What is the best way to deal with relapse?

Written by: Dominic Denison-Pender, Business Development Director at The New Life Centre.

Medically Reviews by: Dr Amal Beaini MBChB FRCPsych (Medical Director and Consultant Psychiatrist at The New Life Centre)

Introduction

Success rates (i.e. sustained abstinence) for addiction treatments are notoriously low, and dramatically so for opioids. The main causes of failure are:

• objectives set too low (i.e. merely shifting the addict from illegal opioids to opioid substitutes)
• failure to complete treatment
• relapse following treatment.

Addiction is a medical condition, and relapse is akin to recurring symptoms in other medical conditions.  This raises the question: should relapse be dealt with by counselling and therapies, or should it be treated or prevented by medical solutions?  Relapse following treatment is so common that it tends to be considered a normal occurrence during recovery, rather than reflecting any shortcomings in the treatment.  The New Life Centre treats its patients with compassion and understanding, but its BONDS Protocol succeeds in dramatically reducing the incidence of relapse to the exceptional rather than the normal through the use of proven relapse prevention medication.

What is relapse in addiction?

Relapse occurs when a previous addict begins abusing or become addicted to drugs and alcohol after a period of recovery and sobriety, and therefore often after the apparently successful completion of treatment. Relapse can occur at any point during recovery. It is most often seen during the first few months of sobriety and throughout early recovery. The term relapse is not confined to addiction. Relapse happens when someone who is suffering from a disease returns to a former, unhealthy state, after a temporary improvement. In the case of substance addiction, it means that a person returns to drinking or drug use after an attempt to stop. It is generally accepted that relapse does not mean that someone has failed, nor does it mean that their prior treatment has failed. Rather, it means that treatment must be resumed or revised to meet that person’s changing needs.

Relapse implies a prolonged or repeated return to substance abuse. It is different from a “lapse” which is a one-off incident after which the individual returns to abstinence or sobriety.

Is relapse a part of recovery?

As far as relapse in addiction is concerned, in practice yes it is.  Relapse rates for individuals who enter recovery from a drug or alcohol addiction are high.  Studies reflect that about 40-60% of individuals relapse within 30 days of leaving an inpatient drug and alcohol treatment centre, and up to 85% relapse within the first year.   The conventional approach is indeed to treat relapse as a normal part of recovery rather than as a reflection of inadequate treatment.  Health insurers, especially those involved with the opioid crisis in the USA, have real problems with multiple relapses and readmissions to expensive treatments.  For the less ethical of the treatment clinics, relapse is even seen as good business. 

The New Life Centre (NCL) rejects the inevitability of such patterns, and sees effective relapse prevention with medication as a fundamental element of its treatment protocol.

Why you keep relapsing

Preparing for relapse?

If relapse happens in so many cases that it is seen as a part of recovery, then the recovering patient should be prepared for relapses.  Families need to be warned that relapses are likely.  This is not easy since families that have had to cope with the original addiction are in all probability warn out by it and dread having to slip back into that vicious circle.  If there is more than one relapse they will wonder if it is ever going to end.  One documentary on the opioid crisis in the USA showed a family having to handle the mother being readmitted to treatment 30 times.

Most clinics have a stated policy of not blaming the relapsed patient, and patients who have been in treatment usually have something to fall back on.  Both the patient and the family should be briefed on discharge from treatment about the warning signs of a possible relapse.  This in turn implies being aware of the triggers that set off a relapse.

Why do addicts relapse when recovery is going well?

Addiction rehab does not necessarily remove all the causes of the original addiction, so there is a propensity for those with an addictive nature to relapse, especially if they are exposed to the specific triggers to which they are susceptible.

Many individuals relapse within the first week of stopping their substance use in order to avoid withdrawal symptoms, or thereafter due to post-acute withdrawal symptoms which can last for up to 6 to 18 months.  Individuals with an alcohol or drug addiction will experience varying degrees of withdrawal symptoms when they stop using their substance of choice.  Depending on the type of substance used, the quantity of use, the frequency of use, the duration of use, and other factors, withdrawal symptoms will be different on a case by case basis.  Some common physiological withdrawal symptoms may include nausea, hot and cold sweats, restlessness, vomiting, diarrhea, insomnia, and muscle aches to name a few.  Withdrawal from substances such as alcohol and benzodiazepines (Xanax, Ativan, Klonopin, Etizolam, etc.) can even be deadly and/or cause seizures.  Relapses caused by withdrawal occur when addicts attempt to cease taking the addictive substance before they are fully detoxed (i.e. they still have remnants of the substance in their systems).  This can be for a number of reasons:

• their detox was not complete
• they are attempting to achieve abstinence without detox
• they are on OST, in which case illegal or prescription opioids have been replaced with opioid substitutes such as methadone or buprenorphine.  In such cases (which probably apply to the majority of those under treatment opioid addictions), the relapse is from opioid substitutes back to the original opiate (e.g. heroin, fentanyl, oxycodones etc.).  Multiple relapses are all too common.

Full medicated relapse prevention using naltrexone can only be attempted if a full detox has been completed and “challenge” tests have established that the patient is “clean” from opioids or other addictive substances.

Alcoholism and drug addiction is a problem in itself, but more often than not there is also a mental health problem (e.g. anxiety, stress, depression, mania, personality disorders, or post-traumatic stress) underlying the dependence which needs to be addressed along with the addiction itself.  This is why many addiction treatment programmes, including The BONDS Protocol, include “dual diagnosis” prior to treatment and therapies to address the problems post treatment.  If this aspect of the treatment is not administered properly, there is a high risk of the recovering addict relapsing to counter the underlying issues.

Individuals with an alcohol or drug addiction often surround themselves with likeminded individuals who continue drinking or take drugs, including previous co-abusers.  This can trigger relapse.  On the other hand maintaining and rebuilding marital, partnership and family relations is important.  There is a particular challenge facing those who did not previously benefit from stable and supportive relationships. Rushing into new relationships too soon after treatment might generate triggers that lead to relapse.

Relapse can be triggered by visiting or frequenting locations associated with the previous addiction (e.g. bars, clubs,  drink shops, parties at certain locations etc.). It is obviously problematic if the ex-addict’s home is such a location, and sometimes to patient needs to go to a designated “sober home” if available to aid recovery.  Making changes within the home to remove domestically located trigger associations, or for example changing bedrooms, can be helpful.

As well as places, objects associated with the previous addiction can act as triggers.  Bottles, glasses, or even credit cards or wallets that have been used to purchase addictive substances can act as subconscious triggers.  They cannot all be avoided, but awareness of the dangers they pose is a step in the right direction.

Another trigger can be low self esteem. Self-care is an important part of addiction recovery.  Recovering addicts benefit from maintaining disciplined and healthy lifestyles , being careful about diet, exercise, sleep patterns, weight, hygiene etc. 

It is also important to strike a balance between avoiding boredom and isolation on the one hand and becoming stressed through, for example, work or other overexertion on the other.  Both boredom and stress can be relapse triggers. Developing a schedule that fits in work, hobbies, and activities focused on sobriety not only helps those in recovery to remain focused on their sobriety goals but can help them derive satisfaction from a sober lifestyle.

In short, recovery from addiction is not easy, especially in the early stages.  It requires determination and commitment on the one hand while avoiding complacency and overconfidence on the other.  In particular recovering addiction should beware of the situations that triggered abuse before they were treated.  Old habits can die hard.

How many relapses do most people have before sobriety?

It is impossible to generalise.  Each person is different and each addiction is different.  There are also wide differences in the treatments offered for each type of addiction.  Furthermore, systematic outcomes monitoring is notoriously lacking.  Studies tend to look at the likelihood of relapse rather than the frequency of relapse.

Research shows that alcohol and opioids have the highest rates of relapse, with some studies indicating a relapse rate for alcohol as high as 80 percent during the first year after treatment. Similarly, some studies suggest a relapse rate for opioids as high as 80 to 95 percent during the first year after treatment.

According to statistics cited by Recovery Village in the USA, over 30% of people who attempt to stop drinking alcohol relapse in their first year of sobriety. However, while the first years can be the hardest, the relapse rate does go down with time: in one study, 21.4% of recovering alcoholics relapsed in their second year in recovery, but only 9.6% relapsed in years three through five, and only 7.2% relapsed after five years in recovery. This means, more than 70% of people struggling with alcohol abuse will relapse at some point.

Chances of opioid addiction relapse are higher than those for any other drug addiction, with one study in the USA reporting that as many as 91% of those in recovery will experience a relapse. The study also found that at least 59% of those who had an opiate relapse would do so within the first week of sobriety, and 80% would relapse within a month after discharging from a detox program.  Anecdotal evidence points to widespread multiple relapses and repeated admissions for treatment.

I relapsed and I hate myself

The prevalent advice coming out of the addiction treatment sector is that addicts should not hate themselves for their relapses or treat relapse as a failure.  In parallel, the sector pleads that nor is relapse a sign of poor or failed treatment.  This “Don’t blame yourself and don’t blame us” message, though compassionate, surely also has an element of self protection about it.  The fact is that not only do outcomes of addiction treatment leave a lot to be desired, but there is also a failure adequately to monitor outcomes.  Certainly as things stand you should not hate or blame yourself if you relapse, but surely you should ask whether you or your treatment has done enough to prevent or at least lower the likelihood of relapses.  The evidence is that most commonly used approaches to relapse prevention help to some extent, but outcomes are poor and expectations are low.  This is especially true for opioid addiction.  There is a challenge to improve things, and The New life Centre intends to take up this challenge through The BONDS Protocol.

What to do when an addict relapses

The most important thing is to be open and honest when it happens, access the help and support that may be needed, learn and hopefully move forward.

Most addiction treatment facilities invite patients to recontact them if relapses occurs, and undertake to treat them compassionately without blame.

If you find yourself having to cope with someone who relapses, the immediate response should be to:

• to seek medical support if the person is experiencing unusual or significant symptoms. There are particular risks if they haven’t used a substance for a long time
• ensure, if possible, that the person has support people nearby to make sure they stay safe.
• call upon the person’s previously agreed support network: friends, a family doctor or a 24-hour alcohol and other drug information/counselling service.

There is no question that addiction and recovery from addiction demands a lot from families or anyone trying to care for the addict.  Unfortunately they may have to be prepared for a long haul:

• it can take repeated attempts before a person successfully achieves long term abstinence. The addict will need reassurance that relapse can be common, but the carer may also need advice and support
• the addict should be encouraged to think of a relapse as an opportunity to learn more about their drug-use triggers.

Proven relapse treatments

From the outset addiction treatment should take into account the possibility, and indeed the frequency, of relapse in the process of recovery and seek to confront this problem.  

As a general rule, it is better to seek help than not to.  Most addictions will not just go away, and attempting to escape from addiction unaided is very hard and might even be dangerous.  Over 100,000 people die of opioid overdoses annually in the USA.  Attempting to withdraw in the wrong way can lead to many adverse health complications including seizures.  

Most treatments help.  Unscrupulous operators do exist. Let’s face it, for addiction clinics relapses and readmissions are good for business. (e.g. “The Florida shuffle” in the USA which milks health insurers with endless claims for readmissions).  Even if a support package is offered for a period after treatment, you do not get a 12 month warranty as you would if you bought a washing machine.

It is difficult to point to “proven relapse treatments” in isolation, because the options depend on so many variables, include the type pf substance abuse being treated and the form of treatment selected. Certainly no treatment guarantees freedom from relapse.

There is one approach that is applied across almost all types of addiction and most types of treatment, and that is the “12 Step” model.  Neither the 12 Step model nor the other “soft therapies” mentioned below are specifically relapse prevention treatments.  They are use to help addicts to move to abstinence in the first place. There is evidence that he use of such therapies help to reduce the incidence of relapse post initial treatment and they may be used again post relapse.

Proven relapse treatment 1: The 12 Step Model

This is without question the most widely used approach to addiction therapy in the world.  Although it started as a response to alcoholism, it is now used for almost all types of addiction in most types of treatment settings.

The 12 Step model was the basis of the foundation of Alcoholics Anonymous (AA) in Ohio in 1935.  The original list of the 12 Steps was as follows:

The following are the original twelve steps as published by Alcoholics Anonymous: 

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory, and when we were wrong, promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

While the 12 steps in use today are based on the same ideas written by the founders of AA in the 1930s, the understanding of the term “God” has since broadened to refer to any “higher power” that a person believes in.  The 12 Steps are supported by AA’s “12 Traditions” which are the spiritual principles behind the 12 steps. This embrace anonymity, singularity of purpose, non-affiliation to other bodies etc.  The original approach was based on mutually supportive groups, of which Alcoholics Anonymous (AA), Drug Addicts Anonymous (DAA) or Narcotics Anonymous (UKNA) are amongst those active in the UK.  The 12 Step model is retained as the basic therapy in several of the UK’s best known addiction treatment clinics whose detox treatments are mostly abstinence based.  It is also used by treatment facilities using OST for opioid addiction.  The approach is spiritual and philosophical rather than scientifically psychiatric or medical.  There is no doubt that the 12 Step model has helped countless people struggling with addiction.  However even its most ardent advocates will accept that it is an aid rather than a solution to relapse prevention.  The very poor treatment outcomes, especially for opioids, do signal that some mor (or different) is needed.

Proven relapse treatment 2: other “soft” therapies:

A wide range of other soft therapies are used by addiction treatment facilities (including those that do and those that do not use the 12 Step model).

These include:

• Cognitive behaviour therapy (CBT)
• Dialectical behavioral therapy (DBT)
• Art and music therapy
• Psychodrama
• Equine assisted therapy
• Drumming therapy
• Fitness, massage, acupuncture, and aromatherapy
• Family therapy
• Eye movement desensitization and reprocessing (EMDR)
• Creative workshops
• Yoga and mindfulness meditation
• Horticultural therapy.
• Contingency management.

Again, these are aids rather than solutions to relapse prevention.

Proven relapse treatment 3: Medicated treatments

Where medicated addiction treatment is used, the relapse prevention element is effectively built into the initial treatment.  Relapse rates are likely to reduced if the addict has been treated to the point of being “clean”using appropriate medications.  To date the The New Life Centre is unique in the UK in adopting naltrexone based relapse prevention into the mainstream of its treatment protocol.

Looking specifically at opioids, there are three main categories of treatment:

• Opioid Substitute Treatment (OST)
• Medication assisted detoxification
• The BONDS Protocol (New Life Centre)

Opioid Substitute Treatment (OST)

The patient is weaned off illegal and prescription opioids by substituting them with opioid substitiutes, mainly methadone or buprenorphine.  

Methadone is a full agonist, meaning that it fully occupies the mu-opioid receptor. In doing so, methadone lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of other opioid drugs. Unlike heroin and other opioid agonists taken for nonmedical purposes, methadone is longer lasting, usually 24 to 36 hours, preventing the frequent peaks and valleys associated with compulsive behaviours.

Buprenorphine is a partial agonist, meaning it does not completely bind to the mu-opioid receptor. As a result, buprenorphine has a ceiling effect—its effects will plateau, and will not increase even with repeated dosing.

OST is not specifically administered for relapse prevention.  It is quite possible for the addict to relapse back to heroin or other illegal opiates.  The direct benefits of OST are seen more in terms of:

• Improved social functioning.
• Increased possibilities for monitoring, testing and treatment of HIV, Hepatitis B and C.
• Reduced overdose mortality.
• Discontinued or reduced incidence of injecting.
• Reduced risks of HIV and Hepatitis.
• Improved physical and mental health (with competent treatment).

Full withdrawal from OST medication can be very protracted, and in the meantime sustaining an addict on OST is expensive. OST is typically used for outpatient addiction treatment and in some charitable residential clinics.

Medication assisted detoxification

Residential addiction treatment clinics tend, for opioids, to opt for medication assisted abstinence based detoxification to aimed at discharging the patient “clean”.  The patient is not sedated, but in order to help cope with withdrawal, is given appropriately controlled medication as part of the detox process. 

Although cravings can reduce gradually, the risk of relapse resulting from withdrawal symptoms are greatly reduced if the patient is discharged clean.  Many such clinics adopt the 12 Step model and/or other “soft” therapies to help the patient achieve and sustain abstinence.  It is difficult to judge the effectiveness of this form of treatment with regard to relapse prevention since the clinics do not publish outcome data by type of addiction.  If the patient becomes fully “clean” following the detox (which needs to be proven by “challenge” tests) it is medically possible to initiate a course of naltrexone specifically as a relapse prevention treatment.  However, except at The New Life Centre, this does not seem to have been adopted as standard practice at UK clinics.

The BONDS Protocol sat The New Life Centre

The BONDS name was originally an acronym for “Beaini Opiate Naltrexone Detoxification Services”, reflecting the particular strength of the BONDS Protocols in opioid addiction treatment, but its application is not restricted to opioids. The BONDS Protocol can be applied successfully to a wide range of addictions including: 

• Opioids:
  • Heroin: an opioid drug that is from the morphine family.
  • Prescription opioid addiction: these include codeine, morphine. Oxycodone/Oxycontin, Tramadol, Diamorphine, Fentanyl or anti-depressants such as Benzodiazepines and Gabapentinoids
  • Opiate substitute treatment (OST) medications: mainly methadone and buprenorphine
• Benzodiazepines and Gabapentinoids: these are prescribed anti-depressants
• Ketamine: hallucinogenic dissociative often used as a party drug
• Cocaine: the second most widely used party drug after cannabis
• Cannabis/marijuana: the most widely used drug
• Alcohol: the most common form of addiction.

As the name implies, the use of naltrexone (though optional for the patient) is a standard part of the treatment.  For opioids, the preference is to use implants, while injections are preferred for alcohol.  The implants have a 6 month life, so a second implant is required if a 12 month protection is to be offered.  The efficacy The BONDS Protocol has been proven over 20 years and 12,000 patients when it was practiced under the Detox 5 banner out of the Cygnet Clinic in Harrogate.  Unlike other clinics, it was the policy at Detox 5 and will be at NLC to monitor as far as possible and to publish the outcomes.  At Detox 5, 97%  of patients completed the  treatment and 66% of opioid patients were abstinent without relapse after 12 months.  This is far superior to anything claimed for opoids by any other UK treatment facility.  

Naltrexone is an opioid blocker and can cut cravings. It works by blocking the pleasure effects of opioids in the brain. At the right levels, naltrexone can cancel out the opioid ‘highs’ and may reduce general cravings in other addictions such as alcohol as well. It can only be used for patients that are fully clean after detox.  Thus the BONDS programme, Protocol, enabling the patient to be painlessly detoxed over about 3 days (within a 7 day stay at the clinic), allows naltrexone to be used after a “challenge” test to ensure the detox is complete.

After a successful detox, NLC encourages its patients to undertake a Consolidation and Relapse Prevention programme that includes the naltrexone treatment. At The New Life Centre, this as a 12-month programme tailored to the individual to ensure that best route to recovery is provided.

Conclusions

Relapse is currently viewed as a “more often than not” part of the recovery process after addiction treatment, most markedly for opioids and alcohol.  The general philosophy is to treat relapses as the fault neither of the patient nor of the treatment.  However, this pattern persists in the context of very poor (and poorly monitored) treatment outcomes, most notably for opioids.  Apart from The BONDS Protocol there are no “proven relapse prevention treatments”.  A range of therapies, of which the 12 Step model is easily the most widely usedd, can help reduce that incidence of relapses, but they are only aids, not solutions.  The BONDS Protocol practiced at The New Life Centre seeks to turn this situation on its head.  With the patient emerging fully “clean” after a painless 3 day detox, it is safe to employ to opioid blocker naltrexone with the aim of making relapse the exception rather than the rule.  Naltrexone can also be used to help reduce relapses for other addictions. The efficacy of The BONDS Protocol was proven over 20 years when The BONDS Protocol was administered under the name Detox 5,