relapse is common. Studies suggest that approximately half of all individuals who try to get sober return to heavy use, with 70 to 90 percent experiencing at least one mild to moderate slip. In other words, not many people say “I want to get sober,” walk into a treatment center, and never use drugs
In this way, addiction is very much akin to other chronic diseases. As with chemical addiction, patients with chronic illnesses such as diabetes, asthma, and hypertension frequently fail to comply with their ongoing treatments—relapsing, if you will, oftentimes with dire consequences. Thus, no matter the chronic disease, it is ultimately up to the individual to adjust his or her lifestyle and assume responsibility for managing his or her own care. Unfortunately, removing the drug (detoxing) is the easy part. Changing the behaviors that compel the addict to use is significantly more difficult.
What Causes Relapse?
Typically, addicts who return to drugs nearly always do so in response to drug-related cues such as seeing drug paraphernalia or visiting places where they’ve scored drugs. These “triggers” are a byproduct of addiction’s two-stage formation process. In the first stage, the reward functions of the brain are hyper-stimulated—taking drugs makes users feel good, which encourages a repeat performance. In the second stage, repeated overstimulation of the reward centers causes long-term changes in how other areas of the brain function, including areas involved with memory, impulsivity, and decision-making.
A helpful analogy is having a flood in your house. You leave the upstairs bathtub running and depart for the weekend. The water overflows and runs into the hall. Like a waterfall it splashes down the stairs and into the living room. When you return, you find that the walls are soaked, mold is forming, and the wood floors are warped and peeling. Your original problem was that the water wasn’t turned off, but now the floor needs to be ripped up and the walls torn out. Turning off the faucet (detoxing) doesn’t undo the damage caused by the water (drugs) to the rest of your house (brain).
In rodent experiments we clearly see this two-stage process. Stage one: Numerous studies show that rats will quickly learn to press a lever that delivers a drug in preference to levers that deliver food or water. The more “rewarding” a drug is, the more furiously the rats will press the bar. We shouldn’t be surprised, then, that when presented with a drug like cocaine rats display behaviors endemic in addiction, foregoing normal activities such as eating and sleeping in favor of getting high.
Stage two: In addition to going crazy for the drug, rats “remember” and “like” the places where they received it. For instance, when cocaine-addicted rats are placed in an environment where they receive only food and water, they accept that no drug is available and they push only the food and water levers. However, when placed back in the cage where cocaine had been available, they immediately engage in a drug-bar-pressing frenzy. They recognize the location and associate it with past drug use. They are triggered by the environment and they become incredibly agitated—they crave—in expectation of the drug reward.
Human addicts react to drugs and develop triggers in much the same way. In fact, modern brain imaging shows that drug use literally alters the connections between the ventral tegmental area (which is part of the reward center) and memory hubs in the brain (such as the hippocampus). Thus, for addicts, triggers to use become hardwired as part of the collateral brain damage of addiction. This is why addicts are highly reactive to cues associated with previous drug use, and also why treatment programs consistently recommend avoiding people, places, and things from the addict’s using past.
The Danger Zone
Study after study shows the first ninety days in recovery are when the greatest percentage of relapses occur. This is because drugs of abuse rewire the brain, and it takes a significant amount of time away from drugs to repair and/or overcome this rewiring. Unfortunately, cravings usually get worse before they get better. In fact, the longer an addict stays clean, the higher his or her response will be to contextual cues. In other words, it’s actually harder to not pick up at sixty days than it is at six days.
Underlying psychological issues such as anxiety and depression are also likely to assert as time away from drugs increases. With proper treatment these symptoms will diminish over time, but from thirty to ninety days sober they hit a peak. On the plus side, after ninety days sober the odds of long-term abstinence increase significantly—a terrific reason to stay in treatment for longer than the currently standard thirty days—and after a year away from drugs the odds of lasting recovery are actually pretty good.
It is incredibly important during initial treatment (and early aftercare) that addicts learn to recognize their triggers because relapse is much harder to prevent when you don’t see it coming. One positive that may actually come from a slip is the addict in question may recognize a new trigger. For instance, the individual may learn that certain music—the tunes he or she plays when using—is slippery. Those songs can then be deleted from the individual’s iPod, phone, and computer. And when they come on the radio, the addict can now see them as a trigger and take contrary action by switching the station, phoning a sponsor, or heading to a meeting. Furthermore, if the addict suddenly has a desire to listen to that music, it is an obvious sign of a deeper issue that needs to be addressed. Understanding this, he or she can actively deal with the deeper problem while at the same time being on guard for other relapse triggers.
The Safety Zone
Interestingly, being in recovery creates triggers the same way using creates triggers. This is one of the many reasons treatment centers want patients to stay longer than thirty days. Repeated attendance in group therapy and 12-step meetings results in cue-induced learning related to recovery. For instance, when an addict hears in group settings, from lots of other addicts, that when they experience a craving to use they immediately call another sober person to ask for help, that individual eventually starts to visualize performing the same action in response to a craving. In so doing, the addict creates a trigger for recovery, and the next time a powerful craving hits he or she will pick up the phone and call a sober friend instead of the local dealer. Thus, triggering cravings in a setting that’s safe and reassuring—a setting in which the person being triggered is unlikely to relapse—dissipates the anxiety and stress caused by the potential relapse trigger. Over time the addict subconsciously dissociates the cue from the past reward of using and associates it with the new reward of sobriety.
David Sack, M.D.,is board certified in Psychiatry, Addiction Psychiatry and Addiction Medicine. Dr. Sack currently serves as CEO of Elements Behavioral Health, a network of addiction treatment centers that include Promises Treatment Centers, The Ranch, Right Step, and Spirit Lodge.