Preventing and managing relapse
Understanding lapses and relapses
There is a difference between the single use of a substance (a lapse or a "slip-up") and use that implies reversion to a previous level of loss of control (relapse). This distinction is often more complex than it may seem, and depends on the severity of the substance use disorder.
Lapses are often seen as part of recovery, whereas a true relapse suggests a need to take stock, reassess the situation and re-engage with some form of treatment. For example, it is rare for someone who is trying to quit smoking to stop completely on their first attempt. It is important to view the occasional cigarette as part of the process of change. Having smoked one cigarette is not cause to step back and start all over again.
Responding to a lapse
Lapses should be reframed as opportunities to learn rather than being considered failures, which is how patients usually see them.
- Explore the patient's thoughts, feelings and behaviours before, during and after the lapse.
- Remember the acronym HALT (hungry, angry, lonely, tired), which refers to conditions that make lapses and relapse more likely. Ask the patient: "What did you need that you couldn't get?"
- Find out what lead to the lapse, what maintained it and what lead away from it.
- Focus the discussion on the positive – "How did you manage to regain control?"
- Elicit positive self-talk:
- "What did you learn?"
- "How were you able to do that?"
- Focus on self-care: "What are you going to do to avoid the HALT feelings?"
- Remind patients that secrecy is fertilizer for lapses – learn to talk and ask for help.
- Review relapse prevention skills.
Helping patients to avoid relapse
Relapse prevention strategies may depend on the severity of the substance use disorder and the degree of risk involved.
General relapse prevention strategies
- Help patients to identify high-risk situations or triggers for drinking, smoking or other addictive behaviours (e.g., the bar, smoking buddies, weekends).
- Ask patients to address the question, "What am I going to do instead of "X" (the behaviour they are trying to change)?"
- Counsel patients to develop alternative ways to cope with negative emotions. Anxiety, anger, boredom, loneliness and depression are common triggers to drinking or other substance use. This may involve treatment for underlying anxiety and mood disorders.
- Focus on patients' successes. Ask patients how they were previously able to achieve abstinence or reduce their substance use, even if it was only for a short period.
- Encourage patients to develop plans to avoid, minimize or cope with triggers (e.g., choosing alternative activities such as meeting with their partner for dinner right after work, temporarily avoiding friends who drink excessively, having a clear plan to follow if they feel tempted).
- Discuss how patients are going to respond to cravings. What are they going to do when this inevitably happens?
Relapse prevention strategies for moderate to severe substance use disorders
- Early on in their sobriety, patients with moderate to severe substance use disorders still need help from addiction physicians, therapists and 12-step groups in setting limits for themselves. A recovery program, is a key component of what is taught in formal treatment programs.
- Encourage patients who have been to treatment to follow what they learned. For patients who have not been to treatment, this is a time to have them consider treatment.
- Encourage patients to reconnect with their family and rebuild their social network. For many, the family is the most powerful motivator for change. Invite supportive family members to office visits. Encourage patients to contact friends not associated with their addictive behaviour.
- Encourage patients to try Alcoholics Anonymous (AA) or other 12-step groups. Attendance at AA has been associated with reduced relapse. It can be very helpful in rebuilding social networks.
- Help patients to plan for dealing with strong cravings. The most common plan for those with alcohol concerns is to call or meet with an AA sponsor or a close friend.
Helping patients who have relapsed
Patients with mild substance use disorders
Patients with mild substance use disorders are often attempting to moderate or regain control over their substance use. Their confidence tends to be shaken by small failures (lapses) and generally needs to be enhanced.
A relapse is more significant than a lapse and should make you reconsider the diagnosis. Recurrent relapses suggest that the disorder is more severe than was initially diagnosed. For example, a moderately heavy drinker with few criteria of a substance use disorder who repeated fails at cutting down drinking may need to be abstinent and in substance use disorder treatment.
A key issue with these patients is to reassess their level of motivation. Are they still committed to their goals?
Develop a plan to continue with the process of change and manage future stresses and triggers.
Patients with moderate to severe substance use disorders
For patients with moderate to severe substance use disorders, relapse is a serious event. The treatment plan needs to be re-evaluated just as it would be with any other serious relapsing, potentially fatal chronic disease.
Direct patients back to their recovery activities – their supports, their self-care, their AA group, their "program."
Most of these patients should already have established a relationship with an addiction physician or an experienced addiction therapist. If not, this is the time to connect them.