WCSAD | Focus on Patients’ Unique Needs When Re-Conceptualizing Relapse Prevention

The industrywide rate of relapse among patients being treated for addiction is 60%—a figure that is cause for concern, JD Kalmenson, CEO of Montare Behavioral Health, told West Coast Symposium on Addictive Disorders attendees in a session presented Sunday.

“Despite immense resources poured into addressing this epidemic, the success rate is consistently below 40%,” Kalmenson said. “It’s obviously something that demands our attention, and we have to realize what we are failing to discern that is causing such results.”

One of the biggest reasons for relapse, Kalmenson explained, is a blanket approach to recovery used by many practitioners that fails to take into account nuances around usage patterns, substance use severity, and causation.

“When that level of general ambiguity is the standard, we will continue to see the unforgivable 60% relapse rates,” he said.

Kalmenson and Tiffany Dzioba, PsyD, LMFT, Montare Regional Director of Clinical Services, shared their vision for addiction recovery that puts an emphasis on recognizing patients’ unique triggers and cravings, and tailoring an approach to addressing those factors. Kalmenson chronicled a series of case studies in which 3 patients exhibited similar substance use, but noted that each presented significant differences in their pathways to and causations of substance use, necessitating different treatment plans.

There are 3 general pathways to addiction, Dr Dzioba explained:

Intrinsic vulnerability or predisposition: Patients in this category exhibit impulsive behaviors or disorders that can become compulsive. They have a natural inclination toward addiction-like patterns that are marked by executive function deficits, self-regulation problems, and dysregulation in frontal-lobe functions.

“You’re seeing differences in the way someone’s brain works,” Dr Dzioba said. “The neurobiology is different. Temperament is different. Personality is different. There may be executive function and self-regulation issues.”

Access or availability to addictive substances: This second category is marked by the intrinsic properties of drugs and circumstances leading to their use. Examples include patients who were prescribed opioids for an injury or college socialization creating access to recreational drugs. Practitioners should identify the initial point of access or use for patients, as well as the context of their usage.

Desire to self-medicate or cope: Substance use in this category stems from patients experiencing disordered emotions, self-care, or self-esteem. For these patients, substance use is a coping mechanism for dealing with painful or threatening emotions, distress, and suffering because of trauma or trauma memories.

Dr Dzioba said it could also be an attempt to cope with feelings of having an unfulfilling life, a lack of meaning or purpose, or even general boredom.

Along with addiction pathways and causation, clinicians must look at substance use severity, as defined by the following: length of use, age of first use, tolerance, dependence, type of substance(s), route of administration, multiple unsuccessful attempts to stop, and impairment in various life domains.

“Putting all of these things together gives us an idea of how severe what we are dealing with is,” she elaborated.

Projected outcomes or expectations for recovery also are largely depended on levels of substance use, from limited, controlled use at the lower end of the spectrum to full-fledged addiction marked by changes to the brain that are measurable and long lasting. Patients with the “addict brain” require different interventions, Dr Dzioba said.

“As an industry, I think this is one area where we are falling behind in significant ways,” she explained. “We have a plethora of research in the last 10 years that shows there is a disease and changes in the brain as a result of addiction. And yet, in our industry as a whole, we tend to do the same things over and over that do not appreciate or take into consideration how the brain has changed.”

Addiction changes the way one thinks and learns, as well as motivation and behaviors to support ongoing use. The reward center in patients with addiction is overly activated, creating an intense, unnaturally strong activation that kicks in primitive survival instincts, Dr Dzioba said.

Patient assessments should be informed by neuroscience, Dr Dzioba continued, as behaviors, such as denial, minimization of problems related to use, intense cravings, romanticizing use, preoccupation with using, and lying, can resemble resistance or that the patient doesn’t want treatment or to get better. What clinicians are really seeing, though, is addiction in the brain playing out.

The brain is functioning in a manner that takes choice out of the equation, Dr Dzioba said. “Just stopping” is not an option, and willpower alone is not enough.

“This is where oftentimes practitioners struggle because we still have the language and some of the policies in our industry that support thinking that people have control and can make better decisions,” explained Dr Dzioba.

Interventions

Dr Dzioba highlighted 7 interventions that may be appropriate for patients, depending on their pathways to addiction.

Medication-assisted treatment is useful for recalibrating the brain and resetting its reward center. In early recovery, it gives the brain time to heal and controls cravings to avoid relapse while a patient works through therapy.

12-Step or alternative support groups enhance self-efficacy and coping skills, improve motivation, build healthy social networks, and are free and easy to access long term.

Emotions are often triggers for relapse and become intertwined with substance use. Part of treatment process is making clients aware of their emotions and building emotional resilience and distress tolerance, so they can learn how to manage trauma and uncomfortable emotions without needing to rely on alcohol or drugs.

Cognitive behavior therapy allows clients to re-examine their life stories and change their narrative. It replaces self-sabotage with a narrative that promotes health.

Two parts of the healing process are reconnecting patients with others and understanding their spirituality. For some patients, a certain belief system might contribute to more shame, Dr Dzioba said. Help them develop a sense of meaning and purpose, evaluate their value system, and align their values and lifestyle with their authentic self.

Every person close to the client is either effected by the client’s addiction or affects it themselves. Couples and family therapy helps those around the patient understand their role in supporting recovery or inadvertently maintaining the illness.

Relapse prevention is an ongoing process that starts at detox and continues through outpatient treatment, stated Dr Dzioba. Clinicians should work with patients to identify their conditioned cues (both internal and external), develop coping skills, identify protective factors and high-risk situations, and develop structure, schedules, and goals for recovery. Dzioba added that when patients relapse, it is beneficial to conduct a “relapse autopsy” that identifies what has worked in treatment, what hasn’t, pitfalls, and new strategies moving forward.

Reference

Kalmenson, JD and Dzioba, T. Reconceptualizing relapse prevention by addressing patients’ unique triggers and cravings. Presented at: West Coast Symposium on Addictive Disorders; September 29-October 3, 2021; Virtual.