The American Society of Addiction Medicine defines addiction as a chronic brain disease that affects reward, motivation, memory, and related parts of the brain. This disease leads to seeking out and using drugs in spite of negative consequences. People suffering from addiction are often unable to refrain from using drugs or alcohol, and may not recognize the extent of the negative impact the addictive substance has on their lives.
The National Institute on Drug Abuse (NIDA) reports that addictive substances affect brain chemistry and structure, which classifies addiction as a brain disorder. The effects of substance use and abuse can be long-lasting. The resulting effects on the brain affect behavior and mood, and often lead to dangerous behaviors.
According to NIDA, physical dependence happens when your body becomes accustomed to the presence of a substance, whether a drug or alcohol. Once this happens, lack of the substance will lead to withdrawal. This is different from addiction, which is a term used in describing various substance use disorders. Physical dependence can play a large role in maintaining addiction to drugs or alcohol and contribute to chronic relapse. Drug dependence changes brain structure, and it can take a significant amount of time for the brain to heal. The altered brain structure and chemistry can make it difficult to avoid relapsing into drug use.
Causes of Relapse
A study from Addiction Science and Clinical Practice found that numerous variables contributed to chronic relapse. High rates of substance abuse, problems in family life, and victimization contributed to difficulties entering treatment and staying in recovery. Recovery is more likely when those struggling with addiction believe the problems are solvable, want help recovering, think they are capable of recovery, and receive professional treatment.
Common causes of drug relapse include:
- Lack of treatment following detox
- Treatment that is not specialized to the individual’s needs
- An unstable home environment
- Lack of treatment for co-occurring disorders
- Lack of aftercare following treatment
Relapse is most likely during the first 90 days of recovery, according to an article published by Psychology Today. Because drugs affect brain structure, it is difficult to resist relapse during this initial 90-day period, because cravings peak during this time. However, rates of lasting recovery increase significantly after this period. The longer the period of recovery, the less likely a person is to relapse. Another article reports that about a third of people who are sober for under a year will remain sober. After a year of recovery, less than half of people relapse, and after five years, only 15 percent of people relapse.
Relapse after a period of recovery can actually be more dangerous, because a person’s tolerance to the drug decreases sharply after time in sobriety. Tolerance to the drug builds up quickly during regular use. Because of this, larger and larger doses are needed to experience the same “high.” But tolerance decreases very quickly after abstaining from drugs. The same amount of the drug that a person once took regularly can lead to a deadly overdose if taken after a period of sobriety.
Drug use tends to occur when addicted individuals experience a “trigger” – an object or environment that they associate with drug use. This may include drug paraphernalia, places they’ve used drugs before, or people they used to use drugs with. This happens because the brain learns to associate these triggers with the “high” of drug use. Treatment can help individuals learn to deal with these triggers and avoid relapsing when they are encountered. Treatment also creates new triggers, associated with positive coping skills rather than drug use. An example would be drug cravings becoming a trigger for attendance at a 12-Step meeting. When cravings are experienced, the individual attends a meeting rather than engaging in drug use, allowing the brain to build the new association. The trigger – cravings for drugs – is eventually associated with recovery, rather than relapse.
According to DHHS, relapse into substance use occurs when a person becomes unable to cope with life circumstances while sober. Distress and difficulties with coping build slowly over time until use of alcohol or drugs becomes unavoidable. Other mental illnesses, including post-traumatic stress disorder, depression, and anxiety disorders can contribute to stressors leading to relapse. A study published by the journal Psychopharmacology found that stress was a large risk factor for relapse into drug use.
People within the criminal justice system, or exiting this system, may be at a higher risk for relapse. High rates of stress can contribute to drug use. People in the criminal justice system may lack family or financial support, and they may be confronted by people and situations they associate with drug use after being released. It is important that those in this situation have access to long-term treatment, including aftercare like group therapy and 12-Step meetings, to combat these additional stressors.
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Treatment of Chronic Relapse
The most effective treatments of addiction incorporate both behavioral therapy and medications, and are tailored to specific individuals and their situations. Medications may be used to treat the symptoms of withdrawal, to help the individual stay in treatment, or to prevent relapse as a part of long-term treatment, according to NIDA. Long-term recovery is most likely when there are strong community ties, participation in self-help groups, and well-managed medication.
Because stressors experienced in everyday life can largely contribute to relapse, it is important that a supportive community be formed. This community is often found through treatment, either in a residential treatment setting, or through group therapy and support groups. These communities can combat stressors like a poor home life or exposure to triggering environments or people.
Another important component of treatment is aftercare; it can be very helpful to transition slowly out of treatment, rather than entering directly back into old environments and situations after a period of intense rehab. This can be accomplished through sober living homes or other transitional environments, or by slowly decreasing the number of hours spent in treatment each day.
Withdrawal can involve many distressing symptoms, including depression, anxiety, restlessness, and physical illness. Certain medications can lessen these symptoms and make the detox process easier. Medications used to help people stay in treatment can lessen cravings and help the brain adapt to functioning without the addictive substance. Preventing relapse with medication generally involves the management of stressful triggers, such as anxiety, that can lead to drug use.
Behavioral therapy can enhance the effectiveness of these medications, and help those in recovery to make behavioral and perspective changes that assist in maintaining sobriety. Cognitive Behavioral Therapy, Contingency Management, Motivational Enhancement Therapy, and family therapy are commonly employed approaches to therapy within addiction treatment.
Effectiveness of Addiction Treatment
NIDA reports that the abuse of substances, including alcohol, nicotine, and drugs – both illicit and prescription – cost the US more than $700 billion a year. These costs come in the form of healthcare, resulting crime, and the loss of productivity of those suffering from addiction. Drugs and alcohol are contributing factors in more than 90,000 deaths per year; tobacco contributes to 480,000 deaths per year.
Addiction is a common illness that can often develop into a lifelong condition. According to NIDA, relapse into drug use during or after addiction treatment is likely, due to the chronic nature of the disease. However, there are many behavioral and pharmaceutical treatments available that can help maintain long-term sobriety and provide support in the case of relapse. The most effective treatment plans provide long-term support and treat addiction as a chronic illness.
While recovery from addiction can be an ongoing process, the effects of substance use can lessen over time. Addictive substances work by flooding the brain with dopamine, which affects the brain’s reward system. Dopamine is a neurotransmitter that affects brain function, including thoughts, emotions, and motivation. Concentrations of dopamine transmitters within the brain drop drastically during drug addiction. Recovery from substance abuse can lead to at least partial recovery of normal dopamine levels, allowing a return to normal brain functioning.
Common Misconceptions and Barriers to Treatment
Relapse rates in substance use disorders are comparable to those seen in other chronic diseases, as reported by NIDA. People with illnesses like asthma, diabetes, and hypertension all experience a relapse of symptoms at the same rate as people with addiction, supporting the view that addiction is a chronic illness similar to other medical conditions. Relapse into substance use should not be viewed as a failure of treatment, but rather as an indication that treatment should be changed or begin again.
According to a study published in Addiction Science and Clinical Practice, over half of people who enter addiction treatment will relapse and require multiple episodes of treatment, which may occur over many years. The more treatment episodes a person receives, the higher the likelihood of sustained recovery from drug use. Despite this, most treatment models follow an acute care approach, which does not provide for the cyclical nature of treatment required by many people suffering from addiction. This can lead to misconceptions about treatment; family and community members sometimes have expectations that their loved one will fully recover from addiction after a single episode of treatment. This can lead to frustration and disappointment when chronic relapse occurs.
The Department of Health and Human Services (DHHS) has found that various other myths about addiction are commonly believed, including the following:
- Addiction results from weakness or overindulgence.
- Addiction is a bad habit.
- Willpower is enough to stop the use of drugs or alcohol when a person is addicted.
- Relapse into drug use is evidence that treatment has failed.
These myths and misconceptions can be barriers to seeking treatment in the case of chronic relapse. The American Society of Addiction Medicine argues that a lack of understanding of the science of addiction among the general public plays a large role in maintaining the negative stereotypes and beliefs surrounding this disease.
Medicaid Health Plans of America (MHPA) supports the chronic disease approach to addiction treatment. MHPA lists the following characteristics of a chronic disease:
- Small chance of complete recovery, free of relapse
- Relapse of symptoms is common
- Various factors contribute to the disease – genetic, environmental, biological, and behavioral
Substance use disorders fit this criteria, similarly to other medical diseases that follow a chronic pattern. MHPA argues that more effective addiction treatment is delivered when a chronic disease model is adopted.