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RELAPSE PREVENTION:
CHEMICAL DEPENDENCY
William J. Udrow Jr. PsyD, LCP, CRADC, MISA I,
PCGC
Ecuador: 2012
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Relapse Prevention: Data
The National Survey of Substance Abuse
Treatment Services (N-SSATS) is an annual
survey of all facilities in the United States, both
public and private, that provide substance
abuse treatment. In 2000, the 13,428 facilities
responding to the N-SSATS were asked about
the provision of 26 services, grouped into five
types: assessment, substance abuse therapy
and counseling, testing, transitional, and other.
In the substance abuse therapy and counseling
domain 77% of the facilities provided “Relapse
Prevention Groups.” (DASIS, 2003).
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Relapse Prevention: Research: Evidence
Based Treatment
Research indicates that the skills individuals learn
through cognitive-behavioral approaches remain
after the completion of treatment. In several
studies, most people receiving a cognitivebehavioral approach maintained the gains they
made in treatment throughout the following year.
((NIDA, 2012)
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Relapse Prevention: Research: Evidence
Based Treatment
Current research focuses on how to produce even
more powerful effects by combining cognitivebehavioral therapy with medications for drug
abuse and with other types of behavioral
therapies. Researcher suggest the combination
of both pharmacotherapy and cognitive-behavior
therapy produces the best results.
Pharmacotherapy can reducing internal (i.e. brain
chemistry), craving and withdrawal symptoms.
This can be extremely beneficial for consumer in
early recovery.
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Relapse Prevention:
Pharmacotherapy
Opioid Addiction:
Methadone: These specialized treatment programs
offer the long-acting synthetic opioid medication
methadone at a dosage sufficient to prevent
opioid withdrawal, block the effects of illicit
opioid use, and decrease opioid craving.
Buprenorphine: Partial agonist (it has both agonist
and antagonist properties). It reduces or
eliminates withdrawal symptoms associated with
opioid dependence but does not produce the
euphoria and sedation caused by heroin or other
opioids.
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Relapse Prevention:
Pharmacotherapy
Opioid Addiction:
Naltrexone: As a treatment for opioid addiction is
usually prescribed in outpatient medical settings,
although initiation of the treatment often begins
after medical detoxification in a residential
setting. To prevent withdrawal symptoms,
individuals must be medically detoxified and
opioid-free for several days before taking
naltrexone.
Suboxone® (a combination of buprenorphine and
the opioid antagonist naloxone).
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Relapse Prevention:
Pharmacotherapy
Tobacco Addiction:
Nicotine replacement therapies: trans-dermal
nicotine patch, nicotine spray, nicotine gum, and
nicotine lozenges.
Bupropion (Zyban®). It has mild stimulant effects
through blockade of the reuptake of
catecholamines, especially norepinephrine and
dopamine.
Varenicline (Chantix®). It acts on a subset of
nicotinic receptors (alpha-4 beta-2) thought to be
involved in the rewarding effects of nicotine.
Varenicline acts as a partial agonist/antagonist
at these receptors.
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Relapse Prevention:
Pharmacotherapy
Alcohol Addiction:
Naltrexone: blocks opioid receptors that are
involved in the rewarding effects of drinking and
the craving for alcohol.
Acamprosate (Campral®) acts on the gammaaminobutyric acid (GABA) and glutamate
neurotransmitter systems and is thought to
reduce symptoms of protracted withdrawal, such
as insomnia, anxiety, restlessness, and
dysphoria.
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Relapse Prevention:
Pharmacotherapy
Alcohol Addiction:
Disulfiram (Antabuse®) interferes with degradation
of alcohol, resulting in the accumulation of
acetaldehyde, which, in turn, produces a very
unpleasant reaction that includes flushing,
nausea, and palpitations if the patient drinks
alcohol.
Topiramate is thought to work by increasing
inhibitory (GABA) neurotransmission and
reducing stimulatory (glutamate)
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neurotransmission.
Relapse Prevention: CognitiveBehavioral
Cognitive-behavioral therapy was developed as a
method to prevent relapse when treating
problem drinking, and later was adapted for
cocaine-addicted individuals. Cognitivebehavioral strategies are based on the theory
that learning processes play a critical role in the
development of maladaptive behavioral patterns.
Individuals learn to identify and correct
problematic behaviors by applying a range of
different skills that can be used to stop drug
abuse and to address a range of other problems
that often co-occur with it. (NIDA, 2012).
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Relapse Prevention: CognitiveBehavioral
Cognitive-behavioral therapy generally consists of a
collection of strategies intended to enhance selfcontrol. Specific techniques include exploring:
• The positive and negative consequences of
continued use.
• Self-monitoring to recognize drug cravings early
on.
• Identify high risk situations for using.
• Developing strategies for coping with and
avoiding high-risk situations
A central element of this treatment is anticipating likely
problems and helping patients develop effective coping
strategies.
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Relapse Prevention: CognitiveBehavioral: Triggers/Cravings
• Triggers refer to experiences, people,
situations, events, or things (objects) that
stimulate a desire or craving to use cocaine or
other substances. A trigger can lead to a relapse
if the recovering person doesn’t have coping
strategies to manage the craving.
• Craving refers to an impulsive, spontaneous
urge to use cocaine or other substances. A
craving may include strong thoughts of using
drugs, physical symptoms such as heart
palpitations and sweating, or behaviors such as
pacing.
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Relapse Prevention: CognitiveBehavioral: Triggers/Cravings
• It is important for the consumer to identify
their personal triggers to use drugs. Once
the consumer recognize what leads them
to crave drugs, they have made a good
start. The next step is for them to know
when and how to avoid the people, places,
events, and things that trigger their craving
for drugs because this will help reduce
their vulnerability to use substances. (Carter &
Tiffany, 1999)
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Relapse Prevention: CognitiveBehavioral: Cravings
Cravings are triggered by many external stimuli in the
environment, such as the sight or smell of
substances or people, places, events, or
experiences related to substance use (e.g., drug
dealer, friends who use, places where cocaine was
used, music associated with getting high, etc.).
Cravings also are triggered by internal factors, such as
obsessions or thoughts about using drugs, or mood
states such as anxiety, boredom, or depression.
Cravings substances are temporary and will pass in
time. The client needs to use coping strategies to
resist giving in to a craving.
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Social Pressures and Triggers
• Drug-using friends or family
•
members.
• Dealers.
•
• Events or celebrations
where alcohol or drugs are
•
present.
•
• Music associated with
partying or using
•
substances.
• Sex and sexual partners. •
• Drug paraphernalia.
•
• Corner or house where
drugs were obtained.
• Neighborhood where drugs •
were used.
Some jobs (particularly if
people used drugs on the job).
Money or the anticipation of
getting money or a check.
Weekends or celebrations.
Smell of crack or the smell of
matches.
Sight or smell of other drugs.
Feeling lonely, sad, angry,
bored, or depressed.
Positive memories of getting
high.
Negative thoughts of
recovery.
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Relapse Prevention: Coping
Strategies for Social Pressure
• Assist consumers to identify high-risk people
and social situations to avoid because of the
pressure they will face to use cocaine or other
drugs.
• Encourage consumers to tell people that they
have a problem with cocaine.
• Encourage consumers to simply refuse any
offers of drugs without giving an explanation.
• Encourage consumers to say that they are not
using drugs today.
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Relapse Prevention: Coping
Strategies for Social Pressure
• Encourage consumers to ask the person who is
offering them drugs not to do so because of the
problems their cocaine use has caused.
• If the consumer begin to feel anxious and
pressured in a social situation, it is advisable to
leave the situation. This is especially important if
the people who are present can influence them
to use cocaine or other drugs, including alcohol.
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Relapse Prevention: Behavioral
Strategies
• Call a friend or sponsor to discuss the craving.
• Go to an AA, NA, or CA meeting or to a
recovery club.
• Get some physical exercise.
• Read, particularly about recovery.
• Spend time with sober people.
• Keep busy.
• Distract oneself with an activity.
• Avoid high-risk people, places, and events.
• Be firm when refusing offers to use substances.
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Relapse Prevention: Cognitive
Strategies
• Remember that cravings and desires for
substances eventually go away.
• Think positive and tell yourself you can
fight off your craving.
• Talk yourself through the craving.
• Pray or ask for strength from your higher
power.
• Practice ahead of time how to refuse
substance offers.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
90 in 90. People who “keep coming back” have a much belier chance
of recovering. We recommend 90 meetings in 90 days; try out lots of
different meetings and fellowships.
“A drug is only an arm’s-length away.” Slipping is really easy: a
moment’s inattention; wrong time, wrong place.
“A slip is the end of a process.” (Also: “On the road to a slip, the first
step is to get rid of your sponsor”; “A slip occurs before you pick up.”)
Abstinence. We can’t get high if we don’t pick up that first drug or
drink. We’ve learned that using other drugs-- alcohol, marijuana,
cocaine, poppers--can lead us back to our primary addiction. We
believe in total abstinence
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Acceptance. “Grant me the serenity to accept the things I cannot
change,” We can’t fix everything--certainly not our addiction; we just
had to calm down and accept that and remind ourselves with the
Serenity Prayer as needed.
Act as if. Also: “Fake it till you make it Life is totally different when
we’re first getting sober-full of crazy feelings and fears, excitement and
gratitude. When we don’t know what to do in a certain situation or state
of mind, we ask for a suggestion from our sponsor or another person in
the program. We can’t “think” our way to right actions, but we can “act”
our way to right thoughts. For example: Most of us had to act as if there
was a Higher Power for a long time when we first entered the program.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Action, “courage to change the things I can.” Life is a program of
action; most of us started small with things like going to meetings or
making our beds
Big Book. The Big Book, Alcoholics Anonymous, is the basic text of
recovery. Most of us read it from time to time, some of us are in study
groups where we use it to work the steps.
Bookending. If we need to do something or go somewhere that may
make us want to use-meet an ex, the office holiday party, a first datemany of us check in with a program friend before we go and after we’re
done.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Burning desires. If a meeting is ending and we have not been called
on, but think we might use if we don’t get a chance to share, we take
the “burning desire” when it is announced. If we are still not called on,
we grab someone right away after the meeting to talk.
Chips. When we were counting days, most of us raised our hands and
shared our progress with the groups. Those plastic key chains we
receive from various meetings as we reach new sober anniversaries
are among our most valued possessions.
Coffee. Between fellowship, meetings with friends and sponsors, and
just generally showing up for life on time now that we’re sober, a lot of
us drink more coffee than we used to. This can make us very anxious;
if we have trouble sleeping, researchers suggest avoiding caffeine
within five hours of bed,
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Compare and despair. We try not to compare our insides to someone
else’s outsides.
“Easy does it.” We tried not to take on too much in early sobriety.
Feelings are not facts. Just because we feel that everyone hates us
doesn’t mean they do.
Fellowship. The meeting after the meeting. We go for hamburgers and
coffee, discuss topics and feelings brought up by the meeting, and chit
chat.
“First things first” We learned to prioritize.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
“Give time time.” Getting sober takes time, and we addicts tend to be
impatient people.
“Go to any lengths.” We did some sick stuff in our pursuit of drugs;
we try to work just as hard to stay sober. If we drank or used every day,
we can go meetings every day.
Good Orderly Direction. One popular conception of a Higher Power:
doing the next right thing.
Group Of Drunks. Another useful concept of a Higher Power (from
AA): people helping each other get and stay sober.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
“Half measures availed us nothing.” We have to give sobriety our all
or we won’t succeed.
HALT. Don’t get to Hungry, Angry, Lonely, Tired. An afternoon spent
struggling with cravings can be explained with these four words We
check in on our physical and emotional condition throughout the day.
Hungry? Eat regular meals at regular mealtimes. Angry? Talk about it a
lot with your sponsor and others. Lonely? Go to a meeting, call
someone. Tired? Take a nap, go to sleep early, schedule less. (gay
version: HALIF don’t get too hungry, angry, lonely, tired, or fabulous.)
HOW. Honesty, Open-mindedness and Willingness, the basic tenets
behind Steps One, Two and Three. This is HOW it works: we get
honest, we open our minds, and we become wilting to surrender and
work a program.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Just for today. We stay sober one day at a time.
“Keep it simple.” Also: “Keep it simple, stupid.” We tried not to do
anything too drastic while we were learning how to live sober, on the
proven principle that anything we put in front of our sobriety would take
us back out. (See No major changes.)
Keep right size. When we are feeling really lousy- really super--we try
to keep our objectivity. Our low self-esteem and grandiosity led us into
addiction in the first place.
“Keep the memory green.” We must never forget that we are
powerless over alcohol and drugs..
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Meditation. We found this is not as mystical as it sounds: We just sit
quietly somewhere for a few minutes and listen to our breath— in, out,
in, out, in, out... Anxiety melts away, and our Higher Power comes in.
Meetings. At meetings we share our successes and struggles, learn
about the steps, explore our spirituality, make friends. We have seen
how “meeting makers make it,”
No major changes ... in the first year. This probably sounds impossible
and even backwards-why did we get sober, after all, if it wasn’t to
change our lives? But the reasoning behind it is sound. During the first
year, we tried not to plunge into new romances, change jobs or homes,
or confront long-standing problems in our families. People said to us:
Who you are will change. Who knows what you’ll want in a year?
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
“Nonalcoholic beer is for nonalcoholics.” “Near-beer” actually
contains a tiny amount of alcohol. We believe we’re better off finding
beverages that don’t remind us of alcohol.
One day at a time. It’s too overwhelming to think we’ll never use again;
we focus on doing whatever it takes to stay clean today. We worry about
tomorrow when it comes.
Outside issues, If we are depressed, we get help--therapy, group
counseling, antidepressants, economic assistance.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
People, places and things. We stay away from anything we identify that
reminds us of using. Dealers, party buddies, friends we ran with, or
others in our lives who throw off our equilibrium; bars, clubs, baths,
certain streets or corners, or other places we associate with copping or
using; stems, vials, lighters, cocktail glasses There’s an AA saying: “If
you hang out in the barbershop, eventually you’ll get a haircut.”
Phone numbers. Telephone numbers are our lifeline. Members who
have been around for a while are happy to share their experience,
strength, hope--and time. If we want to call our dealer, we call someone
from the program instead. For this reason, we always carry the numbers
of friends in the program. Many of us make a habit of calling someone,
our sponsor or a friend, in the program daily. As for our own phone
numbers, many of us changed them to avoid getting tempting calls from
dealers and using friends. (See People, places and things, Go to any
lengths.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Play the tape through to the end. When a using craving starts to
overwhelm us, we remember one of our last runs all the way through to
the end: from the first drink to the bumps in the bathroom and crazy
sex, to desperation, paranoia, STDs, hospitals, lost jobs, evictions,
busted relationships brought us into the rooms. After a while, by playing
the tape the whole way through whenever we get a craving, we
associate using less with the thrill of escape and more with the reality of
our addiction and its consequences.
Prayer. Reaching out to a higher power--whether we believe in one or
not--has an incredibly calming effect on us. Many of us pray in the
morning, asking for help to stay sober another day, and at night, saying
a simple thank-you when we make it to bed sober.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
“Principles not personalities.” This means a couple of things. First,
people in the fellowship may sometimes let us down; but the principles of
the 12 steps never will. We never let someone else who is working our
nerves keep us from seeking the recovery we deserve.
“Progress, not perfection.” We try not to be so hard on ourselves. Even
Bill W the founder of AA, had problems.
Shelf. As in “just put that on the shelf We may feel we have other problems
(cigarettes, debt, sexual compulsion, job problems, family issues) in
addition to our addiction, but we postpone dealing with those other
problems directly for a while, until we’ve begun to lead a life free from drugs
and alcohol, The stress of dealing with these other problems can make our
recovery from addiction more difficult. Just staying sober helps most of our
problems start resolving themselves; in time, when we have some recovery
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under our belts, we take problems off the shelf to be addressed,,
Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Smart feet. Knowing when and where meetings are; having a usual
routine; attending meetings even though we are busy, bored or don’t
want to be bothered, because we know its good for us. “Smart feet” is
the impulse to get to a meeting whenever something happens that
makes us want to use.
Sponsors. A sponsor is another recovering addict, with a year or more
of clean time, who helps mentor us in our recovery.
Steps. There are 12 of them, and they work, The process of selfdiscovery they describe unfolds organically the longer you stay sober,
but it’s best to really work on them--with a sponsor. Everyone works the
steps in his own way, at his own pace. The only step we have to wprk
perfectly is Step One.
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
“Stick with the winners.” We try to hang out with people who have
good attitudes and some clean and sober time in the program.
Surrender. Also, “Surrender to win.” This is the core of the program;
it’s really explored in Step Three. Surrender is not defeat, it’s joining the
winning side. Basically, we are willing to try some other way-ours
wasn’t getting us anywhere.
“Take what you can use and leave the rest.” If a suggestion or
concept is confusing or seems contradictory, we set it aside until we
are ready. We try not to complicate our programs unnecessarily.
Traditions. There are 12 of these, too. The code of conduct for the
organization, they are the principles that guide CMA meetings and the
group as a whole. (See Principles not personalities.)
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Relapse Prevention: Tools of Recovery
Using Alcoholic Anonymous Concepts
Triggers. People, places and things that remind us of using, and anything
else- a fight, depression, being hungry, angry, lonely and/or tired--that
upsets our equilibrium enough to make us want to use.
We are not professionals. We are not doctors. Therefore, we seek
professional help for physical or mental problems such as depression or
mania; financial counseling; or job training.
“We are only as sick as our secrets.” Openness takes the toxic strength
out of shame, If something is eating away at us, we share about it at
meetings and with our sponsor.
Yets. These are things we have yet to do but that, knowing the way our
minds work, we might encounter on our next relapse-smoking, shooting up,
heroin, crack, prostitution, jail, homelessness. Addiction is a progressive
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disease; if we go out, it will most likely be worse next time.
Relapse Prevention: Technology
• Technology—computer software, Web sites, even
telephones—may enhance the potency, reach, and costeffectiveness of behavioral treatment. Patients who
cannot or will not attend live therapy sessions may
benefit from computer software designed to teach
relapse-avoidance skills. Similarly, booster sessions
delivered via telephone or the Web might reinforce
abstinence. Some providers may offer in-person
treatment sessions early in a patient's therapy and then
shift to telephone or computer delivery of treatment.
These technologies should be particularly beneficial for
patients who live in remote areas or have limited
mobility. (NIDA, 2010).
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Reference:
Carter, F. K., & Tiffany, S. T. (1999). Meta-ananlysis of cue-reactivity in
addiction research. Addiction, 94(3), 321-340.
Drug and Alcohol Services Information System (DASIS) (2003).
http://www.samhsa.gov/data/2k3/ServicesTX/servicesTX.htm
Inaba, S. D. & Cohen, E. W. (2000). Uppers, Downers, All Arounders:
Physical and Mental Effects of Psychoactive Drugs. Oregon: CNS
Publications, Inc.
National Institute on Drug Abuse (NIDA), (2010). New Tools and Strategies to
Bolster Behavioral Therapy. http://www.drugabuse.gov/newsevents/nida-notes/2010/10/new-tools-strategies-to-bolster-behavioraltherapy
National Institute on Drug Abuse (NIDA), (2012). Principles of Drug Addiction
Treatment: A Research-Based Guide http://www.drugabuse.gov
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