Relapse Prevention.pps

Doing the Best for our Patients: Relapse Prevention in SUDs By Prof. Amany Haroun El Rasheed Ain Shams Univ., Cairo, Egypt M.N.P., D.P.P., M.D. Master in Mental Hygiene (Johns Hopkins Univ.) Fellowship in Substance Abuse Treatment & Prevention (Johns Hopkins Univ.) APA Membership AMERSA Membership WPA Fellowship ISAM Membership

Relapse Prevention in SUDs
Chemical dependency is a chronic condition that has a tendency toward relapse.
Abstinence from alcohol and other mood-altering drugs is essential in the treatment of chemical dependency.
Because dependency on alcohol or other drugs creates problems in a person’s physical , psychological , and social functioning , treatment must be designed to work in all three areas .

The worse the damage in each area, the greater the chances of relapse and return to old behaviors (criminal activity and/or the use of alcohol or drugs).
Total abstinence (not using any alcohol and drugs) plus personality and lifestyle changes are essential for full recovery.

Detox alone is not adequate treatment for addictive disease.

Sobriety
Abstinence from addictive drugs
+
Abstinence from compulsive behaviors
+
Improvements in bio/psycho/social health

Compulsive Behaviors
Eating/Dieting
Gambling
Working/Achieving
Exercise
Sex
Thrill Seeking
Escape
Spending

Gorski and Kelley (1996) suggested that there are four goals in the primary treatment of dependency on alcohol and other drugs:
Recognition that chemical dependency is a biopsychosocial disease.
Recognition of the need for lifelong abstinence from all mood- altering drugs.
Development and use of an ongoing recovery program to maintain abstinence.
Diagnosis and treatment of other problems or conditions that can interfere with recovery .

Importance of Relapse Prevention in Addiction
Addiction is a chronic relapsing disorder , therefore the prevention of relapse one of the critical elements of effective treatment for alcohol and other drug abuse.
Many patients go through treatment several times before achieving sustained abstinence (Stout et al., 1996).

In the treatment of addiction the proportion of cases that relapse at least once during a year after treatment may be 60% or more, with rates as high as 90% in some instances (Brownell et al., 1986).
It is not unusual for addicts to relapse within one month following treatment and about two-thirds of people discharged from treatment slip or relapse within 90 days after discharge (Hunt et al., 1971; Armor et al., 1978, Polich et al., 1981), it is also not unusual for addicts to relapse 12 months after treatment .

Although relapse is a symptom of addiction, it is preventable .
Relapse prevention methodologies are critical to the success of substance abuse treatment .
A key factor in preventing relapse is improved social adjustment and reintegration .

Definition of Relapse & Lapse
Relapse can be understood as not only the actual return to the pattern of substance abuse, but also as the process during which indicators appear prior to the patient’s resumption of substance use (Daley, 1987).
On the other hand, the term lapse refers to the initial episode of alcohol or other drug use following a period of abstinence ( Marlatt & Gordon, 1985).

Determinants of Lapse & Relapse
Intrapersonal Determinants
1) Self-efficacy. 2) Motivation.
3) Outcome expectancies 4) Coping.
5) Emotional states. 6) Craving.
Interpersonal Determinants
1) Social Support.

Understanding Relapse
Relapse is not an isolated event . Rather, it is a process of becoming unable to cope with life in sobriety . The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide.
The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs (Gorski & Kelley, 1996).

Two decades ago, a relapse was viewed as a “failure”. A person wasn’t trying hard enough nor doing what he or she could to work a program .
The full responsibility was placed on the patient, with the professionals often taking a position of blame. This negative response from caregivers can result in the patient giving way to feelings of hopelessness and despair .

It is often thought that most relapse-prone patients are not motivated to recover . Clinical experience , however, does not support this perception .
However, it is impossible to predict who will make it in recovery and who will not.
A relapse now can be approached as an indication that something within the total recovery system was not working.

Relapse does not occur in vacuum , so when a patient relapses there is frequently a collapse of the supportive systems, either from within or without.
Moreover, Saunders & Houghton (1996) suggested that relapse is probably better understood as a complex , generic , human behavior , undertaken at times by all of us .
Given this, it is possible that mainstream psychological theories, such as decision - making and attribution theory , are important in coming to any understanding.

Because relapse is a common occurrence during the process of substance abuse recovery, it is imperative that it be examined carefully.
It is important that we discuss the treatment with the patient to determine what effectively supported recovery and what was missing . In this manner we can join the patient in a problem-solving manner rather than only focus on the negative.

So, it is important that professionals work creatively with patients in recovery and tailor-make each person’s recovery plan .
It can be concluded that relapse is best understood as a complex process having multiple and interactive determinants that vary in their temporal proximity from and their relative influence on relapse.
An adequate assessment model must be sufficiently comprehensive to include theoretically relevant variables from each of the multiple domains and different levels of potential predictors (Donovan, 1996).

Situations that Lead to Relapse
These are many high-risk situations that increase the likelihood of relapse to alcohol/substance abuse.
Studies have indicated that the highest proportion of high-risk situations for alcoholics involve negative emotional states (Marlatt & Gordon, 1985).

However, Rubin et al. (1996) were able to find a gender difference in relapse situations. They found that men relapsed alone more often than did women.
Men and women report relapsing frequently with same sex friends , and women showed a tendency to relapse in the presence of romantic partners as well.

Moreover, men also tend to report more positive mood states during relapse than women, which is congruent with the finding that women report more depression .
Also, severity of drinking pattern was found to be an important confounding variable in these analyses.
It was suggested that gender differences found in individuals in treatment for alcohol problems may reflect societal differences between men and women.

It is also worth mentioning that Kivlahan et al. (1983) found that among patients who attributed their drinking to negative emotional states , those who either relapsed or were lost to follow-up had significantly more external drinking - related locus of control scores as compared to patients who identified negative physical states (i.e., craving) as their primary reason for drinking, in whom relapse was associated with significantly more internal drinking-related locus of control scores.
On the other hand, the highest proportion of high-risk situations reported by heroin addicts involves social pressures (Marlatt & Gordon, 1985).

Understanding of some of the personal factors, which may contribute to substance abuse relapse, is useful in any discussion of relapse prevention. These may include:
Frequent exposure to “high-risk situations” that have led to drug or alcohol use in the past.
Physical or psychological reminders of past drug or alcohol use (e.g., drug paraphernalia, drug-using friends, and money).
Recurrent thoughts or physical desires to use drugs or alcohol.
Inadequate skills to deal with social pressure to use substances.
Inadequate skills to deal with interpersonal conflict or negative emotions .
Desires to test personal control over drugs.

How Do High Risk Situations Lead to Relapse?
As long as the patient is abstinent , there is an increasing perception of self-control .
This will continue until the patient faces a high-risk situation , defined broadly as any situation that poses a threat to the patient’s sense of control and increases the risk of potential relapse.

1) Negative emotional states
Situations in which the patient is experiencing a negative (or unpleasant) emotional states, mood, or feeling such as frustration, anger, anxiety, depression, boredom, etc., prior to or occurring simultaneously with the first lapse.

2) Interpersonal conflicts
Situations involving an ongoing or relatively recent conflict associated with any interpersonal relationship such as marriage, friendship, family members, or employer-employee relations.
Arguments and interpersonal confrontations occur frequently in this category.

3) Social Pressure
Situations in which the individual or group of individuals who exert pressure on the patient to engage in the proscribed behavior.
Social pressure may be either direct (e.g., interpersonal contact with verbal persuasion) or indirect (e.g., being in the presence of others who are engaging in the same target behavior, even though no direct pressure is involved).

It is worth mentioning that some of the symptoms of withdrawal might even be experienced long after the expected withdrawal in what is known as post - acute withdrawal or protracted withdrawal that might lead to relapse.
If the patient is unable to cope with the high-risk situations because he/she had never acquired the coping skills necessary for these situations or because the appropriate response has been inhibited by fear or anxiety, he/she will relapse .
On the contrary, in patients with an effective coping response in a high-risk situation , the probability of relapse decreases .

The Abstinence Violation Effect was described by Marlatt and Gordon (1985) and Curry et al. (1987).
Prior to the first lapse, the patient is personally committed to an extended or indefinite period of abstinence.
The intensity of the “Abstinence Violation Effect” varies as a function of several factors, including:
The degree of prior commitment or effort expended to maintain abstinence.
The duration of abstinence period (the longer the period, the greater the effect).
The subjective value or importance of prohibited behavior to the patient.

It was hypothesized that “Abstinence Violation Effect” is characterized by the following key cognitive-affective elements :
Cognitive dissonance (conflict and guilt).
A personal attribution effect (blaming the self as the cause of the relapse).
Perceived positive effects of alcohol/substance.

Patients who experience an intense “Abstinence Violation Effect” following a lapse often experience a motivation crisis (demoralization reaction) that undermines their commitment to abstinence goals .
On the other hand, some patients appear to set up their own relapse as the reward of instant gratification is seen to outweigh the cost of potential negative effects that may not occur sometimes in the distant future.

Cognitive distortions such as denial and rationalization make it much easier to set up one’s own relapse episode ; one may deny both the intent to relapse and the importance of long-range negative consequences.
There are also many excuses one can use to rationalize the act of indulgence (Marlatt and Gordon, 1985).

Addictive preoccupation seems to play an important role for some of the patients and forms a major area of abstinence-based symptoms .
It consists of the obsessive thought patterns , compulsive behaviors , and physical cravings caused or aggravated by the addiction.

These behaviors become programmed into the patient’s psychological processes by the addiction.
They are automatic and can cause the recovering patient to return to use unless he or she has specific training to identify and interrupt them (Gorski & Kelley, 1996).

Research findings suggest that the degree of life-style balance has a significant impact on the patient’s desire for indulgence or immediate gratification (Marlatt & Gordon, 1985).
It is worth mentioning that balance is the degree of equilibrium that exists in one’s daily life between those activities perceived as external demands (or “shoulds ”) and those perceived as activities engaged in for pleasure or self-fulfillment (the “wants”).

Also, more recently, Walton et al. (1995) found that after controlling for confounding variables , aspects of the home settings significantly distinguished abstainers from reusers; perceived r i sk for relapse was the strongest predictor of reuse.

THE PHASES AND WARNING SIGNS OF RELAPSE
Phase I: Internal Change
Increased stress
Change in thinking
Change in feeling
Change in behavior

Phase II: Denial
Worrying about myself
Denying than I’m worried

Phase III: Avoidance and Defensiveness
Believing I’ll never use alcohol or drugs
Worrying about others instead of self
Defensiveness
Compulsive behavior
Impulsive behavior
Tendencies toward loneliness

Phase IV: Crisis Building
Tunnel vision
Minor depression
Loss of constructive planning
Plans begin to fall

Phase V: Immobilization
Daydreaming and wishful thinking
Feeling that nothing can be solved
Immature wish to be happy

Phase VI: Confusion and Overreaction
Difficulty in thinking clearly
Difficulty in managing feelings and emotions
Difficulty in remembering things
Periods of confusion
Difficulty in managing stress
Irritation with friends
Easily angered

Phase VII: Depression
Irregular eating habits
Lack of desire to take action
Difficulty sleeping restfully
Loss of daily structure
Periods of deep depression

Phase VIII: Behavioral Loss of Control
An “I don’t care” attitude
Open rejection of help
Dissatisfaction with life
Feelings of powerlessness and helplessness

Phase IX: Recognition of Loss of Control
Difficulty with physical coordination and accidents
Self-pity
Thoughts of social use
Conscious lying
Complete loss of self-confidence

Phase X: Option Reduction
Unreasonable resentment
Discontinues all treatment and AA (or NA)
Overwhelming loneliness, frustration, anger, and tension
Loss of behavioral control

Phase XI: Alcohol and Drug Use
Attempting controlled use
Disappointment, shame, and guilt
Loss of control
Life and health problems

Categories of Patients
According to Gorski & Miller (1986), chemically addicted patients can be categorized according to their recovery and relapse history into:
Prone to recovery.
Briefly prone to relapse.
Chronically prone to relapse.

Patients who are relapse-prone can be further divided into three subgroups:
a) Transition patients
They do not accept or recognize that they are suffering from chemical dependence , even though their substance abuse may have created obvious adverse consequences.
This usually results from the patient’s inability to accurately perceive reality , due to chemical interference.

b) Unstabilized relapse-prone patients
They have not been taught skills to identify their addiction .
In such cases, treatment fails to provide these patients with the necessary skills to interrupt the process and disease of addiction .
As a result, they are unable to adhere to a recovery program requiring abstinence, treatment, and lifestyle change.

c) Stabilized relapse-prone patients
Recognize and are aware of their chemical addiction , that abstinence is necessary for recovery , and that an ongoing recovery program may be required to maintain sobriety.
Despite their efforts , however, these patients develop dysfunctional symptoms that ultimately lead them back to alcohol or drug abuse.

A Model of Change and Recovery
Stage one: The Emergence of Addiction
Phase 1 : Initiation: Drug use begins.
Phase 2 : Substance use produces positive consequences.
Phase 3 :Adverse consequences develop but remain out of awareness.

A Model of Change and Recovery
Stage two: The Evolution of Quitting
Phase 1 : Turning points.
Phase 2 : Active quitting begins.
Phase 3 : Relapse prevention.

Recovery in Substance Use Disorders
Recovery is a structured plan for living that builds a foundation upon which the patient can function effectively and comfortably . This foundation creates the ability for the person in recovery to avoid circumstances in which they might be vulnerable .
Recovery requires change in attitudes , values , lifestyle , and behaviors .

It is not a static condition; it is an ongoing process .
Relapse occurs when attitudes and behaviors revert to ones similar to those exhibited when person was actively using drugs or alcohol.

Vital components of recovery include
Support of the family and friends.
Twelve-step meetings and sponsorship.
Individual, group and family therapy.
Proper rest.
Moderate exercise and nutrition.
Avoidance of “slippery” situations such as bars.
Medical supervision.
Psychiatric support.

Although relapse can occur at any time , it is more likely earlier in the recovery process (at this stage, habits and attitudes needed for continued sobriety, skills required to replace substance use, and relations with positive peers are not firmly entrenched).

The Developmental Model of Recovery
Gorski & Kelley, 1996 Phases of recovery include:
1- Transition stage
2- Stabilization stage
3- Early recovery period
4- Middle recovery period
5- Late recovery period
6- Maintenance stage

1- Transition stage
The transition stage begins the first time a person experiences an alcohol or drug-related problem .
As a person’s addiction progresses , he or she tries a series of strategies to control use . This ends with recognition by the person that safe use of alcohol and/or drugs is no longer possible .

2- Stabilization stage
During the stabilization period, chemically dependent people experience physical withdrawal and other medical problems , learn how to break the psychological conditioning causing the urge to use, stabilize the crisis that motivated them to seek treatment, and learn to identify and manage symptoms of brain dysfunction.
This prepares them for the long - term processes of rehabilitation .

3- Early recovery period
Early recovery is marked by the need to establish a chemical-free lifestyle . The recovering person must learn about the addiction and recovery process.
He or she must separate from friends who use and build relationships that support long-term recovery.
This may be a very difficult time for criminal justice patients who have never associated with people with sobriety-based lifestyle.

4- Middle recovery period
Middle recovery period is marked by the development of a balanced lifestyle . During this stage, recovering people learn to repair past damage done to their lives.

During late recovery, a person makes a change in ongoing personality issues that have continued to interfere with life satisfaction.
In traditional psychotherapy, this is referred to as self-actualization .
It is a process of examining the values and goals that one has adopted from family, peers, and culture.
Conscious choices are then made about keeping these values or discarding them and forming new ones .

Development of health self-esteem, spiritual growth, healthy intimacy, and meaningful living.

6- Maintenance stage
The maintenance stage is the lifestyle process of continued growth and development , coping with adult life transitions , managing routine life problems , and guarding against relapse .
The physiology of addiction lasts for the rest of a person’s life.
Any use of alcohol or drugs will reactivate physiological , psychological , and social progression of the disease.

General Principles & Procedures of Relapse Prevention
1) Self-regulation and stabilization
As the patient’s capacity to self-regulate thinking , feeling , memory , judgment , and behavior increases , the risk of relapse will decrease .
Self-regulation can be achieved through stabilization .

1) Self-regulation and stabilization
Stabilization may include:
Detoxification .
Recuperation from the effects of stress that preceded the chemical use.
Resolution of immediate interpersonal and situational crises that threaten sobriety.
Establishment of a daily structure including proper diet, exercise, stress management, and regular contact with both treatment personnel and self-help groups.
It is worth mentioning that the risk of relapse is highest during this period of stabilization .

2) Integration and self- assessment
As understanding and acceptance increases , the risk of relapse will decrease .
During this phase it is important to explore the presenting problems which may have led to relapse in the past , and which might trigger future relapse.

3) Understanding and relapse education
Understanding the general factors that cause relapse will aid patients in relapse prevention.
Basic information provided in this phase should include, but not be limited to:
Medical , clinical , and social models in addictive disease .
Developmental model of recovery .
Common “ stuck points ” in recovery.
Identification of warning signs .
Management strategies for relapse warning signs.
Planning for effective recovery .

3) Understanding and relapse education
It should be noted that many relapse-prone patients may have memory problems associated with the chemical abuse, which may impede the learning process and retention of educational information .

4)Self-knowledge and identification of warning signs
This process teaches the patient to identify the sequence of problems that has led from stable recovery to chemical use in the past , and then synthesize those steps into future circumstances that could cause relapse .
This can be approached through the self-monitoring procedures by keeping a diary to identify high-risk situations.

5) Coping skills and warning signs management
This process involves teaching relapse-prone patients how to manage or cope with their warning signs as they occur .
This also include relapse rehearsal methods , in this procedure, the patient is instructed to imagine being involved in a high risk situations and performing more adaptive coping behaviors and thoughts .

5) Coping skills and warning signs management
The emphasis here is on active coping rather than on resisting temptation .
To emphasize self-efficacy enhancement , the patient is instructed to imagine that the rehearsed experience is accompanied by mounting feelings of competence and confidence .

6) Change and recovery planning
Recovery planning involves the development of a schedule of recovery activities that will help patients recognize and manage warning signs as they occur in sobriety.

7) Awareness and inventory training
Inventory training teaches relapse-prone patients to do daily inventories that monitor compliance with their recovery program and check for the development of relapse warning signs .

8) Significant others and involvement of others
Relapse-prone patients need the help of others during the process of recovery .
Treatment should ensure that others (e.g., family members , 12-step sponsors , supportive peers ) are involved in the recovery .

9) Maintenance and relapse prevention plan updating
Ongoing outpatient treatment is necessary for effective relapse prevention.
Even highly effective short-term inpatient or primary outpatient program will be unable to interrupt long-term relapse cycles without the ongoing reinforcement of some type of outpatient therapy.

A review of the original assessment , writing a sign list , management strategies , and recovery plan .
An update of the assessment by adding to an addendum any documents that are significant to the patient's progress problems since the previous update.
A revision of the relapse warning signs to incorporate new warning signs that have developed since the previous date.

The development of management strategies for the newly identified warning signs .
A revision of the recovery program to add recovery activities , to address the new warning signs , and to eliminate activities that are no longer needed .

Challenges to Relapse Prevention in Many Developing Countries
The most important problem we face in the area of relapse prevention in substance abusers in developing countries is that most of the personnel working in the field of psychiatry in general, of course including those working with substance abusers, have great difficulty accepting relapses . This is a reflection of the deep-seated attitude that these patients are not motivated .

However, this attitude is firmly held against substance abusers in particular and is not present to any extent on dealing with relapsing schizophrenics, depressives, or manics.
This attitude causes many personnel to refuse treating substance abusers with a resulting shortage in the number of personnel in the field.
Moreover, some of the treatment centers might refuse to admit patients after they exhaust a certain number of relapses (usually a small number as two or three times), which leaves the patient with no alternative except continuing in his/her addictive cycle.

Thus, we are badly in need for a change in attitude , which has to be started early in medical and paramedical education (i.e., on an undergraduate level). This process, of course, has to be continued on a postgraduate level as well as on continuing medical education level.

We are also in need for further research that addresses the benefit of relapse prevention techniques, as well as the tendency of patients (including the chronically relapsing ones) to benefit cumulatively from treatment over time.
On the other hand, there is a lack in evaluation of the ongoing service , as we do not have our own estimates of the cost/benefit of the ongoing services.

Last but not least, it has become a very well known and strongly agreed upon fact that addiction is a chronic relapsing disorder which makes relapse prevention one of the basic elements of its treatment. This is non-negotiable even though its benefits are commonly cumulative on the long run.

THANK YOU

Relapse Prevention.pps

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