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What did we miss?

July 28, 2010
by Mark Sanders, LCSW, CADC
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Exploring these often undetected areas can improve treatment for chronic relapsers

Chronic relapsers often have a hidden problem that is difficult to detect and that leads to continuous relapse. These hidden problems require careful re-evaluation if the client is to move toward a path of recovery. This article outlines seven areas of evaluation for chronic relapsers as well as implications for recovery management.

1. Failure to assess for other addictions
We can begin with the number one drug of addiction: nicotine. Nicotine kills more people than alcohol and all illicit drugs combined. In addition, clients who smoke cigarettes are three times more likely to return to their drug of choice than are clients who do not smoke.

There are also clients who routinely combine drinking and cigarette smoking. For them, smoking can trigger an urge to drink. For clients using illicit drugs that require the lighting of a match, the smoking of a cigarette can trigger cravings for heroin and cocaine use, for example.1

There is also a strong link between process addictions (addiction to mood-altering behaviors such as gambling, sex, etc.) and substance use disorders. Many chemically dependent clients who stop using drugs substitute process addictions for their drug use, and vice versa.2 Clinicians should assess for process addictions with chronic relapsers.

2. A hidden psychiatric disorder
Approximately 50 percent of chemically dependent clients have a co-occurring mental illness. Often, psychiatric disorders are difficult to detect and might include phobias, obsessive-compulsive disorder, personality disorders, anxiety disorders and depression. The difficulty in detection results partly from the fact that drug use can mimic many forms of psychiatric disorders, and withdrawal from drug use can mimic symptoms of mental illness. In addition, many professionals working in the addiction field are not routinely trained in assessing co-occurring disorders.

In an ideal world, all chemical dependency programs would employ a consulting psychiatrist who routinely screens for psychiatric disorders. This is especially important with chronic relapsers.

3. Unresolved grief
There is a strong relationship between unresolved grief and relapse, as many clients medicate the pain of grief with use of alcohol and other drugs.3 For chronic relapsers, clinicians should regularly assess for unresolved grief. Losses that cause such grief include divorce; death; ambivalent losses; loss of custody of children due to drug use; miscarriages and stillborn births (often exacerbated by drug use); and loss of relationships in active addiction.

4. Addictive and abusive relationships
It is important to assess relapse patterns with chronic relapsers. Many clients go from drug use to addictive relationships, involving the use of relationships in a similar fashion to the way they were using drugs—to escape and avoid problems and feelings. Addictive relationships are characterized by extreme jealousy; enmeshment; smothering; abuse; multiple arguments and breakups; and staying in these relationships despite adverse consequences.4

Domestic violence also should be explored, as there is a strong relationship between domestic violence and substance abuse. Research reveals that it is particularly difficult for chemically dependent women to leave relationships that involve domestic violence, because active addiction makes it difficult for a person to mobilize herself.5

5. Post-traumatic stress disorder
The risk of substance use disorders is common among chemically dependent clients who are female, who were exposed to trauma as children, who have done time in prison, or who are war veterans. There is a strong relationship between post-traumatic stress disorder (PTSD) and relapse.6

6. Enmeshment in a drug subculture
Many clients who use drugs that carry the greatest stigma and legal sanctions, such as crack cocaine, methamphetamine and heroin, often find themselves migrating toward “tribes.” These are groups that use the same drugs, provide social support to the user, and often have been shunned by the rest of society. They often have their own language, rituals, styles of dressing, etc. They include motorcycle gangs that use methamphetamine, street gangs, rave party attendees who use Ecstasy, etc. These groups can sometimes have a stronger hold on clients than the drugs they are using, and clients are more likely to use drugs when they are around the group.7

7. Recovery support
It is often helpful to assess the amount of recovery support for chronic relapsers in their natural environment. This support is particularly important in the first 90 days after the client has been discharged from treatment, because most relapses occur within that window. In addition, for those clients who are linked to 12-Step and other mutual aid groups, the great majority of those who drop out do so within the first 90 days of leaving treatment.8 Many clients relapse because they lack recovery support in their natural environment. Recovery management could offer a solution to this lack of support and also address the aforementioned assessment areas.

Recovery management
Recovery management is an emerging model geared toward supporting clients’ recovery across the lifespan. There are many chemical dependency programs that treat aftercare as an afterthought; thus, the majority of clients leaving treatment do not get the amount of recovery support they need.8