Addiction, current research

Relapse:  Potential, Rates and Gender Differences:

According to Breining (2008) a relapse is: “The recurrence of symptoms of a disease after improvement.  In CD [chemical dependency]:  A single event (taking a drink pill or fix) =lapse, and a serial event (a drinking or drugging binge) = relapse” (p. 410).  Relapse prevention is defined as, “A treatment technique that focuses on preventing the recovering addict from using again“ (Inaba & Cohen, 2007, p. 573).  According to McLellan (2003) relapse prevention is a vital part of a patient’s treatment for chemical dependency (alcoholism, drug addiction), because relapse is common following treatment.  Alcoholics or drug addicts in recovery can come to understand their general precipitants and personal triggers of relapse, which makes relapse preventable.  It is evident that psychologists, psychotherapists, and counselors within the professional alcohol and drug treatment community take relapse prevention seriously, as 87% of treatment centers include relapse prevention in their treatment of people with addictions on a regular basis and 9% use relapse prevention sometimes.  Only 4% of treatment centers never used relapse prevention, or did not know about this approach according to the National Survey of Substance Abuse Treatment Services (N-SSATS) report (National, 2010).    To illuminate relapse and relapse prevention this article will examine relapse potential in recovering addicts, relapse rates, and gender differences in addiction and relapse.

Relapse Potential:

Gorski and Miller (1986) maintained that, “Although addictive disease can be controlled, it can never be cured.  There is always the possibility of relapse.  Unless measures are taken on a long-term basis to control the disease, relapse is likely” (p. 83).  Complete abstinence is a key factor for recovery, as research shows that controlled use of alcohol and drugs is not possible for an addict (Ibid).  In a number of studies conducted through the Haight Ashbury Free Clinics, San Francisco, USA, it was found that in 95% of the cases when people had a “slip,” in other words, just used their substance of choice once, a slip turned into a full-blown relapse over time (Inaba & Cohen, 2007).  Larimer, Palmer, and Marlatt (1999) acknowledged this research finding but maintained, “The progression from lapse to relapse is not inevitable” (p. 153).  They asserted that techniques to avert the progression can be acquired through relapse prevention.  Other researchers showed that before 1980 persons in treatment were hardly ever informed about what to do in the case of a slip/lapse, or relapse.  The thought was that such information would cause a self-fulfilling prophecy and that people would slip and go into a full relapse.  Today, psychologists, psychotherapists and counselors provide education and positive reinforcement to not let a slip become a full relapse.  The general approach is to apply cognitive-behavioral and self-management interventions that help patients cope with their slip.  Unlike in the past, psychologists, psychotherapists, and counselors are not confrontational and do not label the patient negatively (Substance Abuse, 2005).

Relapse Rates:

Today’s mainstream approach among psychologists, psychotherapists, and counselors in the field of substance abuse treatment is to assist patients in achieving abstinence and helping them maintain long-term sobriety.  The question that arises is:  How common are relapse rates among individuals in recovery? Surprisingly, alcohol and drug relapse rates are similar to relapse rates for other chronic lifestyle-related illnesses.  When comparing relapse rates of addicts to those of other chronic diseases, such as diabetes, hypertension, and asthma, one finds that the rates are comparable.  Drug relapses average is 40-60%, for type I diabetes 30-50%, for hypertension 50-70%, and for asthma 50-70%.  Since addiction and chronic diseases are similar in that they both have biological and behavioral components long-term recovery requires repeated episodes of treatment and support programs.  Relapse should serve as a trigger for additional intervention by psychologists, psychotherapists or counselors and not be judged as a failure (Relapse, n.d.).

A research study showed that extended abstinence is predictive of sustained recovery.  It indicated that in the first year of abstinence 64% relapsed, from 1-3 years 34% relapsed, from 3-5 years 14% relapsed, and from 5 and more years 14% relapsed. This data shows that after the 3rd year the recovery odds continue to be high and stable.  The conclusion based on this information is that addiction requires ongoing counseling supporting disease management and treatment, especially in the beginning years of sobriety (Extended, n.d.).  This data also validates that for many relapses is part of the process of obtaining long-term sobriety and that there will always be a certain percentage of people who chronically relapse.

In the general community, there might be the perception that a person in recovery is doing well and just one day, without notice, “falls of the wagon.”   Psychologists, psychotherapists, and counselors in the chemical dependency treatment community understand relapse is not an isolated event.

… it is a process of becoming unable to cope with life in sobriety. The process may lead to renewed alcohol or drug use, physical or emotional collapse, or suicide. The relapse process is marked by predictable and identifiable warning signs that begin long before a return to use or collapse occurs. Relapse prevention therapy teaches people to recognize and manage these warning signs so that they can interrupt the progression early and return to the process of recovery.   (Counselor’s, n.d., para. 1)

Gender differences:

Before examining gender differences in relapse, it is interesting to look at why people use drugs and alcohol in general, and women and men specifically.  According to the National Institute on Drug Abuse (NIDA) research has revealed that people take drugs to feel good or to feel better.  Feeling good was seen as having novel feelings pertaining to sensations, experiences and to share them.  Feeling better was seen as an attempt to lessen anxiety, worries, fears, depression, and hopelessness (Why, n.d.). NIDA states that those who want to feel better are dealing with difficult situations, stress, trauma, and symptoms of mental disorders (Why would, n.d.).

Iliff (2008) maintains that women typically begin using chemicals for other reasons than men do.  She attributes the onset of use for men to recreational reasons because they like the effect of the drug.  For women, on the other hand, the onset of use was attributed to a variety of reasons, such as use to lose weight, to reduce sexual inhibition, relieve stress, improve mood, increase self-confidence, belong to their group, or avoid hurting someone’s feelings by declining a drug or drink.  Illiff lists the following factors as high-risk situations for women in recovery:

  1. Beginning and ending a romantic relationship
  2. Physical pain
  3. Spending time alone
  4. Hormonal changes
  5. High stress
  6. Milestones in recovery (“anniversary freakies”)
  7. Complacency
  8. Cravings

When examining gender differences of relapse rates concerning alcohol, research findings indicate that men and women experience the same rates of relapse.  When relapse rates in relation to drugs were compared between the sexes, women tended to have lower relapse rates than men.  When marital and family factors are considered, a pattern emerges in which married women with fewer children in the household have higher relapse rates than men.  This finding reflects that women with substance dependency are more likely to be married to men who are problem drinkers or substance abusers.  Conversely, married substance dependent men are less likely to be married to problem drinkers.  This line of research also found that there is more conflict in marriages when spouses have different drinking patters as would be the case of one spouse drinking heavily and the other lightly.  In this context, it was also found that women report drinking in response to conflict and men report conflict because of their drinking (Walitzer & Dearing, 2006).

Recent NIDA funded studies also found that women in drug abuse treatment have lower rates of relapse than men.  Researchers considered a number of theories to explain this disparity and found one plausible explanation:  Women attended more group counseling sessions as compared to men.  It is believed that women are more inclined to seek professional help than men.  Men and women attended individual and family counseling sessions in equally which was attributed to the fact that they were limited in number.  If an unlimited number of individual and family counseling sessions were available a valid hypothesis is that women would attend in greater numbers than men (Stocker, 1998).

According to Stocker (1998), Dr. Roger Weiss and his colleges also conducted a NIDA funded study in which he theorized that women have lower drug relapse rates because they are more motivated to succeed.  He found that women, as compared to men, had to negotiate more obstacles to get into drug treatment and were thus more motivated to succeed.  What made entry into treatment harder for women were childcare difficulties, dealing with the negative stigma of being a female addict, and the predominance of male patients and staff.

Scientists also studied gender differences in drug abusers’ experiences before and during relapse.

Dr. James McKay and his colleagues found that women in treatment for cocaine addiction were more likely than men to report negative emotions and interpersonal problems before they relapsed.  The men, on the other hand, were more likely to report positive experiences prior to relapsing and were more likely to engage in self-justification and rationalizing afterward. (Stocker, 1998, p. 57)

Another interesting finding of this study was that women were significantly more likely to be compulsive in their return to cocaine use.  In this study 56% of the women and only17% of the men reported relapsing right after the thought of use occurred to them (Ibid.).

Based on the prevalence of relapse of the chronic disease of substance use disorders, considerable research has focused on this topic.  Clearly, psychologists, psychotherapists and counselors know that relapse prevention planning must take place for everybody in treatment for this disease, without exception.  It is also important to remember in this context that abstention rates increase over time and that the first year is the most critical.  What adds to the complexity of relapse prevention is how motivated a person is to change and why people begin using in the first place.  Individuals hold varying attitudes about how exciting life should be, and many have mental health conditions for which they seek relief.   Adding to this complexity are gender differences in why men and women use and relapse.  Skilled psychologists, psychotherapists and counselors know that good relapse-prevention education requires intense individualized attention to address patients’ unique backgrounds and needs.  The therapeutic process also enhances personal development, general life skills, addresses life challenges, and focuses any underlying mental health issues thereby setting the stage for a balanced life.

List of References:

Breining Institute (2008).  The addiction professional:  Manual for counselor competency (2nd ed.).  Orangevale CA:  Breining Institute

Counselor’s manual for relapse prevention with chemically dependent criminal offenders Technical Assistance Publication (TAP) Series 19 / Chapter 3-Relapse (n.d.). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 03, 2011, from http://www.kap.samhsa.gov/products/manuals/taps/19b.htm

Extended abstinence is predictive of sustained recovery.  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching8.html

Gorkski & Miller (1986).  Staying sober:  A guide for relapse prevention.  Independence, MO:  Herald House/Independence Press

Iliff, B. (2008).  A woman’s guide to recovery.  Minnesota: Hazelton Foundation

Inaba & Cohen (2007).  Uppers, downers and all arounders:  Physical and mental effects of psychoactive drugs, 6th, edition.  Medford, Oregon:  CNS Publications, Inc.

Larimer, M., Palmer, R. & Marlatt, G. (1999).  Relapse prevention:  An overview of Marlatt’s cognitive-behavioral model.  Retrieved Jul 01, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

Marlatt, A, Parks, G. & Witkiewitz (2002).  Clinical guidelines for implementing relapse prevention therapy.  Behavioral Health Recovery Management. Retrieved Jul 07, from http://www.bhrm.org/guidelines/RPT%20guideline.pdf

McLellan, T. (2003).  Forward:  Relapse – Removing the taboos on the topic and promoting honest efforts to address it.  Retrieved Jul 01, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf

National Survey of Substance Abuse Treatment Services:  The N-SSATS Report (2010, October 14).  Clinical or therapeutic approaches used by substance abuse treatment facilities. U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 02, 2011, from http://www.oas.samhsa.gov/2k10/238/238ClinicalAp2k10Web.pdf

Relapse rates for drug addiction are similar to those of other well-characterized chronic illnesses (n.d.).  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching8.html

Stocker, S. (1998).  Men and women in drug abuse treatment relapse at different rate and for different reasons.  NIDA Research Findings, 13 (4).  Retrieved Jul 07, 2011, from http://nhts.net/media/NIDA%20Notes%20-%20Women%20and%20Gender%20Differences%20Research%20(40).pdf

Substance Abuse Relapse Prevention for Older Adults:  A Group Treatment Approach (2005). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved Jul 02, 2011, from http://www.kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf

Walitzer, K. & Dearing, R. (2006).  Gender difference in alcohol and substance use relapse.  Clinical Psychology Review, 26,  128-148.  Retrieved Jul 06, 2011, from http://www.genderbias.net/docs/resources/guideline/Gender%20differences.pdf

Why do people take drugs in the first place? (n.d.).  National Institute on Drug Abuse (NIDA).Retrieved Jul 05, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/largegifs/Slide12.gif

Why would anyone abuse drugs? (n.d.). National Institute on Drug Abuse (NIDA). Retrieved Jul 05, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching3.html

….

Relapse Prevention for Sustained Recovery from Alcoholism and Drug Addiction:

A basic premise in the treatment of chemical dependency, alcoholism and drug addiction, is that an addict in recovery cannot learn to consume alcohol or drugs in a controlled way.  There is ample scientific evidence and anecdotal testimony to this effect.  Ongoing recovery work over an extended period of time is necessary for long-term sobriety.  When it comes to relapse prevention, patients should avail themselves of all possible tools.  Psychologist, psychotherapists, and counselors with addiction training can provide evidence based relapse-prevention-education to facilitate long term recovery.  Based on years of research and scientific discovery, it is evident that this is an important aspect to maintain sobriety.

Research results also show that self-help groups during treatment and as a long-term support system are vital for a person’s recovery.  Furthermore,  it is beneficial when the family system can receive counseling by a psychologist, psychotherapist, or counselor, since the disease of alcoholism and drug addiction affects each person in the family.  Self-help groups are available for the families of addicts as well, such as Al-Anon, or Alateen.

Experienced psychologists, psychotherapists and counselors with addiction training draw from several schools of thought during drug and alcohol treatment:

1. Relapse Prevention (RP),

2. Center for Applied Science (CENAPS) Model of Relapse Treatment,

3. Classical Conditioning Theory of Cravings and Relapse Prevention, and 4. Self Help Groups.

4. Relapse Prevention (RP) by Marlatt and Gordon:

Since relapse is a process there are observable events that precede the relapse and continue into the relapse episode.  Marlatt and Gordon in 1985 developed a relapse prevention (RP) model that is based on social learning theory and cognitive-behavioral psychotherapy.  The basic assumption is that people are able to acquire new skills and behaviors when they change the way they think about situations.  Addiction according to the RP model is not seen as a physiological disease, but as a learned habit consisting of maladaptive thoughts and behaviors that can be altered.  “The goals of RP are to anticipate and prevent a relapse and to assist recovery from a slip before it becomes a relapse.   Recovery occurs gradually as the person increases his or her sense of self-efficacy and self-esteem from prolonged abstinence (Gordon, 2003, p. 8).  Lapses and relapses are not treated as personal failures, but as temporary setbacks.  From such a setback, an individual can learn and thus the lapse or relapse can serve as a prolapse.  “Prolapses are defined as mistakes that clients learn from that improve their eventual chances of success (Marlatt, Parks & Witkiewitz, 2002, p.9).

According to this model, individuals are not held responsible for negative habits acquired in the past, but it does put responsibility on the patient to change his or her addictive behaviors to functional behavioral coping skills and to use cognitive restructuring which will replace negative thoughts with positive functional thoughts.  Generally, a patient will pass through 3 stages which are:

  1. Commitment and motivation to prepare for the change
  2. Active implementation of the change
  3. Maintenance of the change (Gordon, 2003)

RP focuses on events of factors that can bring about a relapse episode.  Here factors and situations are classified that can precipitate or add to the relapse episodes.  According to this model there are two categories of such factors:  immediate determinants and covert antecedents.

Immediate determinants or relapse include:

  • Intrapersonal high-risk situations: Negative emotional states, such as anger, anxiety, depression, frustration, and boredom as a result of a person’s perception of a situation.  An example for this might be feelings of anger because of being passed up on a promotion, or feeling depressed due to being alone on one’s birthday.   These negative emotional states are associated with the highest rate of relapse.
  • Interpersonal high-risk situations: Negative emotions due to conflict with another person or group can precipitate a relapse.  Research showed that intrapersonal negative emotional states and interpersonal conflict formed the basis for more than 50% of all relapse episodes studied.
  • Social pressure: Direct verbal or nonverbal pressure to consume, or indirect pressure such as being around individuals who consume accounted for more than 20% of relapse episodes.
  • Positive emotional states: Celebrations, seeing alcohol related ads on TV, or passing one’s favorite bar, or a test of one’s willpower by trying to use one’s substance of choice in a controlled way are also associated with high risk situations that can trigger relapse (Larimer et al., 1999).

According to RP, another dimension to the danger of a lapse or relapse is added depending on how an individual has learned to cope with high risk situations, what expectations he or she has about the effects of using again, and how a lapse is perceived.  If a person has behavioral and cognitive coping skills, he is more likely to get out of a high-risk situation and not lapse/relapse.  Additionally, the expectation of the effect of drugs is important:  If a person sees the alcohol/drug as an aid in coping with a high-risk situation without considering long-term negative consequences a lapse might occur.  Lastly, a lapse does not have to progress into a full-blown relapse.  Marlatt and Gordon in their research found that the abstinence violation effect is a relevant issue.   The abstinence violation effect is how a person thinks about his relapse.  If a person interprets a lapse as a failure and has guilt about a lapse it is very likely that the relapse progression will be set in motion.  Additionally, some individuals attribute their lapse to internal factors such as lacking willpower and might come to believe they will never be able to stay sober.  However, when someone experiences a lapse and comes to understand it as an inability to cope with a high-risk situation, they can learn from their mistake and avoid such situations in the future (Larimer et al., 1999).

Covert antecedents of relapse include:

  • Life-style factors: Here the degree of balance between what persons “should” do and what persons “want” to do is relevant.  When the balance tips toward too many responsibilities and not enough activities people enjoy, negative emotional states can be caused which are conducive to relapse, and using drugs or alcohol might be seen as the only way to obtain pleasure.  Life-style imbalance was seen as the factor that most strongly related to a relapse risk.
  • Cognitive factors: Rationalization, denial, and a desire for immediate gratification.  This faulty thinking can increase the risk of relapse, because it can increase exposure to high risk situations and decrease motivation to resist substance use.  An example for such thinking is when someone thinks that he or she can drop by their favorite bar to say hi to a friend and not sit down for a drink.
  • Apparently irrelevant decisions (AID): Seemingly inconsequential decisions set a person up for a lapse/relapse.  Here decisions are made that on the surface do not seem to add to a relapse risk.   Denial keeps the person at risk from accurately assessing the risk and rationalization provides a reason for making the decision.    A good example cited for an AID is about a recovering alcoholic who buys a bottle of wine in anticipation of guests.  Once guests come and a lapse occurs the presence of alcohol is blamed without greater thought of personal responsibility.  Another example could be to have a bottle of wine on hand for cooking thereby creating a temptation at a later point.
  • Urges and cravings: The RP model proposes that urges and cravings are due to psychological or environmental stimuli.  According to Marlatt and Gordon urge is defined as a relatively sudden impulse to consume the substance of choice, and craving is the subjective desire to have the effects or consequences of using (Larimer et al., 1999).

This RP model proposes to use cognitive and behavioral approaches that target each step of the relapse process.  Psychologists, psychotherapists, and counselors encourage specific intervention strategies that address the immediate determinants of relapse and global self-management strategies to address the covert antecedents of relapse.  These strategies fall into the categories of skills training, cognitive restructuring, and lifestyle balancing.  In short, specific intervention strategies include identifying and coping with high-risk situations.  During counseling, the patient learns to identify the warning signs of entering or being in a high-risk situation.  The patient’s ability and motivation to cope in such a situation is assessed and enhanced.  Additionally, self-efficacy-enhancement procedures help a patient improve his sense of mastery and of being able to cope with difficult situations without relapsing.  The patient will benefit from a client-psychotherapist relationship that is collaborative rather than “top down.”  Patients are made aware that RP is an acquisition of skills and not a test of willpower.  During counseling, patients are encouraged to set small, manageable tasks to increase a sense of self-efficacy. Lastly, psychologists, psychotherapists and counselors can highlight general accomplishments to increase a patient’s sense of mastery, in general, to achieve a carry-over effect into drug and alcohol related efficacy (Larimer et al., 1999).

During counseling, a drinkers’ subjective expectation of the effect of alcohol also must be addressed.  Often positive expectations of the outcome of drinking are based on myths or placebo effects.  Counselors and psychotherapists can assist patients in bringing objectivity into the experience and to juxtapose short and long-term consequences (Larimer et al., 1999).

Lapse management is also incorporated in this RP model.  The idea is to halt the progression into a relapse and to help clients cognitively restructure the event to see that they have not suffered a failure of willpower or morality, but failed to adequately address a high-risk situation.  Psychologists, psychotherapists, and counselors might want to facilitate a lapse-management-plan, which could include a limit of how much of the substance can be ingested, reasons why it is important to put a halt to consumption, to leave the high-risk situation, and to contact the counselor or a supportive person as soon as possible (Larimer et al., 1999).

Psychologists, psychotherapists, and counselors also bring focus to global lifestyle self-control strategies, which include helping patients balance their lifestyles so that a balance is achieved between stress and enjoyment of life.  During counseling patients can be encouraged to tap into enjoyable activities they pursued before they became substance dependent.  Furthermore, specific cognitive-behavioral skills such as relaxation training, stress-management, and time management can improve a client’s life-style balance.  Counseling also fosters positive addictions, such as meditation or exercise, and can have long-term positive effects on mood, health, and coping ability (Larimer et al., 1999).

Psychologists, psychotherapists, and counselors also instruct patients to practice stimulus control techniques to decrease urges and cravings by removing all items relating to their use from their living environment.  This would include alcohol, shot glasses, or any other drug or drug related paraphernalia.  Things associated with using, such as music or furniture can be changed to reduce cues to using.  Lastly, during counseling, psychologists, psychotherapists, and counselors for the benefit of their patients impart avoidance strategies to decline events and places that were associated with use (Larimer et al., 1999).

Patients are taught to anticipate and accept cravings and urges as normal and not to interpret this as a desire to drink, but to see it as a conditioned response to cues in the environment.  It is important that patients learn that they can ride this feeling out, as it will come, swell, and go like a wave in the ocean (Larimer et al., 1999).

Lastly, counseling will show patients how they will benefit from having a relapse road map.  Here patients can apply cognitive-behavioral analysis to a situation and see available choices to cope with or avoid these situations and their consequences.  This approach also assists in identifying AIDs, so that people can make choices and decisions from which they benefit (Larimer et al., 1999).

An evaluation of this RP model found the relapse process and the effectiveness of treatment strategies were supported.  This RP model has been applied to various addictive behaviors successfully, but that it was most effective with alcoholism.  There is a suggestion that in the future modifications be made to this RP model reflecting changes about the assessment of high-risk situations and the conceptualization of covert and immediate antecedent of relapse.  Significant research indicates the effectiveness of RP for alcoholism and to a lesser degree nicotine or cocaine addiction.  It was also noted that people’s self-efficacy might not necessarily rise if they handle a high-risk situation well.  Lastly, research findings show that RP in conjunction with medication assisted treatment (pharmacotherapy) appears to have an enhanced effect on abstention rates (Gordon, 2003).

An extensive review of relapse prevention therapy (RPT) and detailed information on how to work with clients can be found in the Clinical Guidelines for Implementing Relapse Prevention Therapy by Marlatt, Parks, and Witkiewitz.  These downloadable guidelines also contain information on various assessment tools and other valuable resources (Marlatt et al., 2002).

Center for Applied Science (CENAPS) Model of Relapse Treatment:

Terence Gorski developed this approach.  He classifies addiction as a disease that affects bio-psycho-social functioning and asserts that treatment must include ways to address the biological damage caused by addiction, specifically brain dysfunction, and means to enhance psychological well-being and social relationships.  Relapse is framed as the “relapse syndrome,” which indicates that there are a number of symptoms and warning signs preceding a relapse, most notably the presence of unmanaged post acute withdrawal (PAW) symptoms.  Gorski adheres to the 12-Step philosophy, and the therapeutic underpinning is cognitive-behavioral with a focus on lifestyle changes to foster long-term recovery.

Gorski identifies 3 types of chemically dependent people:

  1. recovery prone
  2. transitionally relapse prone
  3. chronically relapse prone

a) Unmotivated to change

b) Motivated to change

His model of relapse prevention is designed especially for the motivated relapse-prone individuals (Gordon, 2003).

CNAPS teaches psychologists, psychotherapists, and counselors to focuses on brain dysfunction as a major physical consequence of addiction as it interferes with one’s ability to think clearly, manage emotions, and regulate behavior.  This brain dysfunction manifests in what Gorski and Miller (1985) call post acute withdrawal (PAW) symptoms…symptoms that occur after a person has gone through acute withdrawal, or detoxification.   Most commonly PAW symptoms are expected to diminish over time. However, there are some who will experience ongoing stable PAW symptoms, and some who will experience more PAW symptoms over time.  It is this last category of people in recovery that have the highest relapse rates. During times of stress, often triggered by change in a person’s life, PAW symptoms can be prompted which can create even more stress.  “This personal distress, caused by the compromised ability to handle thoughts, emotions and behaviors, is the precipitating cause of a relapse (Ibid., p.10).  During counseling, patients in recovery are made aware of PAW symptoms.

Symptoms of PAW are the following:

  • Inability to think clearly:  Inability to concentrate for more than a few minutes, impairment of abstract reasoning, rigid and repetitive thinking/going around and round.
  • Memory problems:  Short and long term memory is affected
  • Emotional overreactions or numbness
  • Sleep disturbances:  Short-term, or life-long
  • Physical coordination problems:  Dizziness, balance problems, hand-eye coordination problems, and slow reflexes.
  • Stress sensitivity:  Difficulty managing stress and inability to assess stress realistically (Ibid.)

Gordon and Miller (1985) describe CENAPS as a developmental model of recovery (DMR).  There are 6 developmental periods that clients pass through in which certain recovery tasks completed:

  1. Pretreatment: recognizing addiction. Learning by the consequences that you cannot safely use addictive chemicals.
  2. Stabilization: Withdrawal and crisis management. Regaining control of thought processes, emotional processes, memory, judgment, and behavior
  3. Early recovery: Acceptance of the disease and learning to function without drugs and alcohol
  4. Middle recovery: Developing a normal, balanced lifestyle.  Resisting substitute addictions.
  5. Late recovery: Personality change. Development of healthy self-esteem, spiritual growth, healthy intimacy, and meaningful living
  6. Maintenance: Growth and development

Staying sober and living productively

As a person progresses through the recovery stages the CENAPS model proposes to use a number of skills to alleviate stress and manage PAW symptoms should they occur.

“Because stress triggers and intensifies the symptoms of post acute withdrawal, PAW can be controlled by learning to manage stress.  You can learn to identify sources of stress and develop skills in decision making and problem solving to help reduce stress.  Proper diet, exercise, regular habits, and positive attitudes all play important parts in controlling PAW.  Relaxation can be used as a tool to retrain the brain to function properly and to reduce stress (Ibid., p. 70).”  During counseling, a psychologist, psychotherapist, or counselor can assist patients to identify and manage their stress.

Classical Conditioning Theory of Cravings and Relapse Prevention:

According to Gordon (2003) classical conditioning theories put an emphasis on the importance of internal and external cues on cravings.

Cravings are strong desires or compulsions to engage in a behavior, such as drug or alcohol use, to experience positive effects or to avoid negatives ones.   Two types of cravings are common among individuals with a chemical addiction:  cravings to alleviate unpleasant emotional states or symptoms of acute withdrawal, and cravings to increase he short-term positive effects of drug use.  (p.10)

Tiffany (1999) emphasized that the first researcher to discover the underlying principle of classical conditioning was Ivan Pavlov and illustrated how this principle could be applied to drug and alcohol cravings:  Someone drinks alcohol (unconditioned stimulus) and experiences positive feelings (unconditioned response).  This person likes to consume the alcoholic beverage while sitting in an easy chair.  Over time, the easy chair becomes associated with the alcohol and becomes a conditioned stimulus.   As a result of this, the sight or thought of sitting in the easy chair can bring out alcohol cravings in the individual.

Alcohol:  unconditioned stimulus à positive feelings

Easy Chair:  conditioned stimulus à craving

Based on this theory many possibilities of classical conditioning can occur during a person’s time of using.  Thus, there will be many conditioned stimuli that will bring out cravings in people in recovery that could bring about a relapse.  Conditioned stimuli are very unique to the individual and the degrees of cravings vary from person to person.  Some more typical conditioned stimuli for addictive behaviors are the presence of the person’s substance of choice, and places were drugs and alcohol are sold.  Additionally,

classical conditioning theories postulate that responses to conditioned stimuli last a very long time.  For example, after years of sobriety, a craving can occur if a person returns to a place where he bought his substance of choice (Gordon, 2003).

Tiffany (1999) described the application of the classical conditioning concept to withdrawal effects.  “Perhaps the most influential model of conditioned craving was developed by Wikler (1948), who hypothesized that stimuli paired repeatedly with AOD withdrawal could become conditioned stimuli that elicited [sic] conditioned withdrawal effects, which, in turn, would generate craving” (p. 216).

In the language of classical conditioning the drop in blood alcohol levels constitutes the unconditioned stimulus that leads to withdrawal symptoms, the unconditioned response.  When the unconditioned stimulus (low BAC) is paired with a certain situation, i.e. counseling, the person in recovery during counseling can experience conditioned withdrawal reactions and cravings that could possible lead to relapse (Ibid., 1999).

Relapse prevention strategies with classical conditioning theories focus on dealing with strong, seemingly irrational, cravings.  There are a number of approaches, such as MT to reduce cravings, or breaking the “pleasure memory.”  One particular method is cue-exposure treatment.  During this treatment, a patient is continuously exposed to their cues of conditioned stimuli in a setting that is safe.  Then the patient can practice coping skills to reduce cravings.  Behaviorist psychologists, psychotherapists and counselors believe that repeated exposure to a drug or alcohol cue in the absence of the usual response (consumption of alcohol or drugs) leads to a reduction in cravings over time.  This reduction in craving however is unique to the stimulus and this positive effect will not carry over to other craving inducing stimuli.  It must be noted that the extinction effect of cues from the clinical setting do not always transfer to a client’s natural environment.  There even are patient reports that cues to which they had become neutral triggered strong cravings once they had returned to their usual setting.  Lastly, even a once extinct cue will be reactivated when a person pairs the cue with a former response (Gordon, 2003).

The Role of Self-Help Groups:

Traditional approaches for the treatment of chemical dependency, in the United States, mostly follow the “Minnesota Model,” which includes a 28-day inpatient/residential rehabilitation program based on the 12-step Alcoholics Anonymous (AA) principles.  The underlying idea is for the psychologist, psychotherapist, or counselor to treat the patient holistically, the mind, body, and spirit.  Typically, at the end of treatment people in recovery are referred to AA for continuing care (McKay & Hiller-Sturmhoefel, 2011).  Gordon and Miller (1986) asserted, “Alcoholics Anonymous is the single most effective treatment for alcoholism.  … AA needs to be a vital part of any recovering alcoholic’s sobriety plan (p.52).   Most certainly, a 12-step self-help group can be chosen according to the substance to which a client is addicted, such as Narcotics Anonymous (NA), Cocaine Anonymous (CA) etc., as the basic steps and principles remain the same regardless of the substance, or behavior over which someone has lost control.  It must be kept in mind though that not everyone embraces the AA concept.  Many patients do not like to share their thoughts and feelings in a group setting and some are not spiritual.  For the less spiritual clients, there are viable alternatives such as SMART Recovery, of Save Our Selves (SOS).  These self-help groups have a more secular focus (supra).  However, these groups are not as prolific as the AA based self-help groups which may make it difficult to find such a self-help group within a reasonable commuting distance.  Technological innovation is evident, as there is the option to attend virtual meetings online. Those who do embrace the AA concept, will be able to benefit from the social support other members offer, and from the structure of the 12 steps as a spiritual and behavioral guide.  People interested in attending a 12-step program can try a variety of meetings to find groups with whom they feel they share a commonality (sex, age, socio-economic status, etc.) (McKay & Hiller-Sturmhoefel, 2011).  Based on the structure of 12 step groups, it is very difficult to assess the drop-out rates.  From a patient follow-up perspective, such statistics are also difficult to obtain, due to tracking issues and possible deception at the time of a follow-up interview.  McKay and Hiller-Sturmhoefel reported on studies that tracked group counseling with 12 step attendance that saw a drop-out rate of 50% before patients reached the 3-month mark.  Despite the difficulties in obtaining statistics on AA attendance and drop-out rates, anyone who has ever attended AA meetings will have discovered many individuals with long-term sobriety and a record of regular attendance.  There is also ongoing anecdotal evidence that not attending meetings is often associated with the relapse process, and many recovering alcoholics report that they attend AA meetings to remember that their disease of addiction is a chronic disease that must continually be kept in check.

RP, CENAPS, classical conditioning models, and information about self -help groups constitute effective tools for relapse prevention.  Each model has significant validity and people in recovery can benefit from learning skills and gaining insights based on all models.  There is enough commonality so that these tools can be seen as complimentary rather than contradictory.  An experienced psychologist, psychotherapist or counselor will use an integrated approach during counseling, so that patients in recovery will acquire skills and gain insights that they can quickly access to avert a lapse, or a relapse.  This knowledge will also assist them in adopting a life-style that is balanced and enjoyable thereby setting the stage for long-term sobriety.

List of References:

Counselor’s manual for relapse prevention with chemically dependent criminal offenders Technical Assistance Publication (TAP) Series 19 / Chapter 3-Relapse (n.d.). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 03, 2011, from http://www.kap.samhsa.gov/products/manuals/taps/19b.htm

Extended abstinence is predictive of sustained recovery.  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.drugabuse.gov/pubs/teaching/Teaching6/Teaching8.html

Gordon, S.  (2003). Relapse & recovery:  Behavioral strategies for change.  Retrieved Jul 02, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf

Gorkski & Miller (1986).  Staying sober:  A guide for relapse prevention.  Independence, MO:  Herald House/Independence Press

Larimer, M., Palmer, R. & Marlatt, G. (1999).  Relapse prevention:  An overview of Marlatt’s cognitive-behavioral model.  Retrieved Jul 01, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

Marlatt, A, Parks, G. & Witkiewitz (2002).  Clinical guidelines for implementing relapse prevention therapy.  Behavioral Health Recovery Management. Retrieved Jul 07, from http://www.bhrm.org/guidelines/RPT%20guideline.pdf

McKay & Hiller-Sturmhoefel (2011).  Treating alcoholism as a chronic disease:  Approaches to long-term continuing care. .  National Institute on Alcohol Abuse and Alcoholism (NIAAA), 33(4). Retrieved Jul 25, 2011, from http://pubs.niaaa.nih.gov/publications/arh334/356-370.pdf

McLellan, T. (2003).  Forward:  Relapse – Removing the taboos on the topic and promoting honest efforts to address it.  Retrieved Jul 01, 2011, from http://www.apofla.com/dl/relapse/2516_relapse_report.pdf

National Survey of Substance Abuse Treatment Services:  The N-SSATS Report (2010, October 14).  Clinical or therapeutic approaches used by substance abuse treatment facilities. U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved July 02, 2011, from http://www.oas.samhsa.gov/2k10/238/238ClinicalAp2k10Web.pdf

Relapse rates for drug addiction are similar to those of other well-characterized chronic illnesses (n.d.).  National Institute on Drug Abuse (NIDA). Retrieved Jul 03, 2011, from http://www.nida.nih.gov/pubs/teaching/Teaching6/Teaching8.html

(2005). U.S. Department of Health and Human Services:  SAMHSA, Office of Applied Studies.  Retrieved Jul 02, 2011, from http://www.kap.samhsa.gov/products/manuals/pdfs/substanceabuserelapse.pdf

Tiffany, S. (1999).  Cognitive concepts of craving.  National Institute on Alcohol Abuse and Alcoholism (NIAAA),23(3). Retrieved Jul 10, 2011, from http://pubs.niaaa.nih.gov/publications/arh23-3/215-224.pdf

Walitzer, K. & Dearing, R. (2006).  Gender difference in alcohol and substance use relapse.  Clinical Psychology Review, 26,  128-148.  Retrieved Jul 06, 2011, from http://www.genderbias.net/docs/resources/guideline/Gender%20differences.pdf

….

Methamphetamine in Pregnancy Delays Infant Brain Development (Source: Medscape, 09.11.2016)

Infants exposed in utero to methamphetamine or whose mother smoked tobacco while pregnant display delays in motor development and white matter maturation.

Sex Differences

The researchers assessed, over a period of 4 months following birth, white matter microstructure and neurologic development of infants exposed to methamphetamine and/or tobacco prenatally and those of healthy control infants who were not exposed to those substances.

Assessments included quantitative neurologic examination and diffusion tensor imaging, which were performed up to three times through age 4 months, and diffusivities and fractional anisotropy (FA), assessed in seven white matter tracts and four subcortical brain regions.

Methamphetamine and tobacco-exposed infants showed delayed trajectories on active muscle tone. Male infants who were exposed to both stimulants also had significantly delayed trajectories in superior and posterior corona radiata that normalized by age 3 to 4 months. Female infants exposed to both stimulants had persistently lower FA in anterior corona radiata.

Tobacco-exposed infants also showed persistently lower axial diffusion in the thalamus and posterior limb internal capsule. These brain abnormalities were likely due to prenatal stimulant exposure, possibly via epigenetic effects, genetic predisposition, or other prenatal factors not evaluated.

The fact that the neonates exposed to methamphetamine and tobacco already showed the abnormal baseline brain microstructures and active muscle tone, although some but not all of these abnormalities may normalize over the first 4 to 5 months of life.

The findings imply that the effects that we observed are likely due to the effects of prenatal drug (meth+tobacco) exposure on brain development, and not due to other environmental influences during early infancy.

Alarming Increase

The use of stimulants such as methamphetamine by pregnant women has increased “alarmingly” during the past decade, with reports suggesting that up to 92% of women of low socioeconomic status use methamphetamine, two researchers from South Africa note in a linked editorial.

These women also often use tobacco, drink alcohol, or use other illicit substances.

“There seems to be overlap in how these substances affect the developing brain,” write Annerine Roos, PhD, of Stellenbosch University, and Kirsten Ann Donald, MD, PhD, of the University of Cape Town.

“The field of brain imaging for infants is evolving fast,” they add, and this new study “confirms that prenatal exposure to methamphetamine and/or tobacco alters white matter developmental trajectories, and the effects are partly dependent on sex.

In particular, because the rate of white matter maturation and development is particularly pronounced through the first year of life, follow-up at 1 and 2 years of age, when much of the process has stabilized, will be important, Dr Roos and Dr Donald write.

….

Internet Addiction Shows Up In the Brain

(Source: The Little Black Book of Billionaire Secrets  17.01.2012, by Alice G. Walton),

Digital thrills

There’s been a lot of controversy over the concept of Internet Addiction Disorder (IAD), especially as the new DSM-V prepares to launch. Some feel that there’s little evidence to warrant IAD as being recognized as an actual disorder. Others disagree. Earlier research has found some changes in the brain of people who are hooked on the Web, and a new study shows reductions in volume of certain areas of the brain and in its the white matter – the highways of connection between brain cells – of young people who are addicted to the Internet. What’s interesting is that these brain changes mirror the ones in people who are addicted to other kinds of things, like heroin, for example.

Researchers quizzed 35 people between the ages of 14 and 21 about their Internet use and feelings about how it affected their lives. Among the eight questions were some like:

“Do you feel nervous, temperamental, depressed, or sensitive when trying to reduce or quit Internet use?” “Have you taken the risk of losing a significant relationship, job, educational or career opportunity because of the Internet?”  “Have you lied to your family members, therapist, or others to hide the truth of your involvement with the Internet?” “Do you use the Internet as a way of escaping from problems or of relieving an anxious mood (e.g., feelings of helplessness, guilty, anxiety, or depression)?”

If respondents answered “yes” to at least five of the questions, as half of them did, they were tagged as having IAD. To confirm the youngsters’ habits, the researchers asked their family and friends about how much their habits were “disrupting others’ lives despite the consequences.”

Then the participants underwent brain scans to look at any differences that might exist in the brains of the IAD sufferers and in controls. They found several areas of decreased volume in IAD participants, and for some of these areas, there was a negative relationship between volume and the length of time the participants had been addicted to the Internet.  In other words, the longer they were addicted, the less volume they had in certain regions.

There were also altered connections in the white matter tracts between brain cells, which suggests disruptions in how the neurons “talk” to one another.

The areas that were affected in the people who were diagnosed with IAD are thought to govern emotional processing, executive thinking skills and attention, and cognitive control. What’s more, the brain changes found in this study are thought to be similar to those involved in other kinds of addiction, like alcohol and drugs. Earlier research had suggested similar links, but this study seems to add to the growing body of evidence that Internet addiction may actually exist.

People who suffer from IAD don’t just spend a lot of time on the computer, but the authors say they also have significant problems in life, like “impaired individual psychological well-being, academic failure and reduced work performance.”

As always, there’s the lingering question of which came first, the chicken or the egg. In this case, it’s not clear whether people became addicted to the Internet first and brain changes then followed, or whether the brain was already wired differently, predisposing the young brains to addiction.

It will probably take a while to figure out this ever-present question that plagues science. Rather than being a straight either/or situation, it could be more of a back-and-forth: brains could be predisposed (genetically and physiologically) to addiction, then addiction develops, then brain changes exaggerate – and so on and so forth.

It will be interesting to see how the study will affect the debate. Since it seems like we can become addicted to just about anything – substances and behaviors alike – it may not be surprising that Internet addiction is a real thing. More work will be needed to understand the phenomenon more fully, but in the meantime, it can’t hurt to turn off the computer and give your brain a little rest.