Drug and alcohol addiction is a chronic condition that requires ongoing treatment. As a chronic condition, there is no cure. After medically supervised detox and at least three months of therapy through a rehabilitation program, people who overcome addiction still need support from peer groups, counselors, case managers, friends, and family to remain sober.
Part of many rehabilitation programs is education on relapse and how to prevent it. According to the National Institute on Drug Abuse (NIDA), 40-60 percent of those who complete detox and rehabilitation will relapse back into substance abuse. Getting appropriate, ongoing care – including stepping up to higher levels of treatment when needed, especially after a relapse – is part of the process of recovery.
What Causes Relapse?
Even when a person has attended an evidence-based rehabilitation program for at least 90 days, according to NIDA’s recommendations, they may still relapse back into alcohol or drug abuse. Current evidence suggests that relapse triggers can be internal, external, or both; they can come from the individual’s mental or emotional state, or they could involve specific places, objects, or people. The United Nations Office on Drugs and Crime (UNODC) has a list on their website of external and internal cues, to help people at risk of relapse understand situations or behaviors that may lead to a return to substance abuse.
External relapse cues include:
- Being home alone
- Being home with friends who may remind the person of intoxication
- Other locations like a friend’s home, a bar, or a club
- Social events, like parties, concerts, or sporting events
- Vacations or holidays
- Going on a date
- Specific weather, like rain
- Gaining weight
- Getting ready to go to work or school
- Coming home from school or work
- Specific meals, like dinner
- After payday
- Physical pain
- Specific days of the week, like Saturdays
Internal relapse cues include:
- Frustration or irritation
- Guilt or worry
- Nervousness or excitement
- Happiness or working to become happy
- Feeling passionate about a project or person
- Receiving criticism, even if it is constructive
- Feeling stressed or under pressure, such as from a work deadline
- Feeling depressed or sad
- Fatigue or exhaustion
- Grieving a loss
Several studies show that the first three months, or 90 days, of the recovery process are the most sensitive. After one leaves a rehabilitation program, ongoing support to stay sober is critical. Drugs and alcohol change how the brain’s reward system responds to specific stimuli, leading to cravings and possibly compulsive behaviors to acquire and consume intoxicating substances. For many people, attending support groups about once or twice per week is enough to stay focused; for many others, however, a higher level of ongoing care and support is needed to prevent or stop a relapse.
The Continuum of Care
The American Society of Addiction Medicine (ASAM) defines four levels of care on their Continuum of Care list. This spectrum helps clinicians understand which level of treatment their client may need to overcome addiction.
- Outpatient services: These services involve low-intensity, group therapy-focused treatment. The person is able to live at home while attending fewer than 10 hours per week of talk therapy to understand the addiction and change their behaviors.
- Outpatient care with medical treatment: This level includes both intensive outpatient treatment (more than 10 hours of therapy per week, spread over several days, while still living at home) and partial hospitalization (20 or more hours per week of treatment, including group and individual therapy), and may include prescription medications to aid detox. Partial hospitalization is more appropriate for people who struggle with co-occurring addiction and mental illness.
- Inpatient and residential services: Treatment where the individual lives in a rehabilitation facility, which helps them stay away from intoxicating substances and triggers to abuse drugs while they work on changing their behaviors, learning better coping mechanisms, and understanding their triggers so they can safely return to daily life.
- Medically managed intensive inpatient treatment: This is for people who are physically unstable, struggling with chronic illnesses, and/or have a co-occurring mental or behavioral disorder. Nurses and physicians monitor the individual, keeping them physically healthy while they go through therapy.
A level before outpatient, defined as 0.5, is early intervention. This includes education about addiction, substance abuse, physical dependence, and relapse, provided to those who are at risk for developing struggles with alcohol or drugs.
Although ASAM lists their Continuum of Care from least to most physically intense, it is not intended to represent a linear progression. People who initially enter outpatient treatment may later require a different treatment facility, like an inpatient program, to stay sober and avoid relapse. When a person does not receive the best level of treatment at first, they are at risk for experiencing relapse even if they complete the rehabilitation program.
Getting Better Treatment after Experiencing a Relapse
When a person experiences relapse, returning to treatment is very important. NIDA states that addiction is like other chronic illnesses, including diabetes or hypertension; relapse simply means a return of symptoms, or an increased severity of symptoms, which means the person should go back to their doctor, assess their treatment plan, and make any necessary changes. For chronic illnesses like diabetes, asthma, or hypertension, this may mean lifestyle changes or a different prescription. For those recovering from addiction, going through medically supervised detox; finding a new, possibly more intensive, rehabilitation program; and devising a better aftercare plan is key.
Finding a physician, therapist, social worker, or case manager who uses evidence-based screening tools to determine the severity of the addiction or relapse is the best start. There are several different questionnaires that can help clinicians understand where their new client falls on the Continuum of Care. If the person is seeking treatment after a relapse, these questionnaires and other assessment methods can help the clinician recommend a new level of treatment. For example, if a person attended intensive outpatient treatment but was unable to stay away from drugs or alcohol while living at home, they may need inpatient treatment instead.
Sometimes, a person attends a less intensive level of rehabilitation due to financial concerns. Insurance coverage, savings, scholarships at specific programs, sliding scale fees, payment plans, and many other forms of financial assistance can be used to help the person attend an appropriate rehabilitation program for as long as they need.
A rehabilitation program may not be enough. Even if the individual completes 90 days of rehabilitation, ongoing therapy to manage co-occurring mental or behavioral conditions may be required. Finding a therapist with an understanding of addiction and co-occurring disorders can help the person continue work on their mental health while also receiving support and encouragement to stay sober.
Many support groups are free. Peer support groups and online forums are available; these resources keep the individual’s mind focused on sobriety.
Emotional triggers within family structures may also need to be addressed. If one’s family does not attend support groups or family therapy while their loved one is first going through rehabilitation, they may not be able to offer emotional support. If a person relapses and returns to treatment, their spouse, children, parents, and other loved ones may consider attending family therapy to address issues at home.
Relapse does not mean that treatment has failed. A return of cravings and compulsive behaviors is concerning, but a renewed commitment to treatment and recovery can stop the relapse before serious harm is done.