Addiction Relapse: One Step Back, Two and Three Steps Toward Recovery

This is the third in a series of blogs contributed by our PM clinician Gregory Rennie, who will introduce you to various aspects of addiction and its treatment using psychotherapy.  Gregory Rennie provides access to collaborative care with PM psychiatrists via the Psychotherapy Matters Virtual Clinic (PMVC) for his clients.

In any given year, 15% to 60% of the US population is afflicted by an addiction to one or more of the following substances or activities: tobaco, alcohol, illicit drugs, eating, gambling, internet, sex, exercise, work, and shopping.

Addiction is a disease of the brain marked by three cycles:

  1. Compulsion to experience the substance or activity leading to excess indulgence or intoxication
  2. Loss of control over the compulsion leading to negative effects on the self, relationships, and function
  3. Negative emotions or symptoms of withdrawal when access to the addicting activity or substance is prevented leading to preoccupation and anticipation of next use.

In any given year, of those who achieve recovery from any addiction, 70% will relapse.   Like other chronic illnesses with a relapsing and remitting pattern, it can take multiple tries before complete recovery is achieved.  In fact, in any given year, only 18% of those who achieve abstinence from alcohol are able to maintain the abstinence.  Those who achieve abstinence are thought to have been able to regain control of brain stress response pathways previously hijacked by alcohol.  Those with normal body cortisol responses to stress and less stress-induced cravings are thought to be less likely to relapse.

Cui and colleagues in 2015 (Ref 2) found that relapse was faster in those recovering from alcohol use disorder with a blunted response to stress in certain brain regions.  Study participants who relapsed also had overactive brain activity in the same regions during relaxation.  Chronic exposure to alcohol and stress cause structural damage to the same region of the brain.  This region is called the prefrontal cortex where executive function or behavioural control takes place.

Despite real changes to the brain, in my experience, those afflicted with addiction eventually do regain control of executive function.  Many eventually achieve sustained remission.  In the process, they find renewed purpose and meaning in their lives.

It starts with the first step of reaching out and asking for help.

To help clients achieve recovery, psychotherapists may use motivational interviewing to move the client from ambivalent readiness for treatment to commitment.  Psychotherapy treatment retrains the brain to chose alternative ways to cope with negative feelings and thoughts leading to the addiction behaviour.

Psychotherapists aim to holistically change behaviours, thoughts, and feelings associated with the maladaptive use of the substance for stress relief.  For any addiction, whether to substances or to an activity like problem gambling, lapses to old patterns and behaviours indicate that treatment needs to be reinstated or adjusted.  Sufferers of addiction(s) and their families need to keep in mind that there is always hope.

The key is not to give up when the journey to recovery takes the expected detour of a relapse.  Causes of relapse may be addressed in psychotherapy to prevent future recurrence.  A relapse can mean one or two more steps closer to sustained remission.

Relapses may be triggered by exposure to rewarding substances and behaviours.  Exposure to cues in the external environment and to cues in the inner emotional world can trigger activity in key circuits in the brain.  For example, people, places, and things associated with sad memories can trigger cravings and return to use.  Enjoyable activities that used to be enhanced by substance or alcohol use can also trigger craving.  For example, going to a favourite bar in early recovery just to play a game of pool and have a soft drink could inadvertently trigger a craving for alcohol and cause a slip up.

Relapse can be prevented with the right know-how about the neuroscience behind the process.  This is a better approach than blaming and shaming the person afflicted with the addiction.  In my experience, it is possible to recover from the impact of the substance use disorder.

In summary:

  1. Relapse is normal and part of  the recovery from addiction.  There is no need for shame, embarrassment or blame.
  2. Much information can be gleaned from short relapses to prevent future relapses.
  3. No one suddenly starts using alcohol or drugs again after cutting down.  Usually a process of exposure to external and internal cues and associations sets a vulnerable person up to use again.
  4. Recovery takes time. With counselling, the warning signs of relapse can be identified, recognized and action taken.
  5. Once these cues and associations or warning signs are identified, recognition and management is possible.
  6. During relapse prevention counselling, responsibility may be encouraged in the person recovering from addiction to learn awareness of the warning signs and to take personal responsibility for appropriate action to prevent a slip-up or a full relapse.

For more information, I strongly recommend the following resources:

  1. Centre for Addiction and Mental Health in Toronto, Ontario at www.camh.net
  2. National Institute on Drug Abuse in the USA at www.drugabuse.gov.

References:

  1.  American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  2. Cui, Changhai et al. “Brain Pathways to Recovery from Alcohol Dependence.”Alcohol (Fayetteville, N.Y.) 49.5 (2015): 435–452. PMC. Web. 30 Sept. 2016.
  3. Hendershot, Christian S et al. “Relapse Prevention for Addictive Behaviors.”Substance Abuse Treatment, Prevention, and Policy 6 (2011): 17. PMC. Web. 30 Sept. 2016.
  4. Sussman, Steve, Nadra Lisha, and Mark Griffiths. “Prevalence of the Addictions: A Problem of the Majority or the Minority?” Evaluation & the health professions 34.1 (2011): 3–56. PMC. Web. 30 Sept. 2016.
  5. Witkiewitz, Katie, M. Kathleen B. Lustyk, and Sarah Bowen. “Re-Training the Addicted Brain: A Review of Hypothesized Neurobiological Mechanisms of Mindfulness-Based Relapse Prevention.” Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors 27.2 (2013): 351–365. PMC. Web. 30 Sept. 2016.

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The views expressed in these blogs are the author’s own and not necessarily reflective of those of Psychotherapy Matters.  Information provided here and anywhere else on PsychotherapyMatters.com is for learning purposes only and should not be used to guide treatment of clients/patients. Copyright © 2016 PsychotherapyMatters.com

Gregory Rennie
Gregory Rennie

Gregory Rennie has been an addiction therapist since 2005 and has also worked at agencies in Southern Ontario as an addiction therapist and concurrent disorders specialist.

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