5 approaches that work in relapse prevention
Relapse rates for addiction are notoriously high, falling between 40 and 60 percent according to the National Institute on Drug Abuse. The relapse rate is even higher among young adults, particularly those who began using drugs in early adolescence, have weak social support networks, abuse multiple drugs, or have co-occurring mental health disorders. These youth lack most or all of the positive predictors of success, such as academic achievement and a healthy peer group, and have many of the factors that increase the risk of relapse.
David Sack, M.D., is board certified in Psychiatry, AddictionPsychiatry, and Addiction Medicine. Dr. Sack currently serves as CMO of Elements Behavioral Health, a network of addiction treatment centers that include Promises Treatment Centers, The Ranch, and The Recovery Place. After receiving his medical degree from Rush Medical College, he completed his residency in Psychiatry at the UCLA-Neuropsychiatric Institute. He served as a senior clinical scientist at the National Institute of Mental Health where his research interests included affective disorders, seasonal and circadian rhythms, and neuroendocrinology.
Editor: Saad Shaheed
Despite the acuity of their problems, most treatment programs group these individuals with young adults who got involved with drugs in college and whose primary issue is substance abuse. Unsurprisingly, they spend many of their formative years going in and out of drug rehab.
How do we help these highly relapse-prone young adults move not just into recovery but also autonomous adulthood? Thanks to scientific research, we have a good idea of what works and what doesn’t. Unfortunately, some of the most effective approaches are widely underutilized.
What Doesn’t Work: Harshly confrontational, boot camp-style programs that get results by using coercion. These programs further damage young people’s self-esteem and have particularly high rates of relapse after discharge.
“Although young people may appear to comply, they haven’t internalized the need for change,” explains Jo-Anne Bliss, Psy.D., the clinical director at The Recovery Place drug rehabilitation center in Florida and creator of a specialized program for young adults with a history of relapse. “They complete treatment to appease the courts or their parents, but they go right back to drinking and using afterward.”
What Works: Helping young people develop the internal motivation to change. This can be achieved by aligning with them and helping them find solutions that make sense to them. Rather than silencing them, treatment is most effective when young people feel safe opening up and allowing themselves to be vulnerable.
What Doesn’t Work: Programs that focus exclusively on substance abuse. As many as 70 percent of the young adults Dr. Bliss works with having psychiatric disorders such as depression, ADHD, oppositional defiant disorder, or post-traumatic stress disorder. Leaving these issues unaddressed or failing to help young people see how all of these issues relate to their substance abuse dramatically increases the risk of relapse.
What Works: Integrated dual diagnosis treatment that addresses substance abuse and co-occurring mental health disorders at the same time. Many treatment centers claim to treat dual disorders but lack the staff and resources needed to treat these intricately intertwined issues. Effective dual diagnosis treatment consists of a coordinated group of professionals from multiple disciplines working with clients at the same time, in the same setting, to seamlessly deliver substance abuse and mental health treatment.
What Doesn’t Work: Programs that expect relapse-prone young adults to develop new skills in the same way as other people their age.
“A lot of programs take it for granted that 20-somethings have certain fundamental skills when, in fact, many do not,” Dr. Bliss explains. “Instead of developing these skills, they spent their teenage years using drugs. They come to treatment in a 23-year-old’s body but emotionally they’re stuck at 13.”
What Works: When these young adults arrive in treatment, they need to learn basic skills from the ground up. Many programs present the same old videos, lectures, and workbook assignments that haven’t worked in the past, and expect a different result. Many young adults, especially those with multiple relapses behind them, need a different approach – one that includes not only education but also an experiential, interactive process for improving their functioning in key interpersonal domains.
Any measure of success at work or school requires the ability to manage emotional responses, particularly frustration and anger. In preparation for life in recovery, young people also need to be able to ask for help and respond to requests for service. Thus, the primary goals of treatment include developing distress tolerance and communication skills.
“We use a three-pronged approach designed to treat the whole person, including thoughts, feelings, and behaviors,” says Dr. Bliss. “Challenging young people’s thoughts and values help provide the rationale for wanting to learn new skills, make better choices, and deal with anger in more socially appropriate ways.”
What Doesn’t Work: Treating addiction as an acute illness. There is a widespread misconception that drug rehab is a “cure” for addiction. In reality, residential treatment is a stepping stone; it’s the beginning of recovery, not the end.
What Works: Long-term treatment that includes support groups, therapy, outpatient treatment, or a sober living home, preferably for at least one year following discharge from rehab. Studies have shown that the risk of falling into the relapse-rehab cycle is greatly reduced with long-term treatment.
“Addiction is a chronic, relapsing disease that requires avoiding triggers, engaging in social support and treating co-occurring psychiatric disorders, not for just 30 to 45 days in rehab but for life,” says Ash Bhatt, MD, who is board-certified in child, adolescent and adult psychiatry as well as addiction medicine, and the medical director at The Recovery Place.
What Doesn’t Work: Failing to prescribe medications that reduce the risk of relapse. Many treatment programs pay lip service to the medical interventions that are available for alcoholism and opiate addiction, but they have a relative lack of confidence in or enthusiasm for using these medications to aid in early recovery.
Particularly when individuals have a history of relapse, some treatment providers are quick to prescribe long-term Suboxone before exploring other options. Although it can be extremely useful during detox and as a maintenance medication in certain cases, Suboxone can be habit-forming.
“Some of the young people we treat have been through multiple rehab programs before coming to us and have never been offered medications other than Suboxone,” says Dr. Bhatt. “If the first medication young people are offered is Suboxone, with little or no explanation of the ramifications, we deprive them of the opportunity to achieve a full recovery.”
What Works: A number of non-addictive medications have proven safe and effective in clinical studies to reduce cravings that often lead to relapse. These include naltrexone, which blocks the “high” for individuals with alcoholism or opioid abuse, and acamprosate, which helps to prevent alcohol relapse by decreasing the desire to drink and repairing the damage to the brain caused by alcohol abuse. These medications, among others, help people stay engaged in treatment and allow them to get right back into their recovery program if they do relapse.
With a chronic, progressive disease like addiction, a successful recovery doesn’t necessarily mean a perfect recovery. It means equipping people with the tools they need to pause, reach out for help, and get back into their recovery program if they do slip back into old habits. We know there are effective ways to prevent relapse even in the most challenging circumstances. What we need to do now is make them widely available to the people who need them most.