A 65-year-old male, whose spouse recently died, continues to battle alcohol misuse and now reports a relapse, consuming a quart of vodka each day. He suffers from alcoholic hepatitis and cirrhosis, and his physician warns that without cessation he faces liver failure.
Addiction is a neuropsychiatric condition that entails compulsion and loss of control, leading to painful consequences for both patients and those around them. It is now understood as a chronic health condition, akin to diabetes and congestive heart failure, where patients can be prone to flare-ups of the illness, especially in times of stress.
Understanding Recurrence of Use
Recurrence of use is always cloaked in shame, and doctors can soften shame by conveying a sense of blameless accountability. This facilitates the trusting and caring connection needed with patients to promote honesty and re-engagement in recovery. Many patients will experience “all or none” thinking, believing that they are a failure, and it’s essential to normalize episodes of return to use as flare-ups of a chronic illness.
Doctors can frame these episodes as opportunities to learn and grow, and celebrate previous episodes of recovery. This is critical to preempt the “abstinence violation effect,” in which patients are driven by their shame and hopelessness into unmitigated use. The mantra is “patience, positivity, and persistence.” To succeed in recovery, patients must be able to fall down and get up again, with their doctor’s support and guidance.
When a patient comes in after recurrence, doctors should connect with curiosity rather than judgment, showing unwavering positive regard, acceptance, and affirmation. The goal is to engage in collaborative, compassionate inquiry to gain a deeper understanding of the sequence of events that led to the recurrence.
Responding to Recurrence
Doctors should analyze the situation, trying to discern internal and external triggers and the ways patients attempted to cope with these triggers. This is part of a recurrence analysis, looking at factors contributing to the sequence: vulnerabilities → triggers → thoughts/emotions → cravings → decisions → use → consequences.
Addressing immediate safety concerns is also important, including intoxication, withdrawal, overdose risk, suicidality, medical complications, polysubstance use, and loss of tolerance. Doctors should ensure patients have naloxone available in the event of potential opioid exposure and provide or arrange for appropriate withdrawal management or refer to a higher level of care when indicated.
Co-creating a recovery plan with the patient is essential, allowing doctors to modify the plan based on the recurrence analysis. This plan should start by identifying positive elements to build on, keeping all recovery care planning strengths-based rather than pathology-based. Doctors should ask patients what they think needs to be changed and allow them to design their own recovery plans as much as possible.
Recurrence should trigger reconsideration of the level of care, and some patients may need only prompt outpatient adjustment, while others may need intensive outpatient, partial hospitalization, residential, withdrawal management, or hospitalization. Doctors should follow up promptly with patients suffering a recurrence.
Modifying the Recovery Plan
Combining compassion with accountability, safety with autonomy, and hope with persistent problem-solving is best practice. The care of patients with addiction involves collaborative, adaptive, iterative planning and care. Just as when treating patients with diabetes or heart failure, we cannot expect perfection in recovery from addiction.