MANAGING RELAPSE AMONG OUR COLLEAGUES

1. This Powerpoint� slide presentation was prepared by Dr. Schoener in June, 2003 for delivery at a conference sponsored by The City of Detroit Health Department entitled �Two Sides of the Same Coin. Exploring the Relationship Between HIV and Substance Use.� The audience was comprised of clinical service providers for persons with HIV and substance use disorder.This Powerpoint� slide presentation was prepared by Dr. Schoener in June, 2003 for delivery at a conference sponsored by The City of Detroit Health Department entitled �Two Sides of the Same Coin. Exploring the Relationship Between HIV and Substance Use.� The audience was comprised of clinical service providers for persons with HIV and substance use disorder.

2. Relapse is a very common term. As a result, its meaning seems to have broadened and, in some cases, lost its original denotative value. This definition, along with the fundamental principles of relapse, helps to focus the discussion. Examples of each statement should be elicited from the audience.Relapse is a very common term. As a result, its meaning seems to have broadened and, in some cases, lost its original denotative value. This definition, along with the fundamental principles of relapse, helps to focus the discussion. Examples of each statement should be elicited from the audience.

3. Elements involved in the process of RELAPSE can be appreciated with this diagram. People often lose control of their behavior momentarily for a variety of internal and/or external reasons (i.e., LAPSE into transient behavior that is hazardous or harmful to them) and from this point they may proceed further into RELAPSE or return to a committed state of ABSTINENCE. In either case, crossing this barrier can be a signal event. Marlatt has referred to it as the Abstinence Violation Effect. Returning to ABSTINENCE is difficult but can bring with it a greater sense of commitment. On the other hand, once an individual has LAPSED, they well may lose their sense of self efficacy and commitment to sobriety. When RELAPSE occurs, it may be sustained for a period of time, but inevitably it will proceed to further deterioration or COLLAPSE. It is possible for the individual to return to ABSTINENCE from the state of RELAPSE or COLLAPSE, usually with the assistance of family, friends or helping professionals. Elements involved in the process of RELAPSE can be appreciated with this diagram. People often lose control of their behavior momentarily for a variety of internal and/or external reasons (i.e., LAPSE into transient behavior that is hazardous or harmful to them) and from this point they may proceed further into RELAPSE or return to a committed state of ABSTINENCE. In either case, crossing this barrier can be a signal event. Marlatt has referred to it as the Abstinence Violation Effect. Returning to ABSTINENCE is difficult but can bring with it a greater sense of commitment. On the other hand, once an individual has LAPSED, they well may lose their sense of self efficacy and commitment to sobriety. When RELAPSE occurs, it may be sustained for a period of time, but inevitably it will proceed to further deterioration or COLLAPSE. It is possible for the individual to return to ABSTINENCE from the state of RELAPSE or COLLAPSE, usually with the assistance of family, friends or helping professionals.

4. This Cognitive-Behavioral Therapy model of Relapse is taken from a chapter by Marlatt, Barrett and Daley,� Relapse Prevention�, in the Textbook of Substance Abuse Treatment edited by Galanter and Kleber, Amer Psych Press, Wash. DC, 1999. It should become clear is describing the sequence of events in this diagram how the experience of coping behavior (effective or ineffective) establishes the mental set for/against RELAPSE. If time allows examples would be helpful, especially those elicited from the learners.This Cognitive-Behavioral Therapy model of Relapse is taken from a chapter by Marlatt, Barrett and Daley,� Relapse Prevention�, in the Textbook of Substance Abuse Treatment edited by Galanter and Kleber, Amer Psych Press, Wash. DC, 1999. It should become clear is describing the sequence of events in this diagram how the experience of coping behavior (effective or ineffective) establishes the mental set for/against RELAPSE. If time allows examples would be helpful, especially those elicited from the learners.

5. When one thinks about the determinants of relapse, first thoughts turn to etiology. While the research on this has not established any absolute causal relationships, we can speak of RISK FACTORS that have shown a high degree of association with RELAPSE. This list includes empirical and intuitive findings.When one thinks about the determinants of relapse, first thoughts turn to etiology. While the research on this has not established any absolute causal relationships, we can speak of RISK FACTORS that have shown a high degree of association with RELAPSE. This list includes empirical and intuitive findings.

6. Once we have understood the predisposing factors of RELAPSE, we should develop a working knowledge of the precipitating factors, cues, or TRIGGERS. Important facets of TRIGGERS are that they are a) unique and individual, b) internal (feelings or thoughts), or c) external (persons, places, paraphernalia.) HIGH RISK conditions set the stage (lower the threshold) for TRIGGERS or may themselves be TRIGGERS. Once we have understood the predisposing factors of RELAPSE, we should develop a working knowledge of the precipitating factors, cues, or TRIGGERS. Important facets of TRIGGERS are that they are a) unique and individual, b) internal (feelings or thoughts), or c) external (persons, places, paraphernalia.) HIGH RISK conditions set the stage (lower the threshold) for TRIGGERS or may themselves be TRIGGERS.

7. If time allows, a discussion of the roles that enabling �defense� mechanisms play in relapse would be useful. This slide and the next one present the more common mechanisms employed by substance abusers (and all of us to various extent.) Following the definition, elicit examples in which these are employed. If time allows, a discussion of the roles that enabling �defense� mechanisms play in relapse would be useful. This slide and the next one present the more common mechanisms employed by substance abusers (and all of us to various extent.) Following the definition, elicit examples in which these are employed.

8. Continue the discussion from the last slide.Continue the discussion from the last slide.

9. To detect impairment (including relapse), one must be aware of the most common behavioral indicators--both signs and symptoms. These may be apparent in all areas of the individual�s life. This slide presents common indicators in the work setting. Remember that many of these signs and symptoms may be due to other factors/conditions. This list and those on the following slides are adapted from a chapter by Talbot, Gallegos and Angres in Principles of Addiction Medicine, second edition (1998), edited by Graham and Schultz, for ASAM.To detect impairment (including relapse), one must be aware of the most common behavioral indicators--both signs and symptoms. These may be apparent in all areas of the individual�s life. This slide presents common indicators in the work setting. Remember that many of these signs and symptoms may be due to other factors/conditions. This list and those on the following slides are adapted from a chapter by Talbot, Gallegos and Angres in Principles of Addiction Medicine, second edition (1998), edited by Graham and Schultz, for ASAM.

10. Signs and symptoms of impairment at home roughly parallel those in the workplace. These may not be readily apparent to coworkers, except through discussion. Often, men will manifest these behaviors at home before they do so in the workplace. Signs and symptoms of impairment at home roughly parallel those in the workplace. These may not be readily apparent to coworkers, except through discussion. Often, men will manifest these behaviors at home before they do so in the workplace.

11. When these become obvious to coworkers/colleagues, these behavioral/functional indicators signal an advanced stage of impairment When these become obvious to coworkers/colleagues, these behavioral/functional indicators signal an advanced stage of impairment

12. This list presents a pot pouri of physical signs/symptoms that also suggest an advanced stage of impairment. These include signs of intoxication, withdrawal and behaviors associated with substance abuse. Eye signs are particularly useful because they are unique for each drug class and can be detected without much difficulty. Tremors are indicative of alcohol/depressant withdrawal or excessive intoxication with stimulants. Loss of motor coordination (unsteadiness) is a sign of alcohol intoxication. Alcohol is excreted in the exhaled air and can be detected rather easily only a few feet away. Sometimes, people will try to cover their alcoholic breath with al lot of breath mints. Handwriting is rather individualized, but deterioration should be the clue here. �Broken beeper syndrome� refers to the excuse that people may offer for their inability to respond to a page. Self medication is a problem that occurs mainly with people who have prescriptive authority (doctors) or facile access to drugs. This list presents a pot pouri of physical signs/symptoms that also suggest an advanced stage of impairment. These include signs of intoxication, withdrawal and behaviors associated with substance abuse. Eye signs are particularly useful because they are unique for each drug class and can be detected without much difficulty. Tremors are indicative of alcohol/depressant withdrawal or excessive intoxication with stimulants. Loss of motor coordination (unsteadiness) is a sign of alcohol intoxication. Alcohol is excreted in the exhaled air and can be detected rather easily only a few feet away. Sometimes, people will try to cover their alcoholic breath with al lot of breath mints. Handwriting is rather individualized, but deterioration should be the clue here. �Broken beeper syndrome� refers to the excuse that people may offer for their inability to respond to a page. Self medication is a problem that occurs mainly with people who have prescriptive authority (doctors) or facile access to drugs.

13. The challenges that colleagues face when a coworker becomes impaired/relapses are imposing. These are just the most obvious ones.The challenges that colleagues face when a coworker becomes impaired/relapses are imposing. These are just the most obvious ones.

14. These �Red Flags� are diagnostic indicators. Presenter should spend some time on examples of these elicited from the audience. These �Red Flags� are diagnostic indicators. Presenter should spend some time on examples of these elicited from the audience.

15. Frequently the indicators of impairment follow a predictable pattern. The figure above illustrates a common pattern for men. It should be noted that this is not applicable to all men and fewer women. It may be useful to discuss the differences between men and women in terms of this pattern. Frequently the indicators of impairment follow a predictable pattern. The figure above illustrates a common pattern for men. It should be noted that this is not applicable to all men and fewer women. It may be useful to discuss the differences between men and women in terms of this pattern.

16. If You Suspect Impairment Health care professionals have an ethical responsibility to protect patients and the public by identifying and assisting impaired colleagues. Intervention or Reporting? Obligation to report if imminent danger to patient exists Intervention is key to rehabilitation State level review boards encourage professional input, although they must remain sensitive to privacy considerations and the ADA. Thus, the process of assisting colleagues requires tact and care. Confidentiality must be assured throughout the process. Intervention seems to be the more collegial approach, especially when performed locally with the assistance of family, friends and coworkers, but reporting may be required if the potential for harm (self or others) exists. In either case, an intervention of some kind most likely will be necessary to encourage health seeking behavior. State level review boards encourage professional input, although they must remain sensitive to privacy considerations and the ADA. Thus, the process of assisting colleagues requires tact and care. Confidentiality must be assured throughout the process. Intervention seems to be the more collegial approach, especially when performed locally with the assistance of family, friends and coworkers, but reporting may be required if the potential for harm (self or others) exists. In either case, an intervention of some kind most likely will be necessary to encourage health seeking behavior.

17. Most of us are reticent to intrude on the private lives of others, particularly coworkers who are not close friends. However, there is a very practical element in this equation. That pragmatism relates to the safety and security of all those listed here. Elicit examples if there is time. Ultimately, we should acknowledge the ethical standards and altruism that we all share. Most of us are reticent to intrude on the private lives of others, particularly coworkers who are not close friends. However, there is a very practical element in this equation. That pragmatism relates to the safety and security of all those listed here. Elicit examples if there is time. Ultimately, we should acknowledge the ethical standards and altruism that we all share.

18. The formal procedure of Intervention was introduced by Vernon Johnson and refined by professionals at the Johnson Institute in Minnesota. This slide outlines the basic elements involved in Intervention. A brief description of the process can be found in the chapter by Talbot et al., referred to earlier. It must be noted that skill and experience are essential to yield the desired outcome. Although it is easy to understand and may even appear simple, the procedure should be guided by a professional with specific expertise. The formal procedure of Intervention was introduced by Vernon Johnson and refined by professionals at the Johnson Institute in Minnesota. This slide outlines the basic elements involved in Intervention. A brief description of the process can be found in the chapter by Talbot et al., referred to earlier. It must be noted that skill and experience are essential to yield the desired outcome. Although it is easy to understand and may even appear simple, the procedure should be guided by a professional with specific expertise.

19. Most worksites today provide access to an Employee Assistance Program. Usually, these EAP services are outsourced to agencies that can separate from the host organization and assure a high level of confidentiality. Some larger organizations may have retained these services within their own health and wellness programs. In Michigan, the state has contracted with a private organization the �Michigan Health Professionals Recovery Program� to assist state boards for licensed health and human service professionals. Most worksites today provide access to an Employee Assistance Program. Usually, these EAP services are outsourced to agencies that can separate from the host organization and assure a high level of confidentiality. Some larger organizations may have retained these services within their own health and wellness programs. In Michigan, the state has contracted with a private organization the �Michigan Health Professionals Recovery Program� to assist state boards for licensed health and human service professionals.

20. This descriptive material comes directly from the MHPRP website. Clearly, the mandate of MHPRP covers substance abuse as well as the many other issues that cause impairment, e.g., mental illness, chronic pain, aging. This descriptive material comes directly from the MHPRP website. Clearly, the mandate of MHPRP covers substance abuse as well as the many other issues that cause impairment, e.g., mental illness, chronic pain, aging.

21. This information is helpful for a Michigan audience, but should be replaced with information that is more germane to another audience, if that is available.This information is helpful for a Michigan audience, but should be replaced with information that is more germane to another audience, if that is available.

22. Once again, this flow diagram/decision tree of procedures employed by the MHPRP was downloaded from the MHPRP website for descriptive purposes. This may serve as a general reference, but procedures do vary by state and even locale. Once again, this flow diagram/decision tree of procedures employed by the MHPRP was downloaded from the MHPRP website for descriptive purposes. This may serve as a general reference, but procedures do vary by state and even locale.

23. It may be useful for an audience to appreciate that the American Society of Addiction Medicine (ASAM) widely known for its publication of Patient Placement Criteria, has a long-standing commitment to wellness of the health professional. First adopted in 1984, these principles were updated in 2001 and are promulgated by the organization on a national basis.It may be useful for an audience to appreciate that the American Society of Addiction Medicine (ASAM) widely known for its publication of Patient Placement Criteria, has a long-standing commitment to wellness of the health professional. First adopted in 1984, these principles were updated in 2001 and are promulgated by the organization on a national basis.

24. Components of a Good Peer Assistance Program* Discretion, Compassion, Confidentiality Coordination of the Intervention Referral for assessment and treatment Return-to-practice assistance Sustained monitoring of recovery Advocacy for participants This list of the components that a competent Peer assistance program must include was adapted from a presentation made by Dr. Vicky Waters, a Fellow in the Project MAINSTREAM Faculty Development Fellowship Program. This list of the components that a competent Peer assistance program must include was adapted from a presentation made by Dr. Vicky Waters, a Fellow in the Project MAINSTREAM Faculty Development Fellowship Program.

25. These key elements of successful treatment are described in greater detail in a chapter by Talbot, Gallegos and Angres in Principles of Addiction Medicine, second edition (1998), edited by Graham and Schultz, for ASAM. Note that many of these points have been raised previously. The discussion of this slide could focus on operational aspects of an intervention program. These key elements of successful treatment are described in greater detail in a chapter by Talbot, Gallegos and Angres in Principles of Addiction Medicine, second edition (1998), edited by Graham and Schultz, for ASAM. Note that many of these points have been raised previously. The discussion of this slide could focus on operational aspects of an intervention program.

26. Recovery is Likely addiction is a chronic, relapsing disease recovery is lifelong This penultimate slide is important because of its positive message. The vast majority of health professionals who become impaired or relapse do achieve sustained recovery. While their knowledge of and proximity to the problem may have worked in conjunction with their defense mechanisms to promote their problem, the same factors can help to support their recovery. People who are invested in this field and who manifest substance use disorder must never lose sight of the fact that chemical dependence (addiction) is a chronic disorder with biological, psychosocial and cultural/environmental determinants. Because we do not presently have a cure, we must view recovery as a condition of managed stabilization that requires ongoing attention.This penultimate slide is important because of its positive message. The vast majority of health professionals who become impaired or relapse do achieve sustained recovery. While their knowledge of and proximity to the problem may have worked in conjunction with their defense mechanisms to promote their problem, the same factors can help to support their recovery. People who are invested in this field and who manifest substance use disorder must never lose sight of the fact that chemical dependence (addiction) is a chronic disorder with biological, psychosocial and cultural/environmental determinants. Because we do not presently have a cure, we must view recovery as a condition of managed stabilization that requires ongoing attention.

27. While the presentation may conclude with the previous slide, a final point might be made that effective anticipation and prevention of relapse are better than intervention after-the-fact. A cognitive-behavioral strategy (Relapse Prevention) can be employed for this purpose. This slide presents a very brief definition and framework for the procedure. While the presentation may conclude with the previous slide, a final point might be made that effective anticipation and prevention of relapse are better than intervention after-the-fact. A cognitive-behavioral strategy (Relapse Prevention) can be employed for this purpose. This slide presents a very brief definition and framework for the procedure.