Management of Lapse and Relapse in Drug Dependence

Transcription

1 OCTOBER 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 Review Article Management of Lapse and Relapse in Drug Dependence RC Jiloha Director Professor & Head, Department of Psychiatry, G.B. Pant Hospital & MAMC, New Delhi Almost all cultures have used psycho-active drugs to facilitate social interaction, to alter consciousness to heal. Our society s expanded chemical manipulation simply represents large technical capacity, more wealth, leisure, individual choice and conversely reduction in constraining social settings, peer and family standards and personal proscriptions. These conditions assume a considerable variety in addiction behaviour. Addiction behaviour like human behaviour in general is conceived of as an outcome of genetic and biochemical characteristics, past learning experiences, motivational states, psycho-social antecedents and cultural context in which it unfolds. 1 Addiction is therefore, a primary brain disease which is determined genetically, expressed biochemically and has psycho-social consequences. Addiction may be defined as a chronic, often relapsing brain disease with compulsive drugseeking and using the drug despite harmful consequences. It is a brain disease because the drug leads to changes in structure and function of the brain. Initial decision of drug-intake may be voluntary but repeated drug exposure affects person s self-control and ability to make sound decision. Regardless of the drug of addiction, relapse rates following addiction treatment are alarmingly high. There is an old saying that Quitting drug and alcohol use is easy, staying quit is hard part. A slip, or a lapse or relapse, are terms that convey the length of time and severity of the fall back into the old addictive behaviors. A relapse is considered a full fall back into the old addictive behaviors. It may be short-term. It may be as short as one or two days. Usually though, it implies a week or two, or months or years. A lapse or a slip is considered a single episode, one day, and not that severely re-initiating, not only the addictive behavior, but all the consequences and all the other associated behaviors that go with it. Relapse is considered a full blown return to the addiction. A lapse or a slip is just a temporary return, picking back up rather quickly, getting back on the horse metaphorically and getting back on with life. Lapse and relapse in addiction Why do they occur? 1. Low self-efficacy to cope up without drink or drug use and positive outcomeexpectancy for drug effects are the immediate precursors to a lapse. 2. After a lapse, the Abstinence Violation Effect (AVE) occurs that involves loss of perceived control experienced by the patient. 3. AVE increases the probability of relapse. 4. AVE prevents patient to stay sober. Abstinence Violation Effect (AVE) The abstinence violation effect (AVE) occurs when an individual, having made a personal commitment to abstain from using a substance, has an initial lapse whereby the substance is used at least once. Some individuals may then proceed to uncontrolled use. The AVE occurs when the person attributes the cause of the initial lapse (the first Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society 199

2 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 OCTOBER 2011 violation of abstinence) to internal, stable, and global factors within (e.g., lack of will power or the underlying addiction or disease). 2 In relapse prevention, the aim is to teach people how to minimize the size of the relapse (i.e., to counter the AVE) by directing attention to the more controllable external or situational factors that triggered the lapse (e.g., high-risk situations, coping skills, and outcome expectancies), so that the person can quickly return to the goal of abstinence and not lose control of the behavior. Specific intervention strategies include helping the person identify and cope with high-risk situations, eliminating myths regarding a drug s effects, managing lapses, and addressing misperceptions about the relapse process. Other more general strategies include helping the person develop positive addictions and employing stimulus-control and urge-management techniques. Researchers continue to evaluate the AVE and the efficacy of relapse prevention strategies. Triggers that lead to relapse There are some very traditional situations that are predictable triggers for relapse. They generally are thought of as both internal and external. Internal ones would be uncomfortable feelings, such as depression, anxiety, stressors, a re-remembering of certain traumas in one s life. These are all internal states that bring about, often trigger, a relapse. External ones, such as the friends and family and liquor stores and people that are associated with that often could trigger a relapse. High-risk situations There are many high-risk situations when a patient is recovering. All high risk situations such as attending parties where alcohol is served should be avoided 3. High risk situations for relapse (There are 8 categories, 5 within the intrapersonal class and 3 within the interpersonal class) are described below. I. Intrapersonal-Environmental Determinants The first category includes all determinants that are primarily associated with intrapersonal factors (within the individual), and/or reactions to nonpersonal environmental events. It includes reactions 200 Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society to interpersonal events in the relatively distant past (i.e. in which the interaction with others is no longer of significant impact). A. Coping with negative emotional states. Determinants involve coping with a negative (unpleasant) emotional state, mood, or feeling. (1) Coping with frustration and/or anger. Determinants involve an experience of frustration (reaction to a blocked goal-directed activity), and/ or anger (hostility, aggression) in terms of the self or some non-personal environmental event. Includes all references to guilt, and responses to demands ( hassles ) from environmental sources or from within the self that are likely to produce feelings of anger. (2) Coping with other negative emotional states. Determinants involves coping with emotional states other than frustration/anger that are unpleasant or aversive including feeling of fear, anxiety, tension, depression, loneliness, sadness, boredom, worry, apprehension, grief, loss, and other similar dysphoric states. It also includes reactions to evaluation stress (examinations, promotions, public speaking, etc.), employment and financial difficulties and personal misfortune or accident. B. Coping with negative physicalphysiological states. Determinants involve coping with unpleasant or painful physical or physiological reactions. (1) Coping with physical states associated with prior substance use. Coping with physical states that are specifically associated with prior use of drug or substance, such as withdrawal agony or physical craving associated with withdrawal. (2) Coping with other negative physical states. Coping with pain, illness, injury, fatigue and specific disorders (e.g. headache) that are not associated with prior substance use. C. Enhancement of positive emotional states. Use of substance to increase feelings of pleasure, joy, freedom, celebration and so on (e.g. when traveling or on vacation). Includes use of substance for primarily positive effects-to get high or to experience the enhancing effects of a drug. D. Testing personal control. It includes use of substance to test one s ability to engage in controlled or moderate use; to just try it once to see what happens; or in cases in which the individual is testing the effects of treatment or a

3 OCTOBER 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 commitment to abstinence (including tests of willpower ). E. Giving in to temptations or urges. Use of drugs in response to internal urges, temptations, or other promptings includes references to craving or intense subjective desire, in the absence of interpersonal factors. (1) In the presence of substance cues. Use occurs in the presence of cues associated with substance use (e.g. running across a pack of cigarettes, passing by a bar, seeing an ad for cigarettes). (2) In the absence of substance cues. Here, the urge or temptation comes out of the blue and is followed by the individual s attempt to procure the substance. II. Interpersonal Determinants The second category includes determinants that are primarily associated with interpersonal factors: reference is made to the presence or influence of other individuals as part of the precipitating event. It implies the influence of present or recent interaction with another person or persons, who exert some influence on the user (reactions to events that occurred in the relatively distant past are classified in Category I). Just being in the presence of others at the time of the relapse does not justify an interpersonal classification, unless some mention is made or implied that these people had some influence or were somehow involved in the event. 4 A. Coping with interpersonal conflict. It includes coping with a current or relatively recent conflict associated with any interpersonal relationship such as marriage, friendship, family patterns, and employer-employee relations. (1) Coping with Frustration and/or Anger. Determinants involves frustration (reaction to blocked goal-directed activity), and/or anger (hostility, aggression) stemming from an interpersonal source. Emphasis is on any situation in which the person feels frustrated or angry with someone and includes involvement in arguments, disagreements, fights, jealousy, discord, hassles, guilt and so on. (2) Coping with other interpersonal conflict. Determinants involve coping with conflicts other than frustration and anger stemming from an interpersonal source. Feelings such as anxiety, fear, tension, worry, concern, apprehension, etc. which are associated with interpersonal conflict, are examples. Evaluation stress in which another person or group is specifically mentioned would be included. B. Social pressure. Determinants involve responding to the influences of another individual or group of individuals who exert pressure (either direct or indirect) on the individual to use the substance. (1) Direct social pressure. Here is direct contact (usually with verbal interaction) with another person or group who puts pressure on the user or who supplies the substance to the user (e.g. being offered a drug by someone, or being urged to use a drug by someone else). Distinguish from situations in which the substance is obtained from someone else at the request of the user (who has already decided to use). (2) Indirect social pressure. It includes responding to the observation of another person or group that is using the substance or serves as a model of substance use for the user. C. Enhancement of positive emotional states. Use of substance in a primarily interpersonal situation to increase feelings of pleasure, celebration, sexual excitement, freedom and the like include enhancement of positive emotions. Distinguish from situations in which the other person(s) is using the substance prior to the individual s first use (classify these under Section II-B, above). What can be learnt from relapse? Relapse can be an extraordinarily positive experience if one analyses after the relapse the things such as (i) what was going on just prior to the relapse, (ii) who were the people with just prior to the relapse, (iii) how were the feelings inside just before the relapse, (iv) what was the person thinking just before the relapse, (v) a life event that could account for the relapse. What the forces were, (a) if hungry, (b) if tired, or (c) if feeling uncomfortable that could lead to the relapse. It is an opportunity that s full of information to gain insight. Generally speaking, these insights are only available right after the relapse happens, so in general, the sooner the better. 5 Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society 201

4 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 OCTOBER 2011 Coping with Lapses What to do when a lapse occurs? Occurrence of a lapse cannot be viewed as a totally benign event; nor should it be cause for catastrophe and giving in to a full-blown relapse. During a lapse episode (slip) the most dangerous period is the time immediately following the event. Since specific coping strategies will vary from client to client, therapist may wish to help a particular client to prepare an individualized reminder card that fits that person unique set of vulnerabilities and resources. 6 The strategies are listed in order of temporal priority, with the most important immediate steps listed first. The main points of this information can be presented to patients in summary form by the use of a Reminder Card that should be kept handy in the event that a lapse occurs. (1) Stop, look, and listen. The first thing to do when a lapse occurs is to stop the ongoing flow of events and to look and listen to what is happening. The lapse is a warning signal indicating that the patient is in danger. (2) Carry out Lapse Management Plan. After a slip, renewed commitments should be turned into a plan of action to be carried out immediately. Therapists can help patients identify Emergency Action Plans, which may include a crisis hotline telephone number, an alternative activity, or a trustworthy friend. (3) Keep Calm. Just because the patient slipped once does not indicate failure. One slip does not have to make a total relapse. Look upon the slip as a single, independent event, something that can be avoided in the future. A slip is a mistake, an opportunity for learning, not a sign of total failure. (4) Renew Commitment. After a lapse, the most difficult problem to deal with is motivation. The client may feel like giving up and may need reminding of the long-range benefits to be gained from this change. Clients should be encouraged to reflect optimistically on their past successes in being able to quit the old habit, instead of focusing pessimistically on current setbacks. (5) Review the situation leading up to the lapse. Look at the slip as a specific unique event. The following questions may help clarifying the lapse episode: (i) What events led up to the slip? (ii) Were 202 Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society there any early warning signals that preceded the lapse? (iii) What was the nature of the high-risk situation that triggered the slip? Each of these questions may yield valuable information concerning sources of stress and high-risk situations for the patient. The fact that a slip occurred often is an event that tells that something is going on that needs attending to. Dealing with the Abstinence Violation Effect The cognitive restructuring process designed to assist clients to cope with a lapse after a period of abstinence or controlled use includes the following points: 6 (1) Teach patient not to view the cause of the lapse as a personal failure or as a lack of willpower, but instead ask him to pay attention to the environmental and psychological factors in the high-risk situation, to review what coping skills they had available but didn t implement, and to notice how they felt decreased self-efficacy when they couldn t deal with the situation adequately. (2) Help the patient to deal with the inevitable feelings of guilt and shame and the cognitive dissonance that usually accompany a lapse. Guilt and shame reactions are particularly dangerous because the emotions they produce are likely to motivate further substance use as a means of coping with these unpleasant reactions to the slip. (3) After the lapse has occurred, react to the patient with compassion and understanding, and with the encouragement to learn everything possible about how to cope with similar situations in the future by a thorough debriefing of the lapse and its consequences. (4) Help patients identify any of the cognitive distortions they may have succumb to in exposing themselves to the high-risk situation, limiting their ability to engage in an effective coping response, and finally, making the decision to choose to take that first drink, dose of drugs, or to engage in criminal activity. (5) Consult and revise the Decision Matrix or Decision Balance Sheet to renew motivation by focusing on the practical advantages for others and the patient of continuing on the journey of habit change. Cognitive Behavioral Model of Relapse Relapse prevention therapy (RPT) is based on

5 OCTOBER 2011 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 a cognitive-behavioral model of the relapse process. 5 This model of relapse addresses several key questions about relapse both as a process and as an event: 1. Are there specific situational events that serve as triggers for relapse? 2. Are the determinants of the first lapse the same as those that cause a total relapse to occur, if not, how can they be distinguished from one another? 3. How does an individual react to and conceptualize the events preceding and following a lapse and how do these reactions affect the person s subsequent behavior regarding the probability of full-blown relapse? 4. Is it possible for an individual to covertly plan a relapse by setting up a situation in which it is virtually impossible to resist temptation? 5. At which points in the relapse process is it possible to intervene and alter the course of events so as to prevent a return to the addictive habit pattern? 6. Is it possible to prepare individuals during treatment to anticipate the likelihood of relapse and to teach them coping behaviors that might reduce the likelihood of lapses and the probability of subsequent relapse? In order to investigate these key questions about relapse, it is helpful to engage in a microanalysis of the relapse process. This approach focuses on the immediate precipitating circumstances of relapse as well as on the chain of events that may precede and set-up a relapse. 7. Interpersonal, and psychological factors that precede a relapse and to the individual s expectations and attributions in reaction to a lapse. This analysis is consistent with the view that the maintenance stage of habit change is a time when mistakes are expected, but can be overcome with renewed effort. Cognitive-Behavioral Model of Relapse Process The cognitive-behavioral model of relapse flowchart (above) refers to the immediate precipitants of relapse that occur once a client is exposed to a high-risk situation. In RPT, it is assumed that clients who have successfully avoided alcohol or drug use for a period of time will begin to feel a sense of self-efficacy regarding their ability to maintain abstinence. If a client has not learned an effective coping response to avoid a lapse in response to high-risk situations, or if an effective coping response is not implemented due to a lack of motivation or anxiety, then there is an increased likelihood of a lapse. This increased probability of relapse is mediated by positive expectancies for the initial use of drug. Relapse Management When a relapse occurs, the incorporation of relapse management strategies prepare a patient to implement damage control skills to reduce further harmful consequences and prevent the situation from escalating into a full-blown relapse. After a lapse, patient may experience the abstinence violation effect (AVE) that involves a loss of perceived control experienced after the client s failure to adhere to his or her self-imposed rules of conduct regarding alcohol and drug use 2. On an emotional level, the AVE increases the probability of relapse because once a lapse has occurred, the shame, guilt, self blame and other negative feelings motivate further drinking or using drugs. In addition, the AVE affects the likelihood of relapse on a cognitive level because a lapse is also followed by an internal conflict over the inconsistency of one s efforts to abstain from alcohol and/or drugs combined with the reality of just using a substance. Finally, the AVE also leads the patient to attribute his failure to stay sober to stable internal factors within his character that demonstrate that they are flawed or beyond redemption. At the same time that the cognitive and emotional reactions that characterize the AVE are operating to disturb and upset a patient about their lapse, the patient is also beginning to experience the intoxicating effects of the substance just used (e.g., enhanced pleasure and/ or reduced pain) further contributing to the likelihood of continued use which may ultimately lead to a full-blown relapse 7. The reinforcing aspects of the initial use of the substance are based in part on the principles of operant conditioning. An individual who experiences a positive consequence (e.g., euphoria) from drinking or using drugs is more likely to do so in the future due to the principle of positive reinforcement. Similarly, if engaging in substance use behavior results in the reduction of negative consequences (e.g., pain or negative emotional Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society 203

6 DELHI PSYCHIATRY JOURNAL Vol. 14 No.2 OCTOBER 2011 states) the person is also more likely to use in the future due to the process of negative reinforcement. Because using alcohol and drugs is so reinforcing, most patients are unable to make the ultimate trip to abstinence from drinking and drug use successfully the first time. Instead of reacting to a lapse or relapse with a sense of self-blame and failure, they should be treated as temporary setbacks that may ultimately have positive outcomes and become pro-lapses. Pro-lapses are defined as mistakes that patients learn from that improve their eventual chances of success. For some patients, the change process is slow and laborious and it takes many attempts before the goal is attained. Others may find that behavior change is less taxing, perhaps based on the experiences they have gained in previous quit attempts or because they have more resources, such as greater coping capacity, stable employment, or social support from family and friends. Whether a patient feels he has succeeded or failed in their previous attempts, the goal of RPT remains the same, to help patient prevent relapse, even if he slip and drink or use drugs at some point after setting out on the trip, through relapse management strategies, ultimately the journey of habit change can still be made! Can medication help to keep a behavioral addict sober Medication can be extremely helpful in recovery depending on the type of addiction. They help to diminish craving. There is going to be a punishment such as that, if you do involve yourself in that destructive behavior, you are going to have a bad experience, such as through the use of antabuse or something like that. So, therefore, I do support the appropriate use or the scientific use of current medications to help one obtain and sustain new behaviors References 1. Cronce, Jessica M. Interview with author. Addictive Behaviors Research Center, University of Washington, Curry SJ, Marlatt GA, Gordon JR. Abstinence violation effect: Validation of an attributional construct with smoking cessation. J Consult Clin Psychol 1987; 55 : Larimer, Mary E. Palmer, Rebekka S, Marlatt G. Alan. Relapse prevention: An overview of Marlatt s cognitive-behavioral model. Alcohol Res Health 1999; 23 : Laws DR. Relapse prevention The state of the art. J Interpers Violence 1999; 14 : Marlatt GA, Gordon JR. Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press Shiffman, Saul, Hickcox, Mary, Paty, Jean A. Gnys, Maryann, Kassel, Jon D, Richards, Thomas J. The abstinence violation effect following smoking lapses and temptations. Cogn Ther Res 1997; 21(5) : Shiffman, Saul, Hickcox, Mary, Paty, Jean A, Gnys, Maryann, et al. Progression from a smoking lapse to relapse: Prediction from abstinence violation effects, nicotine dependence, and lapse characteristics. J Consult Clini Psychol 2004; Delhi Psychiatry Journal 2011; 14:(2) Delhi Psychiatric Society