Relapse or Relapse Prevention: A Choice 26 January 2019 CAPTASA

1. Relapse or Relapse Prevention:A Choice26 January 2019CAPTASA Brian Fingerson, B.S. Pharm., R.Ph., FAPhA President, Kentucky Professionals Recovery Network, Louisville, KY

2. DisclosuresBrian Fingerson, R.Ph. declares no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria.

3. Learning Objectives 1. Describe the six most common reasons for relapse in health care professionals. 2. Define psychiatric factors that can increase the potential for relapse. 3. Describe back-to-work issues, that when addressed, can promote success in maintaining sobriety. 4. Define individual characteristics that statistically increase potential for relapse.

4. Relapse Prevention and Monitoring • You’ve been to treatment (or not) and then what? How do we help them continue the process……of what? • Abstinence? • Recovery? • Sobriety?

5. Recovery • Recovery commonly refers to a process of initiating abstinence from illicit drug and/or alcohol use, along with necessary life changes to help maintain sobriety over time • It’s a life long progression – and there may be obstacles and setbacks along the journey

6. What do you think? • Recovering • Recovered • In remission

7. Relapse – yes or no? • Substance Use Disorder said to be a relapsing disease so…is relapse inevitable?

8. Simple definition of relapse • Relapse involves much more than just returning to drug or alcohol use – it is the progressive process of a once stable recovery program becoming so dysfunctional that returning to use has become a viable option. • ASAM = relapse is defined as the recurrence of behavioral or other substantive indicators of active disease after a period of remission in a healthcare or other licensed professional.

9. So…. • How can relapse happen to an intelligent, high-functioning individual who is trying to stay sober?

10. Six common reasons for relapse • 1. The patient doesn’t buy into the idea (?) or fact (?) that it is a chronic disease. • After a period of time they feel they’ve gotten better

11. Six common reasons for relapse • 2. The patient doesn’t sincerely invest in AA/NA and/or quit going to meetings. • Many reasons to be addressed later • “Meeting makers make it”

12. Six common reasons for relapse • 3. The patient has minimal acceptance of their disease. • Feel they are not as bad as others and therefore do not have to do as much. • “Yets”

13. Six common reasons for relapse • 4. The patient has a mistreated or undiagnosed co-morbid psychiatric disorder (dual diagnosis). • Example = bipolar disorder = compromised judgment especially around use

14. Six common reasons for relapse • 5. The patient has an uneducated family or other support system. • Questions like – “Do you have to go to a meeting tonight? You went to one yesterday.” Or…”Can’t you have a glass of wine with me? Your problem was with pills.”

15. Six common reasons for relapse • 6. The patient doesn’t buy into the concept that they cannot safely use any mood-altering/addicting drug. • They actually have the glass of wine or don’t consult on an Rx or OTC medication e.g. talk with sponsor first or their PHP monitor.

16. Relapse – yes or no? The window of greatest vulnerability for relapse after treatment is the first 30-90 days following discharge

17. It has been said • Yale University researchers concluded that it takes at least three months of abstinence for the brain’s pre-frontal cortex to be able to process the kinds of information related to decision making and analytical functions

18. Lapse • Sometimes called a “slip” • “Sobriety Losing Its Priority” • “Something Lousy IPlanned” • Could be defined as an initial episode of drug or alcohol use after a period of abstinence.

19. Preventing a lapse (slip) from becoming a relapse • Stop consuming the illicit substance(s) as soon as possible. • Stopping sooner means far less physical and mental anguish due to renewed substance dependence and craving. • Use the slip as a learning experience. • Tell their sponsor/home group/significant other/monitor

20. Relapse • It is commonly viewed as a breakdown in the recovery process i.e. a major digression in the individual’s attempt to escape the bonds of addiction.

21. More prevention: • Examine the sequence of events leading up to the slip; what could have been done differently to avoid it? • Do not make excuses but, at the same time, do not beat yourself up. • Get immediately back into the program of recovery

22. More prevention: • Take pride in renewed efforts to stay “clean”; rather than punishing yourself for past events leading up to the slip. • (adapted from: Volpicelli and Szalavitz 2000)

23. Issues that increase the potential for relapse in healthcare professionals • A family history – the genetics = inherited physiology • Isolation • Inadequate monitoring contract – continuing care plan • Lack of a spiritual program – failure to maintain it

24. Issues that increase the potential for relapse in healthcare professionals • Lack of tailored treatment of professionals • Lack of effective coping skills re: stress • Use of an injectable controlled substance esp. Opioid • Under-treated coexisting psychiatric disorder • Previous history of relapse • Lack of 12-Step involvement • Lack of effective advocacy/monitoring

25. Other relapse factors • Drug-related “reminder” cues e.g. sights, sounds, smells, drug thoughts or drug-drinking dreams that are linked to the preferred drug(s) • “Play people, play places, play things”

26. A relapse factor • Negative mood states or stress – want to feel better • Positive mood states or celebrations – more wanting to feel better

27. Other relapse factors • Sampling the drug itself, even in very small amounts • I must add that it doesn’t have to begin with the use of the “drug of choice”

28. Other relapse factors - overconfidence • No longer need to form healthy habits • Can simply resist on my own • Can revert to old patterns of behavior

29. Other relapse factors - overconfidence • Notion that my craving was a phase – over it now • If I can just learn enough about it I’ll be OK • Naïve perception of immunity • Hubris = false pride

30. JAMA. 2005;293:1453-1460 • Domino et al did a study on “Risk Factors for Relapse In Health Care Professionals With Substance Use Disorders.” • And what they found was – and yes…this is some repetition….however….

31. The risk of relapse with substance use was increased in HCP who: • Used a major opioid • Or had a coexisting psychiatric illness • Or a family history of substance use disorder • And……

32. And…. • The presence of more than one (1) of these risk factors and previous relapse further increased the likelihood of relapse. • And these observations should be considered in monitoring the recovery of HCP (and for how long?)

33. Co-morbid diagnoses that decrease stability in a recovery program • Depression • Bipolar disorder • Generalized anxiety disorder • Cognitive impairment • Eating disorders • Sexual/gambling or other process addictions • Severe chronic pain

34. Co-morbid diagnoses that decrease stability in a recovery program • Personality disorders • Avoidant personality disorder • Narcissistic personality disorder • Borderline personality disorder • Antisocial personality disorder

35. Impact of personality disorders on relapse potential • Cause significant dysfunction in personal life, social life, and work life and especially in interpersonal relationships making it far more difficult to connect with 12-Step programs in a meaningful way and to interact in group therapy. • Inflexible • Ingrained • Pervasive

36. Impact of post-acute withdrawal on relapse potential (PAW) • Has the capacity to make an individual believe they felt much better when they were using. Can significantly limit an individual’s enthusiasm for recovery.

37. PAW Symptoms • Mood swings – irritability • Insomnia / tiredness • Inability to think clearly / memory problems • Low motivation / enthusiasm • Anxiety • Anhedonia (strong stimulants) • Depression (strong stimulants)

38. PAW helpful approaches • Encourage the person to talk about it in group and at meetings • Meditation • Yoga • Exercise • Pharmacotherapy – questionable – need a knowledgeable clinician

39. Back to work – environment • Practice stressors – patients, staff, third-party issues • Normal life stressors – finances, home and family issues • Culture of self-medication/treatment • Pharmaceutical invincibility • Ease of access

40. Should you recommend or require? • 90 meetings (12-Step recovery meetings) in 90 days and then….in our case typically 12 meetings per month with a minimum of 2 in any one week period.

41. Factors that inhibit AA/NA (12-Step) involvement • Shame • The religious language • Shy – social phobia • Lack of support from family • Availability of meetings • Other “more important” priorities

42. Could they provide a medication List: Are the meds OK to use? • Yes • No • Maybe • What precautions e.g. MAR, witnesses • “Safe medication booklets” • Non-drug alternatives

43. How to enhance the odds for recoveryby William L. White • Don’t use – no matter what • Choose a treatment program that offers a rich menu of continuing care services and actively use these supports

44. How to enhance the odds for recoveryby William L. White • Find a recovery support group and stay actively involved. Make meetings a priority, get a sponsor, build a sober social network, and apply recovery program principles to the problems of daily living

45. How to enhance the odds for recoveryby William L. White • If you do not have a living environment supportive of recovery, investigate the growing network of recovery homes • Involve your family members in recovery support groups and activities • Become an expert on your own recovery and take responsibility for it

46. So…. • Fellowship and the support of those in a network of recovering HCP can help minimize the risk of relapse in our HCP clients • It works – we’ve shown that it does

47. A required prescription

48. “The alcoholic is like a tornado roaring through the lives of others.” page 82

49. Page 82 also says: “Hearts are broken.” Our goal is: Recovery Recovery: by Mike Vye

50. We would like to return to this: • Successful practice and to “LIFE”