By Lawrence Weinstein, MD
Chief Medical Officer
American Addiction Centers
Now more than ever, with our nation being in the midst of an opioid epidemic, it’s critical that primary care physicians (PCPs) have concrete knowledge and expertise on the disease of addiction. The PCP can be a powerful influence for getting the patient to accept treatment, especially when the physician is empathic without being judgmental. PCPs should be proficiently trained on warning signs of substance/alcohol abuse, prevention and the stages of relapse.
When it comes to relapse in particular, there’s a common misconception that relapse is a single moment when someone with a substance use disorder returns to their drug of choice for the first time after becoming sober. However, relapse is a process, and it often takes a long time before someone finally gives into the triggers. For many people recovering from drug or alcohol use, relapse is part of the process. In fact, 40 to 60 percent of people relapse at least once during their recovery. Although many people see relapse as impulsive, there are many warning signs that signal the danger of a possible drug or alcohol relapse. Relapse is often thought to have three stages — emotional, mental, and physical.
Stage 1: Emotional Relapse
During this stage, a person is not actively thinking about using drugs or alcohol. They remember the last time they used (or relapsed) and don’t want to repeat it. But their emotions and behaviors may be setting them up for a relapse down the road.
It is believed that this stage of relapse aligns with Post-Acute Withdrawal Syndrome (PAWS), during which an addict experiences emotional and psychological withdrawal rather than physical ones.
Physical withdrawals only last a few weeks whereas PAWS can last up to two years after an addict stops using. PAWS episodes tend to last a few days at a time and include the symptoms listed above.
Some warning signs of emotional relapse include:
- Bottling up emotions
- Mood swings
- Intolerance, anger, defensiveness
- Isolating yourself from others
- Not going to recovery meetings
- Going to meetings but not sharing
- Focusing on others and their problems
- Poor eating and sleeping habits
What to tell your patient if they are in emotional relapse:
The most important thing you can do to prevent relapse at this stage is to practice self-care. Think about why you use. Do you use drugs or alcohol to escape, relax, or reward yourself? If you don’t take care of yourself and eat poorly or have poor sleep habits, you’ll feel exhausted and want to escape. If you don’t let go of your resentments and fears through some form of relaxation, they will build to the point where you’ll feel uncomfortable in your own skin. If you don’t ask for help, you’ll feel isolated. If any of those situations continues for too long, you will begin to think about using. But if you practice self-care, you can avoid those feelings from growing and avoid mental relapse.
Stage 2: Mental Relapse
The transition between emotional and mental relapse is a natural consequence of poor self-care for long periods of time. The patient starts to feel restless, irritable and discontent. The longer the patient feels this way, the more they think about using again.
During this stage, the mind is going back and forth between using and not using. Part of them wants to use, while the other part wants to remain sober. Often, a person in recovery is the only one who can pinpoint the symptoms of relapse, as some of these warning signs include:
- A craving for drugs or alcohol
- Thinking about people, places and things associated with past use
- Minimizing the consequences of or glamorizing past use
- Thinking of ways to control using
- Looking for relapse opportunities
- Planning a relapse
What to tell your patient is they’ve progressed to mental relapse:
Play the tape through
When you think about using, the fantasy is that you’ll be able to control your use this time. You’ll just have one drink. But play the tape through. One drink usually leads to more drinks. You’ll wake up the next day feeling disappointed in yourself. You may not be able to stop the next day, and you’ll get caught in the same vicious cycle. When you play that tape through to its logical conclusion, using doesn’t seem so appealing. If you could control your use, you would have done it by now.
Tell someone that you’re having urges to use
Call a friend, a support, or someone in recovery. Share with them what you’re going through. The magic of sharing is that the minute you start to talk about what you’re thinking and feeling, your urges begin to disappear. They don’t seem quite as big, and you don’t feel as alone.
Wait for 30 minutes and try to distract yourself
Most urges usually last for less than 15 to 30 minutes. When you’re in an urge, it feels like an eternity. But if you can keep yourself busy by calling a friend, going to a meeting or taking a walk. Do the things you’re supposed to do, it’ll quickly be gone.
Do your recovery one day at a time
Don’t think about whether you can stay abstinent forever. That’s a paralyzing thought. It’s overwhelming even for people who’ve been in recovery for a long time. One day at a time, means you should match your goals to your emotional strength. Do your recovery in bite-sized chunks and don’t sabotage yourself by thinking too far ahead.
Make relaxation part of your recovery
Relaxation is an important part of relapse prevention, because when you’re tense, you tend to do what’s familiar and wrong, instead of what’s new and right. When you’re relaxed, you are more open to change.
Stage 3: Physical Relapse
When the techniques above don’t work, some people act on their urges. This leads to the third and final stage of relapse: physical relapse. Driving to the dealer. Driving to the liquor store. It’s hard to stop the process of relapse at this point. Some people only use once, realize they made a mistake, and choose to focus on moving forward in recovery, while others continue using for months.
What to tell your patients if they’ve relapsed:
Talk to someone
Rather than continuing to hang out with your friends who use, call a sponsor or a sober friend and make plans. If you feel comfortable, talk through the reasons for your relapse and discuss what you can do differently in the future to avoid the same thing happening again.
Don’t isolate yourself
Even though the last thing you probably want to do is spend time with friends who don’t quite understand what you’re going through, make the plans anyway. Spending time alone will result in feelings of isolation, which can often lead to another relapse. Though a relapse can be daunting, there is always a way back to sobriety and recovery.
Relapse doesn’t mean failure
Relapse is daunting, overwhelming, and disappointing, but it doesn’t mean you’ve failed in your recovery. It’s what you decide immediately following a relapse that matters most. Surround yourself with positive influences, practice self-care, and seek additional treatment if needed. By picking yourself up and moving forward, you can come back from a relapse stronger than ever.
The important thing for PCPs to remember is that you can intervene before physical relapse occurs. Fostering a open dialogue with your patients, as well as screening patients for addiction just as you would for diabetes mellitus or hypertension, is the key.
Lawrence Weinstein, MD, is the chief medical officer at American Addiction Centers, the nation’s first publicly traded company solely dedicated to the treatment of addiction. For more information visit: americanaddictioncenters.org