Supported in part by Arkansas Blue Cross and Blue Shield

1. Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32239-30782

2. Relapse Prevention for the Treatment of Substance Use Disorders Michael A. Cucciare, PhD Associate Professor, Department of Psychiatry Psychologist, Women’s Mental Health Program University of Arkansas for Medical Sciences

3. Disclosures • Dr. Cucciare has no disclosures to report

4. Overview • Describe the components of Relapse Prevention for the treatment of substance use disorders • Discuss why it was developed and how it fits in the care of patients with substance use disorders

5. What is Relapse Prevention? • A counseling approach to help patients, who have received treatment for a substance use disorder, maintain treatment gains • Cognitive behavioral techniques that improve retention, accessibility, and implementation of adapting ways of coping following treatment • Developed in response to the observation that people (once abstinent) often relapsed after treatment • Long-term relapse rates in treated samples who obtain remission range from 20%-80% Moos, R. H., & Moos, B. S. (2006). Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction, 101(2), 212-222

6. What is Relapse Prevention Cont’d..? • It is difficult for patients to implement learned skills from treatment into the “real world” to maintain gains they may have acquired in treatment • Challenges for patients in maintaining gains include: • Forgetting the skills, techniques, and information they learned in treatment; lose of motivation; entering environments that do not support new skills • e.g., UAMS Women’s Mental Health Clinic • Relapse prevention was designed to fill this gap in care • now viewed as a full program of treatment • Helpful for problems often viewed as issues of self-control (smoking, substance use, sexual harassment/offending)

7. Treatment Components • Relapse prevention helps pts predict and anticipate high-risk situations leading to substance use • High-risk situations is something that happens to make us want to use alcohol or drugs when we have made a commitment not to. • Also helps patients identify pathways (triggers such as negative emotions) to high-risk situations and cope effectively with these pathway elements to prevent or stop lapses in substance use Brunswig, K. A., Sbraga, T. P., & Harris, C. D. Relapse Prevention. In O’Donohue, W., Fisher, J. E., & Hayes, S. C. (eds.). Cognitive Behavior Therapy: Applying Empirically Supported Techniques in Your Practice, 2003; John Wiley & Sons

8. Examples of High-Risk Situations • We deny we’re addicted – we’re in control, drugs don’t control us and we can stop at any time • We start romancing the high – exaggerate the good times and minimize problems • We get around alcohol or drugs – we get around people, places and things that make us want to use

9. 1. Psychoeducation and Planning • Difference between a “lapse” versus “relapse” • Get safe as soon as possible • Lapse or relapse as a learning opportunity • These are expected! • Planning for lapse/relapse • What is their role in their recovery, role of others supportive of their recovery (sponsor, significant others, therapist, physician)? • “Who are three significant others who have an investment in your recovery and what is each of them supposed to do if a lapse/relapse occurs?”

10. 2. Identifying High Risk Situations • Personalized assessment of situations that put pt at risk for substance use • prior situations, situations pt is likely to encounter • Assessment of thoughts, feelings, and behaviors that occur before, during, and after substance use • Teach pt to recognize themes and commonalities across their high-risk situations to understand contributors to their substance use

11. 3. Identifying Unhelpful Ways of Thinking • Identify self-statements that can serve as “permission givers” for engaging in substance use • Serve to bring patient from trigger to high-risk situation -“I can control my drug use” or “I’m not using as much as I used to” -“I’m only attractive when I’m thin [drugs kept her from eating]” -“I don’t want to be alone [drugs enhance intimacy]” -“I need a break [from stress]” Gorski T. T., et al. (2000). Relapse Prevention Counseling Workbook: Practical Exercises for Managing High-risk Situations. Herald Publishing House, Independence Press.

12. Identifying Unhelpful Ways of Thinking cont’d… • Pts are assisted in examining how their thinking affects their (or likelihood of) drug use and helped to challenge their thinking • This includes analyzing the validity of their self-talk; develop skills to challenge and dispute thoughts; and practice applying these skills in “real world” • e.g., What does it mean to control your drug use? How well has that worked in the past? • e.g., Pt wants to be in a healthy relationship, not just “thin”

13. 4. Seemingly Irrelevant Decisions (SIDs) • Behaviors that may not lead directly to high-risk situations but are early in the “chain” of decisions that can put the pt in those situations • e.g., Pt reports high likelihood of using drugs when with her boyfriend. The SID could be agreeing to pick up boyfriend from mall • Goals is to teach pt. to identify SIDs and there role in contributing to drug use, and apply coping skills to reduce probability of being in high-risk situations

14. 5. Problem of Immediate Gratification • Disconnect between pursuing immediate gratification and considering future negative consequences of using drugs • Impulsivity, higher delayed discounting • Decision matrix – concise written representation of positive and negative outcomes for engaging or not engaging in drug use + “I need to use to get a break from all of this” + “drug x is really not my problem drug” • “don’t want my husband, kids, mother-in-law to be disappointed in me” • “I know what drug use leads to, I don’t want to go back there” Robles et al, (2011). Delay discounting, impulsiveness, and addiction severity in opioid-dependent patients. Journal of Substance Abuse Treatment, 41 (4), 354-362.

15. 6. Abstinence Violate Effect • Pt does not cope effectively in a high risk situation, lapses, and then determines the lapse is so severe that they might as well fully relapse – I call this the “To heck with it” principle • Focus of treatment is on describing and predicting these situations, learning/applying effective skills to get safe and/or limit negative consequences • Pts who recognize that lapses are normal and expected are less likely to use a minor instance of the behavior as a rationale for relapse

16. 7. Maintenance and Aftercare • Faded sessions, e.g., every two weeks, every month, as-needed • Help pt understand when they might need a booster session • Lifestyle imbalance, unable to or difficulty using coping skills • Booster sessions as needed • Update and review relapse prevention plan with new information

17. Is it Effective? • Metal analysis showed that 58% of substance use disorder patients receiving relapse prevention had better outcomes than comparison conditions (active treatment) • Alcohol • Cocaine • Polydrug • Marijuana • Opiates Magill, M., & Ray, L. A. (2009). Cognitive-Behavioral Treatment with Adult Alcohol and Illicit Drug Users: A Meta-Analysis of Randomized Controlled Trials. Journal of Studies on Alcohol and Drugs, 70 (4), 516-527.

18. Conclusions • Relapse prevention is effective for helping pts maintain abstinence over the longer-term • Helpful for teaching pts skills and strategies for managing their exposure to high-risk situations and reducing negative consequences of lapses/relapse

19. Questions/Comments?

20. Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 32239-30782

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