According to most clinicians and the book Relapse Prevention: Maintenance and Strategies in the Treatment of Addictive Behaviors, there is a definitive dividing line between a person experiencing a lapse and a relapse. A lapse refers to a short return to one’s previous behavior and then a self-correction, whereas a relapse refers to a return back to a pattern of behavior following a period of abstinence.
Many individuals in recovery often confuse lapses with relapses. While lapses should be considered signs that one needs to adjust their recovery program, relapses are obviously a more serious issue. Individuals in recovery from substance use disorders should attempt to develop a program that avoids both lapses and relapses. Any attempt to develop such a program should be focused on understanding the major issue that results in individuals experiencing lapses and/or relapses.
The major obstacle associated with unsuccessful recovery from substance use disorders is the tendency for an individual to give in to cravings for drugs or alcohol. Cravings represent programmed response patterns in individuals that occur as a result of conditions in the environment or alterations in mood or emotional state, and result in an urge to return to previous behaviors. Often, cravings appear to come out of nowhere, but they are most likely triggered by some condition in the environment or by some feeling. Environmental conditions that can trigger cravings can consist of factors that were formally associated with drug or alcohol abuse, the experience of stress, or even the experience of success. Emotional states that can trigger cravings can include negative emotions, such as issues with depression or anxiety, or even positive emotions, such as happiness or the feeling of success.
Cravings often represent very vivid and emotionally driven memories that are associated with the pleasant effects that a person once achieved from the drug of choice. These vivid memories are powerful reinforcers that contribute to the continued use of the drug.
Most individuals in recovery will find that even after years of abstinence, they will occasionally experience cravings; however, for most individuals, cravings are strongest in the initial stages of recovery, and their intensity wanes significantly over time.
The types of situations that are responsible for inducing cravings are often referred to as cues or triggers because these situations result in the experience of certain memories, emotions, or physical sensations that were associated with one’s past drug use. Often, these memories are visceral in nature, such that one actually has the subjective experience of feeling how the drug once made them feel as opposed to rationally trying to convince oneself to use the drug. This makes cravings extremely powerful and often results in what is subjectively experienced as a compulsion to use one’s drug of choice as opposed to some rational, logical, internal debate. The internal debate often occurs after the craving has been experienced and one decides whether or not one should act on it. Often, individuals who give in to cravings feel as if they were under compulsion to return to their formal behavior and had lost control.
Triggers and Relapse
Triggers that stimulate cravings for drugs or alcohol come in numerous forms. They can be quite personalized and specific to one’s personal experience (e.g., being with certain people or in certain places where one habitually used one’s drug of choice), or they can be very general in nature and affect a great number of individuals in recovery (e.g., the experience of psychological stress).
Triggers are associated with neurochemical events in one’s brain that are subjectively experienced as powerful urges to begin using one’s drug of choice. There are numerous mental and physiological associations that occur when one is exposed to an environmental or emotional trigger.
Many physiological changes have been documented to occur when one experiences a trigger that leads to a craving, such as increased blood pressure, increased heart rate, and an increase in sweat gland activity. Physiological changes lead to changes in one’s mental state that can include excitement, stimulation, anticipation of reinforcement, and recalling past pleasant associations with the use of the drug that often include actual feelings and visual images.
Triggers may consistently cue cravings or may be very inconsistent in their ability to induce cravings. In addition, because cues can occur over a variety of different situations and are often inconsistent and unpredictable, many individuals who relapse have the perception that the trigger just “came out of nowhere” and upon reflection are very surprised and confused following a lapse or relapse. Attempting to identify and control triggers or drug-related cues is a major part of relapse prevention; however, since everyone in recovery will experience a craving at one time or another, it is important to address any particular triggers that one may experience and also develop a strategy to deal with cravings.
Addressing Cravings and Triggers
Relapse prevention therapy can rely on two approaches to addressing cravings. These strategies consist of the use of medications or behavioral interventions.
Medications to address cravings: There are numerous medications that can be used to address cravings for individuals in recovery.
- Naltrexone (e.g., brand name ReVia) was originally used to address cravings for opioid drugs but can also be used for other drugs, including alcohol.
- Other opioid replacement medications, such as methadone or Suboxone, can assist in controlling cravings for opioid drugs.
- Acamprosate (brand name Campral) is an anticonvulsant medication that is often used to address cravings that result in issues with insomnia, restlessness, depression, or anxiety.
- Topiramate (brand name Topamax) is an anticonvulsant medication that has been used to address cravings for individuals with cocaine or alcohol abuse issues.
- Baclofen (brand name Gablofen) is a muscle relaxant medication that is used to control cravings for alcohol.
- In addition, the drug Antabuse (disulfiram) may reduce cravings in individuals who use it and drink alcohol since when this occurs, the individual will become violently ill. Individuals may develop an association with these feelings of nausea with their cravings for alcohol, and this may reduce the intensity and frequency of cravings, even though the drug is not designed to directly reduce cravings. The principle on which this medication works is based on the notion of aversive conditioning, a form of punishment.
Medications cannot address triggers; they can only reduce the cravings associated with these cues. Behavioral interventions can address both triggers and cravings.
Behavioral interventions: Behavioral interventions to address cravings are primarily derived from the principles of Cognitive Behavioral Therapy (CBT). CBT is a form of psychotherapy that combines both cognitive psychology and behavioral psychology. The basic assumption is to address an individual’s dysfunctional beliefs or thoughts, challenge them, change them, and then help the individual change their behavior.According to the book Improving Outcomes and Preventing Relapse in Cognitive Behavioral Therapy, some of the principles associated with approaches to addressing cravings from a cognitive-behavioral perspective include:
- Educating the individual regarding cravings by emphasizing that the experience of cravings is a normal occurrence in recovery and that cravings are not signs that one is failing in recovery or that one is weak
- Assisting the person to understand generalized triggers that occur in nearly everyone in recovery
- Assisting the person to identify and target their own subjective triggers
- Developing a formal strategy to avoid triggers when possible
- Helping the individual understand the signs and symptoms of cravings in order to be prepared to identify situations where one is vulnerable to a lapse or relapse
- Developing personalized coping strategies to deal with cravings when they occur, such as helping the individual to focus on the negative aspects of their substance abuse as opposed to the pleasurable experiences that their drug use gave them
- Developing a strong social support network that can help the individual to recognize signs that one may be vulnerable to relapse and to develop a plan to address the issue
Behavioral approaches to relapse prevention offer numerous techniques to help a person develop self-confidence and coping skills, and deal with cravings. When combined with family and peer support and with social support group programs like 12-Step groups, these approaches can support one another and become powerful tools to avoid relapse.
Individuals can also benefit from the use of medications and behavioral interventions as part of their relapse prevention therapy program. Using both available medications and behavioral interventions can increase the effectiveness of one’s relapse prevention program as well as reduce the risk that one will suffer lapses that can evolve into full-blown relapses.
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When people in recovery experience cravings, they are time-limited events. They typically peak rather rapidly, and within several minutes, they have weakened considerably.
Several strategies taught in relapse prevention therapy can help a person ride out cravings.
- Understand that cravings are time-limited. Cravings generally come on very quickly and are very intense. They are often very uncomfortable and feel like they will last forever; however, if one can endure the craving or learn to deal with it for 15-20 minutes, it will generally dissipate. The key is to understand that cravings do not last forever and not giving into them will not result in any significant consequences, even though one may feel as if it is crucial to their sanity that they give in. The first strategy often taught in relapse prevention programs is to delay giving in to them.
- Distraction often works. When individuals in recovery experience cravings, they are often taught to use some form of distraction, such as performing some other activity or engaging in meditation to take up time and allow the craving to dissipate.
- Try stress management techniques. The classic approach to dealing with cravings is to learn to implement stress management techniques that include diaphragmatic breathing, muscle relaxation, meditation, and visualization.
- Learn urge surfing. Urge surfing consists of addressing cravings by concentrating on all the negative aspects of one’s drug use. Instead of thinking of all the positive effects associated with using drugs or alcohol, the individual concentrates on the negative ramifications that suffered as a result of their substance use. Many 12-Step groups referred to this method as “playing the tape through.” This saying indicates that individuals who experience cravings should concentrate on all of the aspects associated with their former use of drugs or alcohol, including both the initial positive effects and the long-reaching negative effects.
- Do not panic. Often, individuals become emotionally distraught or upset when they experience cravings. Instead, decatastrophize the situation, use one of the above techniques, and remember that the craving will dissipate.
Some other approaches to deal with cravings and triggers include:
- Exercise: Becoming involved in an exercise program has numerous benefits for individuals in recovery. Exercise actually stimulates the same area of the brain that is activated when one uses most drugs of abuse, and this can help to replace cravings for drugs with positive activities.
- Meditation: Many relapse prevention recovery programs incorporate aspects of meditation into their interventions. Meditation can be a useful method to deal with cravings and stress.
- Diet: Eating healthy can counteract many triggers that elicit cravings, such as fatigue, lethargy, energy loss, and even stress.
- Keeping busy: Boredom is a major trigger for most individuals in recovery. Learning to keep occupied, but not overly occupied (as this may lead to increased issues with stress) can reduce cravings. Individuals in recovery are encouraged to maintain an active schedule that includes scheduled breaks and sufficient rest and relaxation.
Recognizing the Signs of Relapse
It is important to be aware of the general signs that an individual may be headed for relapse. Some of these signs include:
- Continuing behaviors that were once associated with previous substance abuse, such as hanging out with people who use drugs or alcohol, frequenting places where one commonly used drugs or alcohol, etc.
- Beginning to think that using just one time or having one drink is acceptable behavior (Every relapse begins with the first instance of reusing.)
- Romanticizing one’s past drug or alcohol use
- Beginning to think that one is “cured” of their substance abuse issues
- Missing therapy sessions or skipping social support group meetings
- Not listening to others who are involved in one’s recovery, such as therapists, physicians, peers in recovery, friends, and family members
Relapse prevention therapy can consist of the use of medications, behavioral interventions, or combination of both. Medications can directly deal with the physical aspects of cravings, whereas behavioral interventions can deal with cravings, prepare one to deal with triggers that can induce cravings, and offer a plan to deal with the common triggers and stressors that occur during recovery.
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