Recovery from Addiction: Maintenance and Preventing Relapse

Abstract

Recovery is a multidimensional concept including biological, genetic, psychological, social, and cognitive components. While there are many definitions of recovery, there is no validated tool for measuring it. However, over the past decades, we have gained a deeper understanding of how substance use disorder (SUD) can benefit from psychosocial interventions, assisting an individual to achieve gradual, positive changes by understanding the stages of recovery. Relapse prevention (RP) collects cognitive-behavioral intervention strategies intended to prevent lapse (impulsive and brief use) and relapse (returning to uncontrolled use) among individuals with SUDs. RP is based on the biopsychosocial model of addiction where addictive behaviors are conceptualized as acquired habits with biological, psychosocial, and social determinants and consequences. Progress in recovery is most realistically measured according to the individual’s goals. Any positive changes are valued and reinforced by identifying clinical, nonclinical and self-management pathways for the individual.

Review Questions

• 1. A 50-year-old patient you see in your outpatient practice who was using methamphetamines had been able to stop her use for 2 months while trying to return to work. For the past two weekends in a row, the patient reports use of methamphetamines on Friday and Saturday. You sit down with your patient to discuss a recent relapse. You start by identifying “triggers,” which involve which of the following?

  • A. Feelings, thoughts, and emotions

  • B. Ideals, psychologies, and therapies

  • C. People, places, and things

  • D. Coping strategies

  • E. People, places, things, feelings, thoughts, and emotions

  Correct Answer: E

  Triggers are internal and external cues that cause a person in recovery to crave drugs and eventually relapse. External triggers are people, places, activities, and objects that elicit thoughts or cravings associated with substance use. Individuals in recovery can stay away from the dangers of external triggers by developing action plans to avoid triggers that remind them of past drug use. Internal triggers are more challenging to manage than external triggers. They involve feelings, thoughts, and emotions formerly associated with substance abuse.

  B. Ideals, psychologies, and therapies are not triggers. Humanistic and existential approaches (including empathy, encouragement of affect, reflective listening, and acceptance of the individual’s subjective experience) are useful in any type of brief therapy session, whether it involves psychodynamic, strategic, or cognitive-behavioral therapy. They help establish rapport and provide grounds for meaningful engagement with all aspects of the treatment process.

  D. Coping strategies provide a substitute or alternative that leads to healthier ways of dealing with triggers.

  Reference: Daley DC, Marlatt GA. Overcoming your alcohol or drug problem: effective recovery strategies: therapist guide. 2nd ed. Oxford: Oxford University Press; 2006.

• 2. You have a patient in your outpatient practice who quit alcohol and opioids 3 weeks ago after naltrexone was started, but the patient is struggling with managing his emotions and stress related to his work and his wife. The patient worries about relapsing due to not being able to handle high-risk situations. You feel he would benefit from a group environment where he could learn techniques to manage his cravings as well as work on his interpersonal skills. One thing you know about the patient is his readiness to learn and practice what it is discussed. Which of the following groups would be most appropriate for you to refer him to?

  • A. Milieu group

  • B. Psychoeducational recovery group

  • C. Coping skills group

  • D. Counseling group

  • E. Specialized group

  Correct Answer: C

  Skill groups are aimed at helping patients develop or improve their intrapersonal and interpersonal skills. For example, these groups teach problem-solving methods and stress management, cognitive, and relapse prevention strategies. Relapse prevention strategies help patients identify and manage early signs of relapse (the relapse “process”), identify and manage high-risk factors, or learn steps to take to intervene in a lapse or relapse.

  A. Milieu groups are offered in residential and hospital programs and usually involve a group meeting to start and/or end the day. A morning group may review the upcoming day’s schedule, whereas an evening group may review the day’s treatment and recovery activities and allow participants to reflect on their experiences that day.

  B. Psychoeducational recovery groups provide information about specific topics related to addiction and recovery and help patients begin to learn how to cope with the challenges of recovery. These groups use a combination of lectures, discussions, educational videos, behavioral rehearsals, and completion of written assignments such as a recovery workbook or personal journal.

  D. Counseling groups (also called therapy groups, problem-solving groups, or process groups) are less structured and give the participants an opportunity to create their own agenda in terms of problems, conflicts, or struggles to work on during group sessions. These groups focus more on gaining insight and raising self-awareness than on education or skill development.

  E. Specialized groups may be based on developmental stage (adolescents, young adults, adults, older adults), gender, different clinical populations (pregnant women or women with small children addicted to opioids, or anyone involved in the criminal justice system), or groups addressing specific issues or populations (parenting issues, anger or mood management, or trauma).

  Reference: Group therapies. In: Ries RK, editor. The ASAM principles of addiction medicine. 5th ed. Philadelphia: Wolters Kluwer Health; 2014. p. 847–8.

• 3. A 28-year-old patient got referred by her primary care clinician to you as the addiction expert. When you call the patient, she expresses mixed feelings about attending your appointment because she wants to quit someday but not now. You start by identifying the stages of change. In which stage is the one more likely the patient to be?

  • A. Relapse

  • B. Precontemplation

  • C. Contemplation

  • D. Preparation

  • E. Action

  Correct Answer: C

  The patient is ambivalent about when to start her treatment. She is contemplating a change but has not yet developed a plan for it or taken action to attend the program recommended by her physician.

  A. Relapse is not the patient’s stage of change. It is only after several relapses that the person discovers what recovery from an addiction means.

  B. Precontemplation is the stage where the person does not see their SUD as significant as compared to the benefits. Characteristics of this stage are a lack of interest in change, and having no plan or intention to change. We might describe this person as unaware.

  D. Preparation is a stage where the person accepts responsibility to change her or his behavior. She evaluates and selects techniques for behavioral change. Characteristics of this stage include developing a plan to make the needed changes, building confidence and commitment to change, and having the intention to change within a period of time. We might describe this person as willing to change and anticipating the benefits of change.

  E. Action is a stage where the person engages in self-directed behavioral efforts to change while gaining new insights and developing new skills. Although these efforts are self-directed, outside help may be sought. This might include rehab or therapy. Characteristics of this stage include consciously choosing new behavior, learning to overcome the tendencies toward unwanted behavior, and engaging in change actions. We might describe this person as enthusiastically embracing change and gaining momentum.

  Reference: Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. New York: Guilford Press; 2013.

• 4. A 45-year-old man stopped his buprenorphine treatment a year ago after 10 years of full abstinence. The patient was actively involved in your program where he was attending CBT/SUD groups weekly and monthly follow ups with you. After 6 months the patient came back to you describing intense desire to use opioids after he started to work in a rehab program where he started to perceive substance availability if he asked a person he knows from the past. The patient started to notice an intense desire to use opioids again with an increased likelihood of seeking this substance by planning to find the person and ask where to go and use. Which patient characteristic best defines this experience?

  • A. Withdrawal

  • B. Urge

  • C. Triggers

  • D. Drug craving

  • E. Conditioned positive reinforcement

  Correct Answer: D

  Drug cravings are a longing for or desire to use a substance, varying in intensity from mild to very strong. Cravings can be a desire for the euphoric effects of the substance, or a means to avoid or escape unpleasant emotions or physical symptoms such as those associated with withdrawal.

  A. Withdrawal: A group of symptoms of variable clustering and degree of severity which occur on cessation or reduction of use of a psychoactive substance that has been taken repeatedly, usually for a prolonged period and/or in high doses. The syndrome may be accompanied by signs of physiological disturbance. A withdrawal syndrome is one of the indicators of a dependence syndrome. It is also the defining characteristic of the narrower psycho-pharmacological meaning of dependence.

  B. Urge: An urge is an intention to use a substance once the individual is experiencing cravings. There can be a strong craving with very little intention to use, or the intention to use can be quite high, making the individual more vulnerable to relapse unless the person then utilizes active coping strategies to manage these cravings and urges.

  C. Triggers: Triggers are external or internal events that instigate thoughts or emotions related with the substance use process. Triggers often induce cravings. The goal of identifying the trigger is to learn management of external factors (people, places, events, experiences, or objects) or internal (feelings or thoughts).

  E. Conditioned positive reinforcement: This involves the addition of a reinforcing stimulus following a behavior that makes it more likely that the behavior will occur again in the future. When a favorable outcome, event, or reward occurs after an action, that particular response or behavior will be strengthened.

  Reference: Koob GF, Moal ML. Neurobiology of addiction. London: Elsevier AP; 2011.

• 5. A 33-year-old woman who is in recovery attended for the first time a party after completing 8 months of sobriety. She was offered not once but twice an alcoholic beverage by a stranger. On the third occasion when the same person offered her the drink she briefly and kindly said: “I have a medical problem and I cannot drink. Could you please not offer me a drink again?”. The patient moved to another section of the party where she knew sober friends were socializing. According to the original cognitive-behavioral model of relapse, which of the following helped her to decrease the chance of relapse?

  • A. Ineffective coping response

  • B. Positive outcome expectancy

  • C. Increased self-efficacy

  • D. Abstinence violation effect

  • E. High-risk situation

  Correct Answer: C

  Explanation: The original CBT model of relapse begins with the individual presented with a high-risk situation (E), defined as a situation in which the individual’s attempt to refrain from substance use is challenged. The individual may then respond with either an ineffective coping response (A) or an effective coping response. An individual who utilizes an ineffective coping response will tend to cave to a temptation or pressure, possibly carried along by their positive outcome expectancies (B) of the initial effects of using the substance. This leads to the initial use, or lapse. The lapse can be followed by the abstinence violation effect (D), in which the individual experiences guilt and demotivation, focusing excessively on blaming themselves for their failure, to the detriment of their previous commitment to sobriety (“why even bother anymore, when I’ve already messed up”). The end result of all of these steps is an overall increased likelihood of relapse. The only response that does not follow this is C, increased self-efficacy, which is achieved when the individual is able to exercise an effective coping response, that is., successfully enact their relapse prevention plan to remove themselves from the high-risk situation or otherwise refrain from lapse. The successful maintenance of abstinence reinforces the individual’s confidence that they will succeed again in similar situations, and their risk of relapse is lowered.

  Reference: Witkiewitz K, Marlatt GA. Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. Am Psychol. 2004;59(4):224–35.

• 6. Which of the following is an example of an individual in the preparation stage of the transtheoretical model of change?

  • A. Mrs. A has enjoyed smoking cigarettes for years while socializing with her friends but is thinking about cutting down now that she is expecting a grandchild.

  • B. Mr. B smokes marijuana daily and is adamant that it is the only thing keeping his anxiety under control. He denies any negative impacts on his mental or physical health, and sees no reason to stop.

  • C. Mr. C has not used methamphetamine for 2 years now. He is proud of how he has “rebuilt” his life and is wary of returning to any kind of drug use.

  • D. Ms. D has deleted her drug dealer’s contact information from her phone and has been going to the gym weekly to get her out of the house where she otherwise used to use heroin alone.

  • E. Mr. E has resolved to go to his first AA meeting this coming week, after a recent scare in which he almost got into a car accident while driving “buzzed.”

  Correct Answer: E

  Explanation: Mr. E has made a plan that he intends to act upon within the next 30 days and has come to a realization about how his drinking is jeopardizing himself and others.

  A is an example of the contemplation stage. B is in the precontemplation stage. C is in the maintenance stage. D is in the action stage.

  Reference: Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12(1):38–48.