hand, a relapse entails a full-on resumption of the addictive behavior by the patient after a period of abstinence, usually with no intention of adhering to the guidelines of the treatment program. It is possible that a single patient can relapse multiple times; that is, they alternate between periods of sobriety and indulgence.

While relapse should not be thought of as inevitable, it’s important to understand that relapse is part of the reality of being an addict. Psychology Today points out that “addiction relapse is common,” with as many as 90 percent of patients stumbling post-treatment.[1] Even the best of treatment programs cannot completely prevent the possibility of a relapse occurring. Years of addiction damage the brain’s self-control system, making it difficult to resist the triggers and stressors that once led an addict to their destructive behavior.[2] And as any addict can tell you, there are a lot of those triggers.

The Family Dynamic

There could be dozens of causes behind what makes an addict relapse. Broadly speaking, they fall into two categories: causes based on the addict’s environment and history, and causes based on the drug (or other addictive activity) itself.

For example, environmental causes for a relapse could be related to a lack of familial and social support. In a professional treatment program, the addict’s family and close friends should be made a part of the process. Indeed, PsychCentral explains that alcohol and drug addiction should be considered “family diseases,” since it is those circles that will feel the destructive effects of a substance abuse problem first and worst.[3] There is also the possibility that the family unit encouraged or enabled the addict’s behavior, either knowingly or otherwise. Participation in therapy and aftercare programs will help educate friends and family on their own culpability, and how it can be corrected.

To that effect, a therapist will convene sessions with the key people in the addict’s life, to explain to them the nature of the stressors and triggers that drove their loved one to addiction, what kept them going back to their drugs or destructive behavior, how best the family and friends can support their loved one through recovery, and how they can spot the signs of an impending relapse. This could mean that they will have to change their behavior in order to facilitate the patient’s recovery.[4] For example, they may have to dispose of all the alcohol in the house, if the addict’s weakness was alcohol. If the addiction was based on a particular behavior – gambling, shopping, eating, sex, etc. – then those activities, and all mention of those activities, will have to be curtailed.

Family members will also be coached on how they can offer support and encouragement to the patient, while still maintaining the ground rules and boundaries that provide structure and discipline for their newly abstinent loved one.

Failure to follow these guidelines – for example, by smoking marijuana at home when the addict is trying to stay clean – will make the recovery process unnecessarily difficult for the patient. One of the cornerstones of post-addiction abstinence is that the triggers and stressors that would have led to substance abuse or harmful behavior be removed from the addict’s environment. Unconcerned or obstinate friends and family members who persist in their behavior are one of the main reasons patients relapse.

Similarly, if the addict’s family members are judgmental or critical of the addict’s past behavior – which, when attending therapy sessions or joined aftercare support groups, they can learn not to be – that kind of reaction can also sometimes trigger the patient to resume their destructive behavior, believing it provides some kind of escape or release from the personal haranguing and humiliation by the people closest to them.

For Old Times’ Sake

As stated above, the addict’s environment needs to change if they are to have a fighting chance of avoiding relapse. This means that if they are subject to the same people, places, and events that once facilitated their addiction, they will constantly expose themselves to the temptation to have one more drink for old times’ sake, to get high just like the good old days when they used to be more fun, or some other form of peer pressure. Notwithstanding all the skills and strategies learned during therapy, addicts are still very susceptible to relapse for at least three months after they complete their treatment.

Around 66 percent of relapses for any addictive behavior take place within the first 90 days of achieving sobriety.[5]

The Harvard Medical School explains that even the slightest triggers – a heroin addict seeing a needle, an alcoholic passing a bar at which he used to drink, seeing an old drinking buddy – puts the addict in danger of relapse.[6]

So, when an addict receives an invitation to watch a football game on Sunday, attend a wedding, or simply blow off steam on a Friday night, one of the changes in a post-therapy life is drawing a line in the sand. If sobriety is to be taken seriously and relapse is to be denied, this may mean rejecting certain invitations; it may mean attending social events with a sponsor; it may even mean moving to a different city, to put as much distance as possible between the now-abstinent patient and the lifestyle that once drove him or her to the depths of addictive behavior. Here, out of sight might not just mean out of mind – it might be the difference between well-being and relapse.

Stress

If it is true that chronic stress leads to drug use and addiction,[7] it is similarly true that stress can trigger relapse.[8] Maintaining sobriety in the face of temptation, scorn, celebration, and ignorance about the patient’s past can heap enormous amounts of pressure on the addict: the pressure to conform, the pressure to abstain, the pressure to join in, the pressure to work the treatment program, the pressure to be accountable, and the pressure to be enjoy life. Where a patient might have once turned to alcohol, drugs, or some other behavior to cope with the stresses and challenges of life, the task now is to channel those negative emotions and bad moods into a more positive and healthier expression. But that is much easier said than done, especially in that fragile 90-day period following treatment discharge.

It’s in that 90-day period that the physiological toll of the addict’s substance abuse comes into play. Research conducted on drug users shows that there is substantial overlap between the brain systems involved in stress and emotions, and the brain systems involved in drug rewards. A 2005 article published in the journal Psychopharmacology found that increased activity in key brain regions during stress was “significantly associated with stress-induced cocaine craving.”[9]

Similarly, long-term alcohol abuse can lead to chemical and neurological alterations in the brain’s reward and stress pathways, which is particularly of note given how drugs target the reward centers in the brain.[10] While people who have never struggled with substance abuse may easily dismiss the notion of self-medicating, even in the most stressful of situations, the changes caused by drugs and alcohol in an addict’s mind prime them to seek respite from stress with their poison of choice. Even after completing a successful course of detoxification and psychotherapy, the physical craving for another shot, another hit, or another indulgence can be a source of stress in itself.[11]

Over-Confidence

A writer for PsychCentral says that one of the most common reasons for relapse she hears from her patients is: “I got complacent.”[12]

In retrospect, it’s not very surprising that patients feel like they’re on top of the world when they leave treatment. Their past is behind them, and the future is ahead of them. They feel refreshed, clearer, and cleaner than they have in months or even years. When they are confronted with a stressful situation or the temptation to use again, they remember the coping tools they learned in therapy. They call their accountability partner, they deal with the challenge in a positive and healthy way, and they move forward with life.

Success like this can manifest in grandiose feelings. The patient wonders if his or her addiction was really that bad, or they reach a point where they feel their accomplishments in abstinence mean they can have one drink without it killing them. There may be subtle lifestyle changes, too: they may not attend support group meetings as much as they used to, feeling that they don’t need to because of how well they’ve been doing. They might even consider going back to their old stomping grounds and hanging out with old connections, confident that their resolve is strong enough to say “no” to the inevitable pressure to drink or shoot up again.

Complacency might be the most insidious form of relapse because, as the American Bar Association says, it doesn’t come up on a patient when they’re down in the dumps and wistfully wishing they had a drink to make the pain go away; complacency sets in when life is going well, when a patient least expects it.[13] It is what Psychology Today calls “addiction’s blind spot.”[14] While confidence in and of itself is not problematic, the danger of relapse rises when that confidence becomes exaggerated and starts to assume unrealistic proportions.

The PsychCentral writer recommends that, notwithstanding how strong a patient feels after treatment, they should always continue working in whatever program of recovery helped them get sober. As important as it is to move forward in life – and to do so with confidence – it is equally important to have a sense of foundation. A good aftercare program will not only help a patient keep that perspective, but its members will also notice if the patient is disengaging because of a misguided sense of confidence or complacency.

Loneliness

For all the positive changes encouraged (and required) by drug treatment, breaking off ties with people and environments that once seemed fun and exciting can be disappointing. When a patient cuts those triggers and stressors out of his life, what’s left can seem underwhelming, and even boring. When a normal, healthy life doesn’t have the same thrill and atmosphere of the honeymoon period of a substance abuse lifestyle, the sense of loneliness that can arise can be a prime trigger for relapsing.[15]

Loneliness is enough of a trigger that it is part of an oft-repeated mantra of relapse warning signs, collected under the mnemonic:

“H.A.L.T”

  • Hungry
  • Angry
  • Lonely
  • Tired[16]

These moods and emotions, goes the theory, are most likely to push a recovering addict past the threshold of relapsing. It’s no accident that on the list of just four factors that would entice a patient to relapse, loneliness makes the cut.

It’s important to realize that one doesn’t have to be physically alone to be lonely. Even a patient who diligently attends 12-Step meetings and checks in regularly with their sponsor can feel disconnected from society and the world around her. Research on rats has shown that social isolation increases the susceptibility of addiction,[17] and the susceptibility for relapse is similarly present if a patient feels that, for all the support groups in the world, there’s no one they can really talk to.

One of the ways an addict might get around this problem is by developing new hobbies and interests. Exposing themselves to new crowds of people with similar interests will keep the feelings of isolation and discontentedness at bay. The benefit of making friends on the basis of something other than getting over addiction will introduce new things to talk about, and new ways to keep anxiety, frustration, and loneliness under control and in perspective.[18]

The Signs of a Relapse

Relapse should not be thought of as an inevitable part of the recovery process, but it is a part of the process nonetheless. Whether it is the temptation to use again, the opportunity to drink again, the pressure to gamble, or the compulsion to overeat, there will always be something to lure the addict off the straight and narrow. Before that actually happens, however, there are key warning signs that friends, family members, and support group members can – and should – watch out for.

For example, we’ve seen how stress can play a big role in pushing an addict to relapse. If the addict overreacts to stressful triggers – flying off the handle, plunging into depression – this may be a sign that they are losing the battle against the temptation to indulge in an addictive behavior to calm their anxiety. Relatedly, losing their temper at the slightest provocation, real or imagined, could also indicate that they are reaching a point where drinking or using doesn’t seem like such a bad idea (to them).[19]

Another relapse warning sign might be if the patient starts to reminisce on their previous lifestyle with fondness and nostalgia. Choosing to focus on the fun times and party atmosphere of a drinking problem, and ignoring the negative effects – health problems, relationship issues, financial woes – suggests that the siren song of the destructive behavior is sounding again, and the patient is listening to it. Further signs of this may be downplaying the severity of their problem (“It wasn’t that bad”), or flirting with danger by reconnecting with old friends from their pre-treatment days. Of course, romanticizing the past shows nothing more than their craving trying every possible way to manifest again, and this particular method involves making the patient’s history seem better than it was.

There are a number of other signs of relapse, including:
  • Withdrawing from social activities and interactions
  • Experiencing sleeping difficulties
  • Disengaging from aftercare support and follow-up treatment
  • Refusing or rejecting offers of support help from loved ones

If these signs are observed, the patient should be questioned on whether they have started using again, even before any evidence (empty bottles, receipts, drug paraphernalia, etc.) is found. The intention is to head off the danger of relapse as early as possible, or encourage the addict to reconnect with support groups immediately. In worst-case scenarios, it may be necessary to stage an intervention to confront the addict with the reality of the relapse, and the reality of the severity that a relapse entails.[20]

Citations

[1] “Why Relapse Isn’t a Sign of Failure.” (October 2012). Psychology Today. Accessed December 24, 2014.

[2] “Understanding Relapse.” (n.d.) HBO. Accessed December 23, 2014.

[3] “Family Involvement is Important in Substance Abuse Treatment.” (2011). PsychCentral. Accessed December 24, 2014.

[4] “Chapter 1 Substance Abuse Treatment and Family Therapy.” (2004). Substance Abuse and Mental Health Services Administration. December 24, 2014.

[5] “Relapse Prevention — Planning for Success.” (n.d.) Alberta Health Services. Accessed December 24, 2014.

[6] “How addiction hijacks the brain.” (July 2011). Harvard Medical School. Accessed December 24, 2014.

[7] “Chronic Stress, Drug Use and Vulnerability to Addiction.” (August 2009). Annals of the New York Academy of Sciences. Accessed December 24, 2014.

[8] “How Does Stress Increase Risk of Drug Abuse and Relapse?” (December 2001). Psychopharmacology. Accessed December 24, 2014.

[9] “Neural Activity Associated With Stress-Induced Cocaine Craving: A Functional Magnetic Resonance Imaging Study.” (December 2005). Psychopharmacology. Accessed December 24, 2014.

[10] “DrugFacts: Cocaine.” (April 2005). National Institute on Drug Abuse. Accessed December 24, 2014.

[11] “How Does Stress Lead to Risk of Alcohol Relapse?” (n.d.). Alcohol Research: Current Reviews. Accessed December 24, 2014.

[12] “5 Didn’t-See-It-Coming Relapse Triggers (And How to Avoid Them).” (n.d.) PsychCentral. Accessed December 24, 2014.

[13] “Relapse After Long-Term Sobriety (2009). American Bar Association. Accessed December 24, 2014.

[14] “Addiction’s Blind Spot.” (May 2012). Psychology Today. Accessed December 24, 2014.

[15] “10 Ways to Stop Being Lonely in Recovery.” (n.d.) PsychCentral. Accessed December 24, 2014.

[16] “5 Tips for Managing Triggers During Addiction Recovery.” (n.d.) PsychCentral. Accessed December 24, 2014.

[17] “Social Deprivation Enhances VTA Synaptic Plasticity and Drug-Induced Contextual Learning.” (January 2013). Neuron. Accessed December 24, 2014.

[18] “Hidden Benefits of Recreation: Hobbies Can Provide Physical Therapy, Stress Relief, Mindfulness.” (August 2013). United States Army. Accessed December 24, 2014.

[19] “6 Signs Your Alcoholic Loved One May Be Relapsing.” (December 2012). The Huffington Post. Accessed December 24, 2014.

[20] “Recognizing an Addiction Relapse.” (April 2009). Everyday Health. Accessed December 24, 2014.

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