Prevent and Respond to Recurrence of Use

Co-occurring conditions, such as anxiety or chronic pain, may increase an individuals risk for returning to substance use.⁵⁷ Patients with co-occurring conditions may particularly benefit from recovery supports such as counseling and extensive prevention planning.

Returning to substance use is typically a gradual process that can be categorized by stages, rather than a singular act of using substances.⁵⁷ Educate patients and their families about this process, as understanding the risks and appropriate coping strategies is fundamental to preventing recurrence of use.

The stages of returning to substance use include:

• Struggling with Emotions and Self-Care: During this initial stage, patients are not actively thinking about using opioids or other substances again. This stage may be characterized by signs including restlessness, anxiety, anger, mood swings, social isolation, and poor eating or sleeping habits. Patients need to practice self-care for their emotional, psychological, and physical needs to combat these symptoms.
• Considering Using Substances: This stage is characterized by patients mentally grappling with decision to use again. They may engage in bargaining, rationalizing situations where it might be acceptable to use or convincing themselves they can do so in a controlled or limited way. Signs of this stage include reminiscing about past use (e.g., people, places, and things); lying or hiding the truth, spending time with old friends who use substances, and fantasizing about using.
  • During this stage, advise patients to remind themselves of the negative consequences of past substance use or to talk with a supportive family member or friend. Encouraging patients to set small, incremental goals can be more manageable than focusing on the overwhelming commitment to lifetime abstinence. These smaller goals can help patients feel empowered and maintain their focus on recovery.
• Actually Using Substances. At this point, the individual has started using substances again. Once patients begin using, it becomes much more difficult to stop and prevent a full return to use, as well as disengagement from treatment.

Include a prevention plan in the patients treatment plan. Collaborate with patients to identify strategies for preventing a recurrence of use.⁵⁸ A prevention plan (such as this Relapse Prevention Plan (PDF - 58.9 KB) from the West Virginia Department of Health and Human Resources) can prepare patients to manage setbacks by helping them recognize early warning signs, anticipate emotional or situational triggers, and outline concrete steps to take if they notice their condition beginning to worsen. Supporting patients in developing these skills can empower them to respond effectively and avoid a full return to substance use.⁴

A prevention plan should describe:

• Feelings or emotions the patient can 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 to prevent recurrence of use.

Monitor patient progress to detect recurrence of use early and intervene quickly. Use motivational interviewing to identify and remind patients of why THEY want to be in treatment. If a patient returns to use, prioritize keeping them engaged in treatment and continuing buprenorphine.

Consider revising the treatment plan to increase the buprenorphine dose, increase the frequency of medication management visits, shorten prescription durations, and/or refer patients to and confirm their engagement in counseling or other psychosocial supports. Referral to a higher level of care may also be appropriate. (See the Tracking Patient Outcomes section for more guidance.)