Despite the best efforts of clinicians, patients with addiction problems sometimes relapse after successfully undergoing treatment.

Physicians can support these patients in their recovery efforts by developing a strong therapeutic alliance with them, and by better understanding the mechanisms of relapse.

 

Understanding relapse

The American Society of Addiction Medicine defines relapse as the recurrence of behavioral or other substantive indicators of active disease after a period of remission. For example, if an individual who had stopped drinking for a period of time (such as 2–3 months) resumes drinking in an uncontrollable manner, they are experiencing a relapse.

Some treatment professionals distinguish between a relapse and a lapse, or even a slip. If a patient had just one drink after recovery, that could be considered a lapse or slip, but not a complete relapse.

According to research published by the National Institute on Drug Abuse, relapse rates vary widely from 40%–60%.

National Institute on Drug Abuse. Treatment and recovery. In: Drugs, Brains, and Behavior: The Science of Addiction. March 22, 2022.

The substances most commonly associated with relapse are opioids, followed by alcohol, stimulants, and benzodiazepines, according to research by the Hazelden Betty Ford Foundation.

Understanding and avoiding a relapse into addiction. Hazelden Betty Ford Foundation. April 21, 2021.

 

The American Addiction Centers has found that up to 91% of individuals in recovery from opioid addiction will relapse, and at least 59% of those individuals do so within their first week of sobriety.

Watkins M. Opiate relapse: Prevention and addiction treatment. American Addiction Centers. DrugAbuse.com. Updated October 28, 2022.

 

 

3 phases of relapse

Research published in the Yale Journal of Biology and Medicine defined three phases of relapse: emotional, mental, and physical.

Melemis SM. Relapse prevention and the five rules of recovery. Yale J Biol Med. 2015;88(3):325–332.

Emotional and mental relapse are usually precursors to physical relapse—the actual use of drugs or alcohol.

 

Emotional relapse is characterized by hiding emotions, isolating oneself, missing meetings (or attending them but not opening up), focusing on others' problems, and poor sleeping or eating habits. Poor self-care is the common denominator of this phase.

Mental relapse refers to the stage when the individual is thinking about using again but avoids it through bargaining and denial. Signs of mental relapse include cravings for use, thinking about triggers associated with past use, minimizing the consequences of (or glamorizing) past use, lying, bargaining, looking for opportunities to relapse, or planning to use.

Physical relapse occurs when the individual uses again.

Most physical relapses are relapses of opportunity. They occur when the person has a window in which they feel they will not get caught.

 

Why is addiction so difficult to treat?

Activation of the brain's reward system releases dopamine and serotonin. This incentivizes people to do things they need to thrive, like eat and spend time with loved ones. Substances such as drugs and alcohol also activate that system, according to the National Institute on Drug Abuse.

National Institute on Drug Abuse. Understanding drug use and addiction. DrugFacts. June 2018.

 

When drugs and alcohol are used repeatedly over time, the brain adapts by reducing the reward system's ability to respond. Consequently, the addicted individual needs to use more of the substance to get the same desired effect, and the cycle repeats itself. People become vulnerable to relapse because their brains have adapted to this addiction cycle, and it takes deliberate, sustained effort to overcome how their brain is operating.

In other words, overcoming addiction means retraining the brain. Long-term therapy is often necessary for this retraining. Relapse does not mean treatment has failed, but that the individual needs to resume treatment, modify their treatment plan, or try another therapy.

 

The stages of recovery

The Yale Journal of Biology and Medicine article mapped out three stages of recovery:

Abstinence—Dealing with cravings and refraining from substance use is the objective of this stage, which requires that patients accept they have an addiction and be honest with their clinicians—and themselves. Patients may feel they’re not making progress during this stage; it’s recommended that clinicians encourage them to measure progress month-to-month instead of by weeks or days.

Repair—Focused on repairing damage caused by substance abuse, this stage could last 2–3 years, according to the research. Patients typically feel better during this stage, because they’re starting to take control of their lives—although some may feel worse for a time as they confront the damage caused by their behavior.

Growth—In this stage, which typically occurs 3–5 years after the patient stopped using, they address family issues and past trauma that may have contributed to their addiction in hopes of repairing their self-destructive behavior.

 

Importance of therapeutic alliance

The quality of the relationship between the healthcare provider and the patient—known as the therapeutic alliance—is the main factor that determines the success of treating addiction, according to The Family Institute. And it's the patient’s perception of the relationship that's the strongest predictor of success.

Clinicians who establish strong relationship with patients have made them feel comfortable talking about their thoughts and behaviors. Should they indicate they have been struggling lately—and may be on the brink of a relapse—physicians can promptly intervene, assessing their situation and recommending coping strategies or treatment to help them avoid it.