A relapse to drug or alcohol use occurs when a person goes back to patterns of addictive behavior following a period of abstinence. Relapses stall recovery from substance abuse and addiction; however, they don’t mean that recovery has failed. They are merely signs that something in the treatment approach must be adjusted.
What Is the Basic Issue?
Cravings for drugs and alcohol are some of the biggest obstacles to recovery from addiction. The vast majority of relapses are associated with individuals giving into cravings. But what exactly are cravings?
Suppose for a moment you could return to a place from your early childhood. You might not remember too many specifics about the place, but it is associated with very general, pleasant memories. Perhaps it was your grandparents’ home, someplace where you had fun as a child, such as a video game arcade, or another place associated with very fond and early memories. As you would walk around and observe this environment, certain aspects of the environment may trigger very fond memories, perhaps memories that you have not even retrieved in quite some time. As you look at say a videogame or your grandmother’s collection of stuffed animals (or whatever the specific aspects of the environment are for you), very pleasing memories flash through your mind. You might even smile, cry a little, or laugh as result of the emotions stirred up by these cues in your environment. The experience would be quite moving for you.
Cravings for drugs or alcohol are actually programmed responses that occur as a result of environmental cues. These environmental cues are associated with one’s past experiences with drug use, and for most people, the cues are associated with the pleasant aspects of past drug usage.
Cravings are similar to the scenario described above. They are vivid emotional memories of the pleasant effects associated with the person’s past drug use. These memories represent reinforcing effects of alcohol or other drugs that were related to aspects of the environment or are associated with certain thoughts or emotional states the individual had during times of drug use. These environmental events are often referred to as triggers or cues because they actually set off or release certain physical sensations or feelings. They are often very visceral and not rational. You “feel” them or visualize them; you do not naturally explain or debate them.
There are a number of different types of triggers that can be very general in nature and can affect most people who have alcohol use disorders or other substance use disorders (e.g., a beer commercial on TV), or they can be quite specific to the individual (e.g., a particular spot or bar where the individual had many pleasant experiences while drinking alcohol). These triggers are associated with a powerful neurochemical bond in the brain, and they are experienced as powerful urges to use one’s drug of choice.
Some of the physiological and mental responses to triggers are:
- An increase in heart rate and blood pressure
- Changes in respiration
- Increase in sweat gland activity
- A sense of anticipation as if some reward or pleasant experience is about to occur
- Feeling excited or stimulated
- Memories of pleasant experiences associated with past drug or alcohol use (these are often visual or emotional)
Because cues and triggers can potentially be associated with nearly any feeling or environmental stimulus, they often appear just to “come out of the blue,” and some people may even be surprised by them.
Strategies for Avoiding Relapse Associated with Cravings
Depending on the severity of one’s abuse or addiction, or even other factors such as stress, cravings can occur only a few hours after one has stopped drinking or using drugs, or they may not occur for days, weeks, or even months after one has discontinued use. However, most everyone attempting to recover from an alcohol or drug abuse problem, or an addiction, will experience cravings at some time during the recovery process.
As part of a relapse prevention strategy, there are two general approaches that can help individuals deal with cravings that will inevitably occur. These approaches consist of either specific medications that can reduce the experience of cravings for particular drugs or alcohol, and therapy aimed at relapse prevention.
There are a number of medications that are used for different drugs of abuse. Some of the medications that may control cravings for alcohol include:
- Naltrexone (Depade, ReVia, or Vivitrol) has been used to control cravings for opioid drugs, such as heroin and OxyContin. It has also been found to be effective in reducing cravings for alcohol. However, this drug may not work for everyone with an alcohol use disorder.
- Topiramate (Topamax, Qudexy) is an anticonvulsant medication that may also help to reduce cravings for drugs like cocaine and alcohol.
- Acamprosate (Campral) is another anticonvulsant medication that may reduce symptoms associated with cravings that include anxiety, depression, insomnia, and restlessness.
- Baclofen (Gablofen) is a muscle relaxant shown to reduce alcohol cravings.
- Disulfiram (Antabuse) is a medication that interferes with the body’s ability to break down alcohol. This results in a buildup of a substance in the body (acetaldehyde), which results in individuals becoming very unpleasantly ill if they drink any alcohol at all. The association with getting sick when drinking alcohol may also reduce cravings.
Some other medications may also help reduce cravings for alcohol; however, most of these medications require the individual to actually take the drug on a regular basis. Therefore, the individual must remain motivated to be abstinent in order to take the drug.
Therapeutic Approaches to Relapse Prevention
Within a formal treatment context, the standard approach to relapse prevention and dealing with cravings is often influenced by Cognitive Behavioral Therapy (CBT). Almost all relapse prevention programs use or borrow from the principles of CBT. In general, these principles are designed to:
- Prepare individuals for cravings.
- Educate individuals regarding the process of cravings by:
- emphasizing that cravings are normal for most recovering addicts.
- realizing that cravings do not represent signs of being weak or failing within the recovery program.
- Help individuals to identify personal triggers and issues.
- Educate individuals about generalized cues that most recovering individuals associate with their past pleasurable experiences of drug use.
- Assist individuals in developing strategies and plans of actions to avoid triggers so they can avoid situations that might lead to relapse.
- Educate the individual regarding the signs and symptoms of cravings so individuals understand when a potential relapse may be about to occur.
- Help people develop coping strategies when cravings occur, so they can deal with potential relapse situations.
- Help individuals remind themselves of the negative aspects of their addiction when they crave their drug of choice.
- Develop a support network that can help spot issues that may be signs of an impending relapse, and offer support and a backup plan for dealing with issues that might lead to relapse.
These principles allow individuals to build self-confidence, coping skills, and social support that assist them in identifying high-risk situations for relapse and implementing a plan of action that can increase the probability of success in recovery. Twelve-Step programs, such as Alcoholics Anonymous and Narcotics Anonymous, use many of these same principles in their overall plan of action.
Other Options to Help Avoid a Relapse
There are several other individual strategies individuals can use to avoid potential high-risk situations for relapse. These include:
- Beginning an exercise program: Exercise stimulates the same reward system in the brain that is stimulated by repetitive drug use, and regular exercise may help reduce cravings for drugs and alcohol.
- Eating healthy: A solid diet may lead to the reduction of certain upsetting internal states, such as fatigue, hunger, and so forth. These states can spark cravings and lead to potential relapse.
- Meditation: A meditation practice and overall mindfulness may help reduce cravings.
- Keeping busy: Setting goals, and working toward them, helps reduce boredom, which is a very common trigger for cravings.
Relapse rates for recovering from any substance use disorder are high; however, there are certain signs and symptoms of impending relapse that can signify that vigilance is needed. Some of these signs that one may be heading toward a relapse include:
- The person stops attending treatment sessions or support groups. In many cases, some form of ongoing treatment, such as periodic therapy or attendance at 12-Step meetings, is needed throughout one’s lifetime. Discontinuing treatment is the single most common occurrence associated with relapse.
- The person begins to romanticize past alcohol use and concentrates on only the good feelings or positive aspects of drinking.
- The person begins to think that “just one drink” will not do any harm. All alcohol relapses begin with “one drink.”
- The person continues to engage in behaviors that were associated with the substance use disorder, such as going to the same bars, hanging out with the same friends, and so forth. Many people find that they have to let go of these activities in order to avoid relapse.
- The person gets defensive or becomes upset when someone else points out the possibility of relapse. This is often a defense mechanism used by recovering individuals to justify their behavior.
The Bottom Line
Relapse is often part of the recovery journey; however, there are things that can be done to reduce the likelihood of relapse. Understanding the signs of relapse, and creating a plan to deal with cravings, is crucial to a successful long-term recovery from any substance use disorder.