{"id":16377,"date":"2023-03-14T18:24:31","date_gmt":"2023-03-14T18:24:31","guid":{"rendered":"https:\/\/drugprevent.org.uk\/ppp\/?p=16377"},"modified":"2023-05-16T19:48:04","modified_gmt":"2023-05-16T19:48:04","slug":"recognizing-and-reversing-relapse","status":"publish","type":"post","link":"https:\/\/drugprevent.org.uk\/ppp\/2023\/03\/recognizing-and-reversing-relapse\/","title":{"rendered":"Recognizing And Reversing Relapse"},"content":{"rendered":"<div class=\"page-articles-show__meta-container\">\n<div class=\"article-notes\" style=\"text-align: justify\"><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><strong>Michael Weaver, MD<\/strong>\u00a0Medical director, Center for Neurobehavioral Research on Addiction\u00a0<em>Dr. Weaver has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.<\/em><\/span><\/div>\n<div><\/div>\n<\/div>\n<div class=\"page-articles-show__content\">\n<div class=\"body gsd-paywall\" style=\"text-align: justify\">\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><em>I first met 32-year-old Miranda after a drug relapse that followed a stay in a residential addiction treatment facility. She had begun experimenting recreationally with prescription opioids in her early 20s, but her use escalated after she was involved in a car accident a few years later and a doctor began prescribing opioids for pain. Because of her increased use, Miranda decided on her own to enter a 28-day detox and rehab, but relapsed immediately upon discharge. Several months later, she made an appointment with me to discuss opioid agonist treatment. I prescribed buprenorphine, and for the first few months of treatment she appeared to be doing well.<\/em><\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Addiction treatment often begins with high hopes and apparent success, but it\u2019s important to remember that addiction is a disease with a relapse rate of 40%\u201360% (McLellan et al, JAMA 2000;284(13):1689\u20131695; Dawson DA et al,\u00a0<em>Alcohol Clin Exp Res<\/em>\u00a02007;31:2036\u20132045). Be realistic: Expect that patients will go through cycles of relapse and recovery. Learn the warning signs for relapse, the measures you can take to prevent it, and what to do after it has occurred.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><strong>Recognizing relapse<\/strong><\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">There are a number of clues that someone has relapsed\u2014or may be headed that way:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Reduced eye contact during a \u00adsession<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">A more anxious demeanor than usual<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Less engagement, or a sense of holding back from the treatment process<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Exacerbated emotional distress or worsening co-anxiety or depression<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Vague answers to questions<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Reduced attendance at 12-step programs or therapeutic groups<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Missed visits with a psychiatrist or other caregiver<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">None of these red flags individually spell impending relapse\u2014instead, it\u2019s the pattern of behavior that tells the story. Your patient may not actually have used yet, but (wittingly or unwittingly) is starting to go down that road. This is known as desire thinking (Martino F et al,\u00a0<em>Addict Behav<\/em>\u00a02017;64:118\u2013122), and in 12-step programs, it\u2019s called \u201cdrinking thinking.\u201d<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><em>After three months of buprenorphine treatment, I began to notice worrisome signs of potential relapse during one of our sessions. Miranda\u2019s answers to my questions were more vague than usual, her eye contact faltered, and she seemed a little more anxious. Before that session, we had started talking about smoking cessation, but that day she didn\u2019t seem interested.<\/em><\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><em>At that point, I told Miranda I would need a urine sample. She hemmed and hawed for a minute, then admitted that she had started using again within the past few days. She had been spending time with her sister, who also abused a variety of illegal and prescription drugs; while there, her sister had told her, \u201cI know you can\u2019t use opioids, but here are some benzodiazepines. Why don\u2019t you try those?\u201d Miranda acquiesced, and that quickly escalated to use of marijuana and finally opioids.<\/em><\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Miranda\u2019s story is fairly typical. Pressure from peers not in recovery, or simply spending time with old friends not in recovery, is cause for concern. In fact, if a patient divulges spending time with past friends to you, this can be a clue that\u2019s just as telling as poor eye contact or unusual jitteriness.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">The marijuana Miranda\u2019s sister provided only complicated things more. For many people, using marijuana or alcohol provides a false sense of confidence. They think, \u201cI can smoke some pot or have a couple of drinks because they aren\u2019t my problems, and I can handle them.\u201d But these substances are called gateway drugs for a reason\u2014they can impair judgment and lead people to the very drugs they want to avoid.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><strong>Proactive is better than reactive<br \/>\n<\/strong>It\u2019s much easier to prevent a problem than to treat one, so I spend a lot of time teaching patients how to \u00adidentify their own risk factors for relapse. The key is reminding patients that any unusual event can reduce their resolve because if they are caught off guard, it is hard to stay focused on abstinence goals. Examples of such events include things like visits by a disliked in-law, a chance meeting with someone from the patient\u2019s drug-using past, and waylaid plans for a vacation.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">I find it helpful to talk to patients about potential challenges they might face, and then help them cope with the stress of such situations by rehearsing responses and planning tactics. For a troublesome in-law, for example, you can encourage the patient to express concerns to her spouse and to explain the need to keep away for much of the visit. You can do some role-playing to simulate a chance conversation with a past friend who still uses so the patient has a script that will make saying \u201cno\u201d easier and more automatic. Responses can range from, \u201cNo thanks, I\u2019ve decided not to use because I don\u2019t want any problems at my new job\u201d to, \u201cMaybe another time,\u201d which is non-judgmental and helps avoid confrontation.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Relapse triggers are often situational. For instance, if everyone from work is going out for a drink, a patient might feel obligated to drink too. Walk the patient through a discussion about whether attending the event but not imbibing alcohol would actually affect his job security. For example, if he nursed a club soda rather than an alcoholic beverage, would anybody really care?<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">To help patients deal with temptations, I encourage them to write daily in a journal, even if it\u2019s only half a page. This helps them identify what might be troubling them, put the issues in perspective, and work out solutions. (Ed note: For more information about relapse prevention skills based on cognitive behavioral therapy, see<em>\u00a0Cognitive Behavioral Skills Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals With Alcohol Abuse and Dependence<\/em>:\u00a0<a style=\"color: #0000ff\" href=\"https:\/\/pubs.niaaa.nih.gov\/publications\/ProjectMatch\/match03.pdf\">https:\/\/pubs.niaaa.nih.gov\/publications\/ProjectMatch\/match03.pdf<\/a>.)<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\"><strong>If a relapse is already in progress<br \/>\n<\/strong>You can\u2019t always capture the problem before it has occurred. If your patient has relapsed, the most important task is to help minimize the severity of the relapse. Substance-using patients often slip into an all-or-nothing attitude, in which they say to themselves, \u201cI\u2019ve relapsed; I\u2019ve failed treatment. My abstinence is over, so I might as well give in to the drugs and forget about treatment altogether.\u201d (For more information on cognitive distortions in substance use disorder, see Beck A et al,\u00a0<em>Cognitive Therapy of Substance Abuse<\/em>. New York: Guilford Press, 1993.)<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">In such cases, it\u2019s important to reassure patients that a relapse doesn\u2019t mean the end of the world\u2014in fact, it doesn\u2019t even mean the treatment didn\u2019t work. Just like any chronic disease process, addiction treatment involves remissions and exacerbations, and sometimes all that\u2019s needed is a change of approach. I will often give patients the analogy of treating an infection: \u201cSay you have an infection that requires oral antibiotics. If the infection comes back, you don\u2019t decide that the treatment was worthless. Instead, you talk about it with your doctor, who might need to prescribe stronger oral antibiotics, or even recommend a hospital stay for intravenous \u00adantibiotics. It\u2019s the same thing here. Our first approach to maintaining recovery only worked for so long, so now we\u2019ll try a different approach.\u201d<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">How do you step up your treatment game to help a relapsing patient? There are many next steps, depending on the circumstances:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Seeing the patient more frequently on an outpatient basis<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Requiring more frequent urine testing to keep the patient accountable and provide an incentive to think twice about using<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Having the patient go to more 12-step meetings or more group or individual therapy sessions<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Increasing the dosage of medication-assisted therapy, such as an opioid antagonist<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<ul>\n<li style=\"list-style-type: none\">\n<ul>\n<li><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Having the patient undergo a brief inpatient stay for detox<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">After Miranda\u2019s relapse, I increased her dose of buprenorphine\/naloxone from 12 mg\/3 mg to 16 mg\/4 mg daily to help with cravings and prevent any withdrawal from her recent opioid use. I also asked her to commit to seeing her therapist more frequently. We worked on some of the issues that led to the relapse; specifically, I talked with her about avoiding contact with her sister. In this case, I didn\u2019t suggest 12-step meetings, because she wasn\u2019t particularly interested in that approach. However, because her depression had started to worsen, I made an adjustment to her antidepressant medication.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">These steps worked. Miranda went to see her therapist more often, and she responded to the adjustments in her buprenorphine dose. She also stayed away from her sister for a while and worked on refusal skills: \u201cI know you\u2019re trying to be helpful, but it\u2019s not what I want or need right now. Please don\u2019t offer me anything.\u201d<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Miranda was highly motivated\u2014more than many other patients. But this doesn\u2019t mean she\u2019s immune to problems leading to other relapses (hopefully short-lived ones), even months or years down the road. That\u2019s often part of the process of recovery\u2014it doesn\u2019t always happen in a straight line.<\/span><\/p>\n<p><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Like what you just read? Dr. Weaver\u2019s new book,\u00a0<em>Addiction Treatment<\/em>, is replete with practical tips for helping addicted patients yourself rather than losing them to follow-up when referring them elsewhere. The 14 brief chapters contain detailed instructions on how to frame sensitive questions to elicit honest answers, user-friendly charts to help you describe what drugs to prescribe in which circumstances, and much more. Feel great about helping your patients pull their lives together. Go to\u00a0<a style=\"color: #0000ff\" href=\"https:\/\/thecarlatreport.com\/AddictionGuide\">https:\/\/thecarlatreport.com\/AddictionGuide<\/a>\u00a0for more information.<\/span><\/p>\n<\/div>\n<\/div>\n<div><span style=\"font-family: verdana, geneva, sans-serif;font-size: 10pt;color: #0000ff\">Source: <a style=\"color: #0000ff\" href=\"https:\/\/www.thecarlatreport.com\/articles\/2582-recognizing-and-reversing-relapse\">Recognizing and Reversing Relapse | 2017-05-01 | CARLAT PUBLISHING (thecarlatreport.com)<\/a> May 2017<\/span><\/div>\n","protected":false},"excerpt":{"rendered":"<p>Michael Weaver, MD\u00a0Medical director, Center for Neurobehavioral Research on Addiction\u00a0Dr. Weaver has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity. I first met 32-year-old Miranda after a drug relapse that followed a stay in a residential addiction treatment facility. She had begun experimenting recreationally [&hellip;]<\/p>\n","protected":false},"author":12,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[73,86,36],"tags":[],"class_list":["post-16377","post","type-post","status-publish","format-standard","hentry","category-addiction","category-prescription-drugs","category-treatment-addiction"],"_links":{"self":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/16377","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/comments?post=16377"}],"version-history":[{"count":0,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/posts\/16377\/revisions"}],"wp:attachment":[{"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/media?parent=16377"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/categories?post=16377"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/drugprevent.org.uk\/ppp\/wp-json\/wp\/v2\/tags?post=16377"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}