I Relapsed, Now What?

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“Remember that just because you hit bottom doesn’t mean you have to stay there.” ~ Robert Downey Jr. Iron Man actor Robert Downey Jr. relapsed multiple times and nearly let addiction to alcohol, heroin, cocaine and meth consume him. In 2003, he met the woman who would become his second wife, and she gave him an ultimatum. He cleaned up his act, committing himself to a life of sobriety. Oscar-winning actor Philip Seymour Hoffman relapsed in 2014 after two decades of sobriety, dying alone with a needle in his arm. Heroin, cocaine, benzodiazepines and amphetamine were found in his system.

Addiction Relapse Facts

Addiction is a powerful disease that claims thousands of victims every year, many of whom relapse after a period of abstinence. Multiple relapses are often part of the equation when dealing with substance use disorders. Research shows 65-70% of abstinent alcohol-dependent subjects relapse within 1 year, especially within the first 3 months of sobriety. An estimated 26-36 million people worldwide abuse opiates, with higher relapse rates in opioid-dependent individuals than alcohol. Some studies have reported alarming rates of opioid addiction relapse compared to other drugs, with one study reporting a relapse rate of as high as 91%.

What Causes Relapse?

Addiction relapse is generally considered a return to a previous pattern of substance use. Many individuals who relapse have a notable decrease in cognitive vigilance of high-risk situations from their first use of the substance to subsequent relapse. Conversely, people with excellent self-efficacy can cope with high-risk situations and maintain abstinence. Recent research indicates a gene-environment relationship in context with biological and psychosocial factors causes relapse vulnerability.

Relapse Factors

  • Individual traits
  • The type of drug
  • Environmental triggers (e.g., drug cues)
  • Interpersonal reasons
  • Diminished self-efficacy
  • Physiological states (e.g., acute withdrawal)
  • Negative mood states (e.g., anger, anxiety, depression, frustration and boredom)
  • Co-occurring disorders
  • External pressures
  • Craving (desire to use the drug)
  • Lack of family support

The Role of Individual Factors

Individual factors explain why the addiction stories of two famous actors ended so differently. Hoffman’s widow, Mimi O’Donnell, talked about the triggers that led to his relapse and tragic death. Among the triggers were some “common to men in their 40s” and others specific to him such as his love/hate relationship with acting/stardom, the death of his long-time therapist and a falling out with his AA friends. In the summer of 2012, he started using prescription drugs again, followed by heroin. Hoffman checked himself in and out of rehab repeatedly. And although he maintained sobriety occasionally, “it was a struggle, heartbreaking to watch,” O’Donnell said. Three days after relapsing for the last time, Hoffman was found dead in his apartment. From 1996-2001, Downey was arrested numerous times on drug-related charges including cocaine, heroin and marijuana. He served a 180-day jail sentence in 1997 for violating probation. In 1999, after failing to show up for a court-ordered drug test, Downey served one year of a three-year sentence at a state-run substance abuse facility and prison in California. After his last arrest in April 2001, he was ready to make serious changes and stay committed to recovery. Downey credits his current wife, 12-step programs, meditation and martial arts for helping him stay sober.

Preventing Relapse

An important component of relapse prevention is understanding that relapse happens gradually. It can begin weeks, months or even years after a period of abstinence. Setbacks are a normal part of recovery, but they can set up a vicious cycle and reinforce a person’s sense of failure, negative thoughts and behaviors. Repeated relapses can thwart progress because individuals start to believe recovery is impossible. The Relapse Prevention (RP) model has been a mainstay of addiction theory and treatment for more than three decades. This model is based on the assumption relapse is immediately preceded by a high-risk situation, broadly defined as any context causing a vulnerability to engage in addictive behavior. A thorough assessment of the client’s substance use patterns, high-risk situations and coping skills is conducted. Their self-efficacy, outcome expectancies, readiness to change and concomitant factors that could complicate treatment (e.g., comorbid disorders and neuropsychological deficits) are also assessed. RP strategies include specific intervention techniques to help a client anticipate and cope with high-risk situations, coupled with global self-control approaches intended to reduce relapse risk by promoting healthy lifestyle changes. Specific cognitive and behavioral strategies are often necessary to maintain early treatment gains and minimize relapse risk following initial behavioral change. What works for one person may not work for another, which is why individualized treatment is so important. Effective inpatient and outpatient treatment helps counteract addiction’s powerful disruptive effects on the brain and behavior, enabling people to regain control of their lives.

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