Addiction is a chronic, relapsing brain disease. Setbacks are a common part of one’s recovery journey. Relapse is a term to describe when a person “who has been in remission experiences a return of symptoms or loss of remission.”1 Historically, relapse has been a commonly used term throughout substance use treatment and the recovery community. However, some believe it denotes a moral failing and perpetuates stigma. Throughout the Playbook, we use the term “recurrence of use” wherever possible as it is a more neutral, descriptive term.
Everyone will experience setbacks on their path to recovery, but they do not have to end in recurrence of use.2 Providers need to understand that preventing recurrence of use is more complicated than saying “no” to temptation.3 It is important to work with patients to plan how to address these setbacks and prevent recurrence of use. Patients need help to understand that setbacks are not a failure and that learning from the circumstances of recurrence of use can help avoid known triggers in the future.
Providers work collaboratively with patients early in the treatment planning process to develop plans to prevent and respond to recurrence of use. These plans are updated periodically as patients’ needs evolve over time.
How Do You Do It?
Understand the Process That Leads to Recurrence of Use
Providers, patients, and patients’ families need to understand that returning to substance use is a gradual process that can be categorized by stages, rather than a singular act of using substances.2 Understanding the risks and appropriate coping strategies is fundamental to preventing recurrence of use.
Struggling With Emotions and Self-Care. During this initial stage, individuals are not actively thinking about using opioids again. Signs include restlessness, anxiety, anger, mood swings, social isolation, and poor eating or sleeping habits. To combat these symptoms, it is important to practice self-care for one’s emotional, psychological, and physical needs. Patients need to be able to recognize their concerning behaviors and habits and actively work to take better care of themselves.
Considering Using Substances. When patients have transitioned to this stage, they are struggling mentally with whether they want to use again. They may engage in bargaining, in which they think of situations that would be acceptable to use or rationalize that they can use in a controlled way for a limited amount of time. Signs include thinking about past use (e.g., people, places, and things); lying or hiding the truth; spending time with old friends; and fantasizing about using.
During this stage, providers should advise patients to remind themselves about the negative consequences of their past substance use or talk to a supportive family member or friend. It may also be helpful for patients to set small, incremental goals rather than grapple with the overwhelming commitment to staying abstinent from substances for their entire life.
Actually Using Substances. At this point, the individual has started using substances again. When patients have begun using, it is much more difficult to stop and to prevent a full return to use and disengagement from treatment.
Providers should also understand that co-occurring conditions, such as anxiety or chronic pain, may increase an individual’s risk for returning to substance use. Therefore, these patients even more so than others may benefit from additional behavioral counseling and recovery supports, as well as extensive prevention planning.
Develop a Prevention Plan
It is important to work with patients early in the treatment planning process to design a recovery plan that includes strategies to prevent a recurrence of use.3 A prevention plan can help patients be ready to deal with setbacks. The plan can help patients think about what symptoms or feelings may arise if or when their conditions begin to worsen and what they can do when they notice these changes. Providers should try to help patients recognize the warning signs and develop the skills to prevent recurrence of use.2
A prevention plan should describe:
- Feelings or emotions the patient should recognize as warning signs that may lead to a return to using substances;
- Life stressors and triggers for substance use;
- Family members, friends, or other points of contact who can serve as supports during a difficult time; and
- Additional steps or strategies to cope with setbacks and prevent recurrence of use.
Respond Appropriately to Recurrence of Use
As discussed in the section on Tracking Patient Outcomes, providers should systematically monitor patient progress so that recurrence of use can be identified and an intervention can occur as soon as possible. When a patient returns to use, providers should do their best to keep the patient in treatment and increase the intensity of treatment and recovery supports.
Revisions to the treatment plan may include:
- More frequent medication management visits,
- Shortened prescription lengths,
- Confirmation of attendance or engagement in counseling and psychosocial supports, and
- Referrals to additional behavioral health services or a higher level of care.
Additional tools to help prevent recurrence of use are cognitive therapy and relaxation techniques, which can help change negative thinking and build healthy coping skills.2
What Not To Do
- Don’t assume that a prevention plan will stay the same throughout the course of treatment. The risks of returning to substance use change over the course of recovery and a patient’s stressors, coping strategies, and needs will similarly evolve.
- Don’t respond to recurrence of use by punishing or involuntarily discharging a patient.
- Don’t feel disappointed in the patient if he or she returns to using substances. Setbacks should be expected. The most important thing is how you respond and what you do when they occur.
- Substance Abuse and Mental Health Services Administration. Treatment Improvement Protocol 63: Medications for Opioid Use Disorder. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2018. Publication No. SMA18-5063. https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document-Including-Executive-Summary-and-Parts-1-5-/SMA19-5063FULLDOC. Accessed June 12, 2019.
- Melemis SM. Relapse prevention and the five rules of recovery. Yale J Biol Med 2015 Sep;88:325-32. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553654/pdf/yjbm_88_3_325.pdf. Accessed June 12, 2019.
- American Psychiatric Association. Relapse Prevention for Opioid Use Disorder. Washington, DC: American Psychiatric Association; 2016. https://www.psychiatry.org/psychiatrists/education/signature-initiatives/model-curriculum-project-for-substance-use-disorders/relapse-prevention-for-opioid-use-disorder. Accessed June 12, 2019.