Relapse Is Common But Not Required
The hope was there for everyone. Our loved one made their way through the seemingly required denial. An event of some sort opened their eyes (or scared them straight) and the process of recovery began. There were early signs of success. There were days, maybe weeks of clean and sober behavior or, at least, no alcohol and/or drugs. Then, seemingly without warning, they use again. Perhaps, as a result, another difficulty was created. The loved ones are disappointed and scared. The person with SUD is all those things and discouraged. What happened?
Relapse is generally considered to be use of one or more substances after a period of attempting recovery. We should note that there is brewing controversy about this definition. As AA and offspring such as NA have been the most common form of treatment for ninety years, abstinence has been the most frequent if not exclusive approach. Harm Reduction has emerged with one tenet that there are those for whom abstinence is not a realistic goal and that ongoing use is to be expected. The evolution of substance use disorder treatment is trending toward chronic disease approaches such as is the case for type II diabetes. These two approaches would not hold immediate, continuous abstinence as a goal at least early on and therefore not define relapse this strictly. Today the general population would define relapse as using after an attempt at recovery.
We should accept, first, that relapse is common. As noted, substance use disorder is a chronic disease much like Type II diabetes for which there is no cure but there is treatment that can be successful. Relapse is a part of that process. The Addiction Group reports that relapse rates by substance within one year are:
· Cannabis 10-50%
· Stimulants 75% (5 years)
· Alcohol 60-80%
· Opioids 80-90%
· Nicotine 90%
The evidence is that most relapses occur within the first six months of recovery. Achieving one year of continuing abstinence is a significant benchmark after which relapse is less common. After five years relapse rates are reduced to 15% across substances.
A 2019 study by the National Institutes for Health found that the mean of relapse events was 5.35 attempts and that this number was consistent across all substances. Race, prior use of treatment and mutual‐help groups, and history of psychiatric comorbidity were associated with higher number of relapses. As one might expect, as the number of relapses increases, the success of long term recovery decreases.
While we focus on relapse in substance use disorder, we can see that this is not uncommon for chronic diseases. In “Drugs, Brains, and Behavior: The Science of Addiction” published by the National Institute for Drug Abuse in 2020 we see that diseases such as asthma (50-70%) and hypertension (60-70%) have similar and sometimes higher rates of “relapse” than SUD depending on the substance. The data for heart disease and Type II diabetes are similar. In your everyday experience you know that is the case as you see diabetics not regulating diet and COPD victims smoking. Managing a disease that lacks a “cure” is, obviously difficult.
The causes of relapse have been described in several studies within the NIH. They fall into five categories:
· Quality of Life speaks to the circumstances in which one finds recovery. People experiencing homelessness and the many challenges associated will have a much harder time avoiding relapse than the average addict who, as we have reported previously, has a family, a home and a job
· Happiness is closely correlated with these circumstances but involves one’s ability to achieve a positive outlook. Of course, shame and personal disappointment attend early recovery but the extent to which one can achieve a sense of well-being this helps avoid relapse
· Self‐esteem involves one’s self-assessment and outlook. Again, shame is a normal, initial reaction but to the extent one assumes they can “beat this” they have an advantage
· Psychological Distress refers to events but more often to comorbidity. Estimates are that 50% of people with a substance use issue have a co-occurring behavioral health issue. Treating multiple issues and their co-occurring influences on each makes recovery from each that much more difficult
· Recovery Capital speaks to clinical treatment, twelve step communities, family infrastructure support and employment support among others. Studies have shown repeatedly that clinical involvement combined with twelve step communities is the most powerful treatment approach.
Obviously, acceptance is key. One doesn’t need to treat a condition that one does not believe they suffer. The added psychologic challenge of denial is the hallmark of this disease. Too, effort is required. We know several people in long term recovery who speak to a “power greater than themselves” who say that if the grace of God alone could make the difference they would have been clean and sober long ago. As is often said in twelve step circles, “you have to put in the work”.
Of course, it would be far better if everyone who made an attempt at recovery never drank or used again after their first try at recovery. That is rare. Rather, some number of relapses are common. The addict and their loved ones may be devastated but they should not lose heart. Acknowledging that relapse is a part of the process can go along way to “getting back on the horse”.
One note of caution is that accepting multiple relapses is very dangerous. Each relapse brings with it many dangers. As noted elsewhere, about one-third of people with SUD die from an incident while using. Too, the point arrives at which it is very difficult if not impossible to get back. Relapse is common but not required.
Gene Gilchrist
Louisville, Kentucky
