How Can Relapse Be Prevented?

Date: 27-05-2022

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

Relapse after addiction treatment is so common, especially where opioids or alcohol are concerned, that it considered as a normal part of the recovery process.  Various treatments, therapies and medications are used both to help the patient towards abstinence in the first instance and in an attempt to reduce the incidence of relapse.  Of these the 12 Step model is the most used worldwide.  It is the mission of The New Life Centre to make relapse the exception rather than the norm through the administration The BONDS Protocol’s proven medicated approach to relapse prevention.

Why do addicts relapse?

Why do addicts relapse when they seem to be doing well?

It is simply a fact of life that while most current addiction treatment help addicts on the road to abstinence, they are unable to prevent a high incidence of relapse, especially in the early days of recovery but often well into the recovery process.  Studies show that relapse rate are highest for opioids and alcohol. Indeed, those involved in addiction treatment consider it best to warn patients that relapse typically forms a part of the recovery process, and that relapsed patients should blame neither themselves nor the treatment they have received. 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. The immediate causes of relapse are generally linked to “triggers” that reawaken cravings in the recovering addict.

Relapse triggers

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, diarrhoea, 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.

What percentage of addicts 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.

What is relapse prevention therapy?

Except in the case of The BONDS Protocol, it is perhaps inaccurate to refer to “relapse prevention therapy”.   “Prevention” implies stopping relapses altogether, which is not realistic even though aims to achieve such a goal as nearly as possible.  Most prevalent treatments and therapies are administered in the context of an acceptance that relapse is an anticipated part of the recovery process, and, especially for opioids and alcohol, is more likely to occur than not.

Although, the most commonly practiced treatments and therapies are intended in the first instance to aid the patient towards his or her’s initial achievement of abstinence, they hope also to result in a lower incidence of relapse than would have been the case in the absence of such treatments.  However they are not specifically relapse prevention therapies.  Only the type of naltrexone based treatment offered BONDS Protocol’s Consolidation and Relapse Prevention programme is specifically aimed at relapse prevention.

It is important to distinguish between relapse prevention treatment using naltrexone and the emergency treatment given to addicts who have overdose. For the latter naloxone, not naltrexone, is used. Naloxone is a medication approved by the Food and Drug Administration (FDA) designed to rapidly reverse opioid overdose. It is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids, such as heroin, morphine, and oxycodone. Naloxone is also one of the drugs used by clinics to reduce the pain of withdrawal during medication assisted detoxes.

Relapse prevention strategies

As stated above, for the most part attempts to limit the incidence of relapse are built into the treatments and therapies used in the initial addiction treatment.

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 used 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.

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.

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.

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 substitutes, 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 non addictive 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.

Naltrexone based relapse prevention

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.

Relapse prevention plan example: Naltrexone and The BONDS Protocol

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.  

Currently naltrexone is little used in the UK except by The New Life Centre.  Where it is used by other clinics, it is usually taken orally in tablet form. With the oral form of naltrexone, there may be temptation to stop taking it and go back to opioids whilst long-acting naltrexone in the form of implants or injections can last weeks or months at a time, and the patient cannot interfere with them.  Preference of the experienced team at The New Life Centre is to use implants for opioids and injections for alcohol.

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.

Thus The BONDS 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.

As the name implies, the use of naltrexone (though optional for the patient) is a standard part of the NLC treatment.  For opioids, the preference is to use implants, while injections are preferred for alcohol.  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 opioids 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, and includes access to therapies based near the patients home and to ongoing support.

Following a successful detox, oral naltrexone may be used to support relapse prevention in both the NHS and private sector. There is a risk of missing doses of daily tablets. In the UK, oral naltrexone is licensed for use in alcohol or opioid misuse. 

Naltrexone injections are currently licensed and used extensively in the USA. They last one month each and can give consistently higher blood levels of naltrexone. There is a significant amount of published data for use in both formerly opioid and alcohol dependent patients. The injection is straightforward to give: it is injected into a muscle, similarly to a vaccination; naltrexone is usually injected into the buttock muscle. The monthly injections are only licensed in the USA at present, under the brand name of VivitrolTM.  They can be administered at The New Life Centre on specific individual patient demand. The NLC team believes they represent the most effective relapse prevention treatment for alcoholism.

Naltrexone implants can be effective for several months at a time and have been around for many years. Russia is currently the only country in the world to have a licensed implant. Outisde of Russia, all use of naltrexone implants is on an “unlicensed” use which means it must be on a “named patient basis”. The longest lasting implant with the most published data is the O’Neil Long Acting Implant (OLANI). This is the naltrexone implant of choice The New Life Centre offers.

Naltrexone implants have been used in previous iterations of the BONDS treatment programmes since 2006 (when provided by Detox5 in the past). The NLC medical director has overseen the use of around 3,000 implants at Detox5 in previous years, prior to the opening of The New Life Centre at Broughton Hall. Whilst other services may market the same implants as lasting longer for example, The New Life Centre believe in safety first. We recommend that a ‘double’ OLANI should be considered as standard and it is envisaged to last on average around 6 months. There is however no guarantee on the length and efficacy of an implant and this may depend on individual circumstances.

Naltrexone implants may help with the challenge of potentially missing doses of naltrexone tablets. The slow-release pellets are placed in the fatty part of the abdomen under local anaesthetic like a minor surgical day-procedure. This can be particularly helpful for relapse prevention, creating the opportunity to stay abstinent and provide vital time needed to work on mental health and wellbeing. Treatment with naltrexone is only considered after a consultation with your medical team.

Conclusions

Most treatments and therapies for addictions, including the much used 12 Step model, are first and foremost intended to assist the addict’s journey towards initially achieving abstinence.  There is evidence that undergoing such treatment has some beneficial effect in reducing the incidence if relapse. However, especially for opioids and alcohol, relapses occur more often than not and are seen as a part of the recovery process.  Naltrexone is used specifically for relapse prevention.  It remains little used in the UK, and except at NLC it is almost entirely administered in tablet form.  The BONDS Protocol at NLC sees naltrexone based relapse prevention treatment as its preferred route towards sustaining abstinence, and is probably unique in offering naltrexone in implant or injection form based on specific individual patient demand.