What is a relapse?

By Timothy Conley, Ph.D.

One question often asked by people who have participated in an in-patient treatment facility for chemical dependency is: How many of us will relapse? The newly recovering addict is looking for some sense of the odds they have of staying sober. Moreover, it is often wondered if having one drink or drug on one day as an isolated incident counts as a relapse. What is the difference between a drug or alcohol relapse and what recovering people call a “slip?”

The term “relapse” usually refers to drinking or using drugs again after a period of abstinence, or trying to quit drinking/using and not being able to. Sometimes it is used interchangeably with the terms “slip” or the older “falling off the wagon.” Many alcohol/drug abuse clinicians differentiate between a slip and a relapse by defining a slip as a one-time isolated mistake followed by a renewed commitment to and effort at treatment and abstinence. A slip may be seen by the recovering person as a wake-up call regarding how much more effort will be required to achieve a lasting continuous abstinence.

Relapse may be defined as a complete or near complete return to pre-treatment levels of use and an addictive lifestyle: the individual has quit recovery efforts and returned to unmitigated substance use. This is a much more serious event. I can recall phone consults and supervision with other clinicians where they would report to me, “My client used this week.” I would ask: “Have they relapsed or was it just a slip? Are they off the wagon altogether and questioning their whole need for treatment, or did they just make a mistake and are back at treatment?” Sometimes the recovering person was in-between—unsure of what they were doing. They had used and were not at all sure what it meant.

How an individual personally defines the event of using again plays a large role in how they will react. For example, an alcoholic who believes that even one errant sip will lead to massive, loss-of-control binge drinking will do just that. Whereas, another person may believe that a slip is just a slip and that by getting honest with themselves and another person they can get right back on the wagon—so they do. The newly recovering person will often be looking to others to help them define what it is that is happening and will be happening now that they have used. It is the proper role of the counselor to help the recovering addict try to minimize the loss of control, maximize the learning potential of the event and assist in further healing.

The fact is that research evidence indicates approximately 90% of help-seeking alcoholics are likely to experience at least one episode of use (slip or period of relapse) over the four-year time frame following treatment. But by far, most do not abandon the quest for continuous sobriety. Similar relapse rates for alcohol, nicotine, opiate and cocaine addiction indicate that whatever it is that's driving the slip/relapse process for many addictive disorders, it may share common biochemical, behavioral or mental/emotional components.

Does this mean most addicts seeking recovery are doomed to relapse? Not really. Over many years of practice I still have not learned how to call it with regards to who is at higher risk of relapse and who is not. My colleagues in the addiction treatment profession and myself can predict correctly sometimes but over the years so many people that I thought for sure were destined to hit bottom, completely surprised me and made a complete and total recovery of continuous abstinence. Others who were star clients with a great prognosis fell repeatedly before getting to the real underlying causes of their drinking and achieving abstinence. Of course, many more never make it at all and either continue to use despite repeated, often desperate, attempts to stop, or succumb to the risks of the addictive disease and die. This includes many smokers. Trying to determine who will make it right away and who will not is all very unscientific and defies even prediction based on clinical wisdom.

One useful question though is “what leads to relapse?” Craving is one problem that often drives relapse. Chemical craving, be it for alcohol, nicotine, opiates, cocaine, cannabis, etc. is an appetitive urge, similar to hunger, that varies in intensity and is characterized by withdrawal-like symptoms. This psychological phenomenon is subjective and very difficult to measure from person to person. The outward symptom of chemical-seeking behavior is driven by internal and external cues that evoke memory of the euphoric effects of the drug and of the discomfort of withdrawal or not getting it. This is reported to me by persons attempting recovery in statements such as:

“I just knew I had to have it—had to, period.”

“I felt sick and the only thing I knew would make it go away was the substance.”

“I was obsessing, something was missing, and it just seemed normal to go and have some so I was all there again.”

The powerful sense of being incomplete or unwell was consistently reported to me by addicts in treatment. AA refers to craving as “the desire to drink” and indicates that it will be removed by following the suggested program of 12 steps to recovery. These include in part not fighting the craving but surrendering to a benevolent higher power which will relieve it. It is noted that many hundreds of thousands of people achieve abstinence release from craving this way.

Relapse prevention is desirable. Knowing that most relapses are associated with three high-risk situations helps: 1) frustration and anger, 2) social pressure, and 3) interpersonal temptation. Learning to cope in an effective and healthy way with frustration and anger may help prevent relapse. This usually means developing interpersonal skills to cope with not just these but other unpleasant feelings; group therapy and individual counseling are usually helpful with this. Social pressure is particularly challenging for recovering persons who have spent a great deal of social time involved with others who were also using. Developing alternative social activities is a painstaking process and minimizing the temptation to run with the old crowd takes tremendous effort. Moreover, learning to respond in an emotionally comfortable and effective manner when tempted to drink by another person requires developing new skills: many, many recovering people literally never said no to an offer to drink or get high before. It takes getting used to. Following a series of client relapses in my practice I wrote the following song/poem concerning relapse:

Relapse
By Tim Conley

It’s easy to get lazy, when the pain goes away
Memories growing hazy, of the price we have to pay
Like children who will wander, from the safety of a home
A never ending nightmare, waking up and all alone.....
It’s crazy to go easy, on the things that keep us sane
To look and find a reason, to turn and walk away
Feeling like we’re better, like our wounded mind has healed itself somehow
And even though we hate it, turning back beneath that cloud
People who would love us lose - leaving in the guilt regrets and shame
Lost somewhere so far between, believing lies and feeling all the pain
Relapse to the bottle, to the wickedness and hollow place inside
Wandering in madness, from the spirits poured within you can not hide...
It’s easy to get lazy, when the pain goes away
Memories growing hazy, of the price we have to pay

Relapse in recovery is often a cold and lonely nightmare for the addict. It is a survivable experience and may be used to drive home the seriousness of their addictive disease. The prescription following relapse always includes a recommendation to increase the amount of daily/weekly time spent on recovery related activities: meetings, counseling, self-help book reading, exercise, etc. It is always possible to relapse to a condition of recovery as well.

Dr. Conley is a Certified Addiction Specialist with the American Academy of Health Care Providers in the Addictive Disorders, and associate clinical professor at Wurzweiler School of Social Work at Yeshiva University. Learn how you can support those in recovery with the online Master of Social Work from Yeshiva University and its Joint MSW and Credentialed Alcohol and Substance Abuse Counselor (CASAC) Credentialing program.

(1) Some factual material for this article came from the NIAAA publication: Relapse and Craving: Alcohol Alert: 6 PH 277