Relapse occurs when an individual interrupts their sobriety by drinking or using a mood-altering substance. Individuals who relapse, gradually stop participating in all, or some, of their recovery. Although recovery programs are different for each individual, they commonly include (but are not limited to) the following:
- Detoxing from alcohol or a mood-altering substance in a hospital setting
- Attending an intensive outpatient program (IOP)
- Attending a partial hospitalization program (PHP)
- Attending recovery meetings (Alcoholic Anonymous, AA) (Narcotics Anonymous, NA),
- Communicating daily with a sponsor,
- Participating in weekly family, individual/couple counseling,
- Working through a 12-step program
- Completely avoiding and/or coping with un-avoidable “triggers” in the environment
Unfortunately, relapse rates for addicted individuals are high. According to the National Institute of Drug Abuse, relapse rates for addiction are anywhere from 40 to 60 percent, resembling relapse rates for other chronic diseases such as diabetes, hypertension, and asthma. Therefore, it is important for recovering addicts to know what they can do to mitigate their risk.
In my practice, inquire about how to prevent relapse. Although there is no “one sure way” to accomplish this, understanding the power of triggers is imperative. A trigger is an event or situation that causes one to crave the use of alcohol or drugs. Each individual has a set of unique triggers. Triggers cause stress and weaken one’s resilience, gradually eroding recovery efforts. This results in relapse.
“Why do some addicts keep relapsing?”
Because addiction is strong and powerful. The disease of addiction can overwhelm one’s emotions, sense of self, and ability to cope. Triggers can cause overwhelming stress that pushes the individual back to familiar ways of handling emotions, namely, using mood-altering substances. Using alcohol and drugs takes the edge off, allowing the individual to relax and decrease feelings of overwhelming stress.
“What is missing from treatment that could help?”
What I have observed “missing” from treatment is an emphasis on learning skills to deal with stress caused by triggers. When an individual becomes sober, they have to deal with stress without the use of mood-altering substances. This can be challenging, especially for newly recovering individuals who are not yet comfortable experiencing emotions and thoughts while sober. Learning effective coping skills to manage this type of stress is key to preventing relapse. Stress is generated by the external triggers in one’s surroundings and by the internal triggers generated by what the individual thinks and feels in their own mind.
By managing the 8 stressors listed below, the recovering individual can identify how each stressor impacts their specific vulnerability for relapse. Becoming aware and understanding one’s specific triggers will close the gap, eliminating the pieces of treatment that are missed if ignored.
1. Dope sick stress. “I feel so sick. If I use just a little, I will feel better.”
You are dope sick. In your head, you keep focused on how sick your body feels because of withdrawal. It feels like it’s lasting forever. Dope sick stress may cause you to start thinking that using again is the solution to not feel sick. At some level, you know this is false. You know using again will bring you back to where you started, or worse. Still, some people justify using again by convincing themselves they will use, “just a little” to take the edge off.
When you are dope sick, you may have symptoms of diarrhea, nausea, cold sweats, and muscle cramps. You may not be able to hold food down, sleep or focus on a conversation. How sick you are may depend on what you have used, how much, and how often. Withdrawal symptoms can last weeks, months, or over a year.
Instead of relapsing, call your doctor, hospital, or treatment center and ask for help. Professionals who deal with withdrawal symptoms can suggest a detox center or they may prescribe medications, such as Valium or Suboxone that will decrease withdrawal symptoms. For 24/7 help with withdrawal symptoms in English or Spanish, call the Substance Abuse and Mental Health Services (SAMHSA) at 1-800-662-4357.
2. Stressed by surroundings. “Everywhere I go seems to trigger my desire to use again.”
Environments are powerful. The places you are familiar with are some of the same places you used alcohol or other substances. You may associate many of these places with having fun, relaxing, vacationing or helping you deal with the stress of daily life. Some places may be easy to avoid such as strip clubs, casinos, and bars because it may take planning ahead to get there. However, other places where you have used substances may be difficult to avoid, such as your own basement.
Make a list of each place and deal with them individually with your sponsor or with others who support your recovery. Avoid the places you can avoid. For the places you cannot avoid, ensure that they are cleaned out and substance-free. Re-decorate, paint, and change the environment as much as possible to help make new and healthy drug-free associations. Stay aware of your triggers and let someone know if and when “random triggers” enter your mind.
3. Psychological symptoms causing stress. “I can’t take this anxiety and depression anymore. I want to use to take the edge off and relax.”
In many situations, using alcohol or other substances is a way to self-medicate. Substances allow the individual temporary relief from symptoms of anxiety, depression, trauma, or mood swings. However, once the individual is sober, mental health symptoms may seem to increase because their drug of choice is no longer hiding mental health symptoms. This can cause panic, significant stress, and a high risk for relapse.
With proper medical treatment, recovery can include a mental health assessment and a recommendation for counseling and medications. The combination of counseling and medication may properly address mental health symptoms. Without addressing mental health needs, the individual is at risk of relapsing back to old familiar habits of self-medicating with unprescribed mood-altering substances.
4. Stressed by people and things. “They all drink or use and I went right along with them. The things I see, including them, have me thinking about using alcohol/drugs again.”
Many people and things in our lives may trigger cravings for using alcohol and substances. I remember a newly recovering individual telling me that he was triggered by the smell and taste of stadium mustard. Stadium mustard triggered cravings that generated memories of when he sat all day at baseball games drinking beers and eating hot dogs with his friends. The association was so strong, he avoided stadium mustard for the first five years of his recovery. Although “things” that trigger cravings are different for everyone, random things can include items such as foods, aluminum foil, toilet paper rolls, street names, and music.
Certain people, especially those with whom you used with, are clearly associated with addiction. If these same people understand and support your goal to remain sober, they will respect your recovery and not use any alcohol or substances around you. However, if they are not able to respect your sobriety, you can set healthy and firm boundaries with them. Ideally, once your recovery is solid, you can decide whether or not to resume contact with them. Many recovering individuals plan ahead and are accompanied by their sponsor (or another sober support) when they know they will be exposed to high-risk trigger situations involving people or things.
5. Too stressed to take care of yourself. “I know I should exercise, eat better and get some sleep. I’m too tired to think about it today. Maybe tomorrow.”
Many addicts do not take care of themselves. Self-care includes many life choices such as eating nutritionally, exercising, getting proper sleep, and hydration. Proper self-care can prevent future health problems such as diabetes, depression, and obesity. It can also give an individual a sense of control, resulting in less irritability and frustration. Talk with your counselor and physician about how to begin developing healthy self-care habits. Identify short-term realistic goals such as walking around the block each day. Send the message to yourself that you are worth the time and energy. This is the beginning of a better life. Give yourself credit for starting this journey, one step at a time.
6. Stressed about intimacy. “I can’t remember the last time I was sober and talked, went out with friends, or had sex with my (husband, wife, partner). Being sober in this marriage/relationship feels so strange to me.”
Relationships, before and after recovery can feel very different. If you are newly sober, and in a long-term intimate relationship such as a marriage, you may find that communication and comfort levels with this person feel different and possibly unpleasant at first. Working through conflict and problem solving with your partner may feel like a new experience, even when you have known them for years.
Remember, this is new. You may have always been high or intoxicated to some degree, regardless if you felt happy, sad, angry, lonely, disappointed, fear, etc.… Your substance use may have accompanied every emotion and every interaction you had with your intimate partner.
In the past, you may not have paid attention to decisions in your relationship. You may not have talked through decisions with your partner. Possibly, you were a poor listener. Now that you are sober, you may want to participate with discussions. Understand that you and your partner may experience an adjustment period to this new communication style. In time, this experience may be positive and enhance your relationship. Sex and intimacy may also feel different and can possibly trigger insecurity and a desire to use alcohol or other substances. This too should also be discussed so that the supporting partner understands.
You and your intimate partner may have to alter the activities you do or change people you associate with, depending on the level of alcohol or substance use involved. Planning ahead about how to alter social activities before the event is most helpful. When you cannot avoid people, places, or things that involve triggers, you and your partner can discuss how to minimize exposure and set healthy boundaries in those situations.
7. Stressed with nothing to do. “I can’t go out with my friends or hang out where I used to go. Watching sports or T.V. without a beer is boring.”
Feeling bored and isolated is a common complaint of newly recovering individuals. They realize that they have spent a lot of time being high/intoxicated, recovering from intoxication/hangovers, and planning the next high. Now that they’re sober, they may have a lot more time on their hands. Feelings of boredom and isolation may set in.
If this is you, tell your sponsor that you are bored and need to fill in the time. Your sponsor can suggest home-group meetings, alternative Alcohol Anonymous (AA) meetings, sober social events, and volunteer activities that will support your recovery. You can also fill time learning hobbies and activities you have always wanted to do (i.e., cook for your family). As you gain more days and months of sobriety, you may feel more comfortable with alone time. However, until then, alone time can trigger frustration and a desire to use again in an effort to block feelings of loneliness and isolation. Prevent this trigger from taking hold of your recovery by planning ahead and filling your time wisely.
8. Stressed by grief and memories. “I know using drugs almost killed me, but there were some good times. It was fun with a lot of laughs. I miss those days and want the fun back.” AND/OR “My alcohol/drug use really hurt a lot of people. I think about what could have been.”
Memories can go both ways: remembering (and grieving) the good times and remembering (and grieving) what could have been had addiction not interrupted one’s life.
Remembering the “good times of using days” often causes newly recovering individuals to grieve the fun times they had. As one recovering addict recalls, “Camping with friends, parties, golfing, and going to baseball games were fun before my drinking got out of hand.”
Sometimes memories about the “good times” can overpower the reality of the negative consequences such as being sick, arrested, and involved in conflicts with others. Remembering the fun times can be stressful when they increase one’s desire to use.
Memories can also be stressful because they cause the individual to grieve what could have been had their addiction not taken over their life. Grief can relate to lost opportunities and failed relationships. Grief is real. When feelings of grief are not addressed, stress can build, resulting in relapse.
One way to deal with the stress of grief is to talk with a sponsor and other recovering individuals who can relate to this type of grief. Understand that it is normal to grieve “the good times” and “what could have been.”
Closing the recovery gap on what is missing in treatment
Relapse rates are high at over 50% in the first year of sobriety. To decrease this rate, one can address what is missing by paying attention to triggers. Regardless if the individual is triggered by withdrawal from feeling dope sick, people, places, and things associated with using or underlying mental health symptoms, stress builds and eventually overpowers one’s strength of recovery.
To close this gap, recovering individuals must remain open identifying how each stressor impacts their specific vulnerability for relapse. They must be open to receiving support from groups, sponsors, family and friends who support their sobriety. With support, the individual can develop ways to cope with triggers and vulnerable situations that threaten sobriety.
The longer you are able to maintain sobriety, the better chance you will have at long-term recovery. Fill the gap of what is missing by addressing stressors head-on. The more coping skills you have, the more confidence you will have in yourself and your recovery.
If you or someone you love is dealing with stressors that may increase their vulnerability for relapse, schedule an appointment with Dr. Musarra by calling, tel:216-954-5665 or emailing firstname.lastname@example.org.