Relapse Prevention Dr. Jay Piland MD

1. Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center

2. Spectrum of Substance Use Disorders
Misuse
20% 65% ?%
Regular
Use
Zero
use Mild
Moderate
Severe
“Pickle Line”
adapted from Ray Baker MD
Healthy No Problem
Use Related
Problem
Substance Use
Disorders
Road to Recovery

3. DSM 5 Diagnostic Criteria
11 Criteria in 4 groupings (2-3=mild, 4-5=moderate, 6+=severe)
Impaired Control
Inability to quit or cut down, using more than intended, time spent, craving
Social (Functional) Impairment
School, Work, Home Obligations Not Met
Social and Relationship Problems
Social, Occupational, Recreational Activities Abandoned
Risky Use (Using Despite)
Hazardous Situations
Physical or Mental Illness/Psychological Problems
Pharmacological (Physiological)
Tolerance and Withdrawal
Road to Recovery

4. “Sometimes it’s not so much seeing the
light as feeling the heat.”
Road to Recovery

5. Barriers for HCP’s seeking and
receiving assistance
Road to Recovery

6. • 2/3 of pharmacists in recovery treatment programs
are discovered by their state board of pharmacy, a
peer, or another HCP
• Some discovered by law enforcement caught abusing a
substance or engaging in a related illegal activity
• Many may actually believe their own knowledge of
medications will somehow prevent them from
becoming addicted or dependent
• Many studies show that HCP’s may believe their
knowledge of drug therapy justifies self-treatment
Road to Recovery

7. The Addicted Pharmacist and the Effect of Their Environment
University of Findlay College of Pharmacy
PRN Survey (N 171—25%)
• From Discovery to Recovery
• 93% attended Some form of Rehabilitation
– Of which 63% Successful on First Attempt
– Of which 18% Successful on Second Attempt
– Of which 11% Successful on Third Attempt
Road to Recovery

8. CDM: Performance Measures
Help Guide Care
Road to Recovery

9. “Blueprint” Study
McLellan et.al., BMJ, Nov. 2008
• 16 American PHPs retrospective longitudinal study
• 904 consecutive MDs with SUDs, 647 monitored
• 81% never relapsed over five years
• 79% licensed and working after five years
• 11% revoked
• 3.5% retired
• 3.5% died
• 3% status unknown
Road to Recovery

10. Relapse Risk (Washington State PHP)
(Domino, et. al. JAMA, Mar 23, 2005)
Retrospective Cohort Study
• Relapse rate: 25% (74 of 292 cases between 1991-
2001)
• Increased relapse risk if:– Concurrent psychiatric disorder (HR 5.79)
– Family history of substance use disorder (HR 2.29)
– Previous major relapse (HR 1.69)
– Combinations of these adds to cumulative risk
– Major Opioid/Dual Diagnosis/Family History (HR 13.25)
• No increased relapse risk:
– Drug of choice
• Including major opioid as long as above factors absent
– Specialty
– Gender
Road to Recovery

11. OMA PHP Relapses - 5 Year Program
First 100 monitored participants
Brewster, Kaufmann et al; BMJ Nov 2008
Road to Recovery

12. LIFE SATISFACTION* BY
PROGRAM YEAR - OMA PHP
YEAR IN PROGRAM
* Mean of 14-items: 4-Very satisfied; 3-Satisfied; 2-Dissatisfied; 1-Very dissatisfied
R2 = .813; Regression constant = 3.266; Slope = 0.0498 (p = .037)
Road to Recovery

13. PFSP Program Evaluation 2008: Did PFSP
make a difference for participants in case
coordination?
90% of responding participants reported that the problem that
had caused them to access the program had improved (46%
responded)
• Overall wellness
• Job effectiveness
• Relationships with
others
full 76% partial 14%
full 71% partial 14%
full 71% partial 24%
Overall life satisfaction
• Beginning of case coordination3.7/10
• Conclusion of last interaction 8.1/10
Road to Recovery

14. Special Issues of Return to Work
• PHP/PRNs usually spell out the conditions for
a HCP’s return to practice via a contract.
• Most Regulator’s specify only that the HCP
return to work should be based on her/his
ability to practice with “reasonable skill and
safety”—leaving judgement up to treatment
team
Road to Recovery

15. Special Issues of Return to Work
• Assessment of her/his:
– Acceptance of SUD diagnosis
– Understanding of addiction as a chronic disease requiring lifelong attention
– Completion of SUD treatment, with support of treatment team to resume
work
– Documentation of sustained abstinence(UDS).
– Treatment and status of Co-occurring Mental Disorders
– Judgment and cognition (neuropsychological testing)
– HCP’s ability to manage stress and triggers
– Support Network including Family support
– Estimated risk of Relapse
– Motivation to follow an established continuing care plan
– Occupational Factors:
• Legal/Licensure Requirements Satisfied
• Workplace monitor/supervisor identified and accepts responsibilities
• Necessary Workplace modification or practice restrictions have been agreed to
Road to Recovery

16. Special Issues of Return to Work
• Staged Process
• May have limited work hours, tasks, time of day, or settings
• May face restrictions to access to mood-altering medications
• Workplace monitor in contact with PHP/PRN (release for communication
in effect at all times)
• Settings of practice limited to provide for easier monitoring/better
accountability
• Accountability System for dispensing/administering addicting drugs to
patients
– Not being the person in the practice to check a patient’s medications for
compliance
– Keeping track of prescriptions written for controlled substances
– Using double locked systems for addicting substances on premises
– Periodic checking of wastage from injectable opioids to assure all vials and
their contents are properly accounted for & have not been diverted
Road to Recovery

17. Applying Occupational Health
Principles
• Safety-Sensitive Profession
• Workplace education and accommodations are
often required
• Participate in return to work planning with the
participant and the workplace
• Fitness for work measured by performance on a
range of work tasks from low to higher risk
• Scrutiny and accountability in the workplace is
necessary
• Monitor long-term for Health and Recovery
Road to Recovery

18. Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center

19. Road to Recovery

20. Road to Recovery

21. Relapse:
• Definition varies according to source text.
• Addiction Medicine-Fourth Edition 2009:
• Uses terms Lapse, Relapse, and Recovery.
• Some argument over what constitutes a
Relapse-but not from PHP programs. Use a
higher standard of complete abstinence from
mood altering substances.
Road to Recovery

22. Lapse
• Marlatt defines as the initial episode of use of
a substance after a period of abstinence.
• Not really recognized for professionals.
Road to Recovery

23. Relapse:
• “ a discrete phenomenon or a process of
behavioral change”
• “an unfolding process in which the
resumption of substance use is the LAST
event in a long series of maladaptive
responses to internal or external stressors or
stimuli”
• “ a continuous process defined by a series of
transgressive behaviors”
Road to Recovery

24. Road to Recovery

25. Road to Recovery

26. Interventions Do Work

27. Behavior Patterns
• It’s the behavior stupid.
• Mechanism of response to stressors and
stimuli—I.E.—LIFE.
• Response can be healthy or maladaptive
Road to Recovery

28. Recovery
• Recovery is defined as a long-term and
ongoing process rather than an endpoint.
• Specific areas of change during the process of
recovery include physical, psychologic,
spiritual, behavioral, interpersonal,
sociocultural, familial, and financial.
• Recovery tasks and areas of clinical focus are
contingent on the phase of recovery .
Road to Recovery

29. Stages of Relapse:
• Used by PHP and RNP programs nationwide.
• 3 stages of relapse.
• Evidence shows progression over time.
• Measurement of severity of relapse but not
necessarily indicative of recommended
corrective actions from monitoring programs.
Road to Recovery

30. Level 1 Relapse
• A level 1 relapse consists of missing therapy
meetings, support groups, dishonesty, or
other behavioral infractions.
• Note-no mention of substances.
Road to Recovery

31. Level 2 Relapse
• A level 2 relapse involves the reuse of drugs or
alcohol but outside the context of medical
practice.
• Not necessarily a person’s drug of choice.
Road to Recovery

32. Level 3 Relapse
• Involves the use of drugs or alcohol within the
context of medical practice.
• Main goal of PHP programs is to prevent this
occurence.
• PHP’s, PRN’s, and RNP’s primary directive:
Protect the Public.
Road to Recovery

33. Consequences
• Different for professionals than the general
public because we present a greater danger
than just to ourselves.
• “Physicians who have difficulty maintaining
abstinence should be removed from the
workforce until treatment providers….feel that
the physician is safe to return to work.”
Road to Recovery

34. Consequences 2
• “ The point in time when a physician is safe to
practice is best determined by a joint decision
of the physician’s treatment provider and the
monitoring PHP.”
Road to Recovery

35. Determinants of Relapse
• Marlatt’s Relapse Taxonomy:
• Intrapersonal Determinants
– Self Efficacy
– Outcome Expectancies
– Cravings
– Motivation
– Coping
– Emotional States
• Interpersonal Determinants
Road to Recovery

36. Intrapersonal Determinants
• Self-efficacy: refers to the individuals beliefs in
their capabilities to organize and carry out
specific courses of action to attain some goal
or situation specific task.
• This construct is intimately related to the
individual’s coping abilities.
• The patient’s personal belief in his or her
ability to control substance use is a reliable
predictor of relapse.
Road to Recovery

37. Self-Efficacy
• If you believe you can you will.
• Confidence in your ability to control your
substance use is intimately related with your
coping skills.
• Coping behaviors should be thoroughly
assessed during treatment and appropriately
targeted for interventions.
Road to Recovery

38. Road to Recovery

39. Outcome Expectancy
• A factor enhancing the likelihood of relapse is
the set of cognitive expectancies that
individuals develop regarding the expected
outcomes of substance use.
• If it feels good do it. Not a good plan.
• Treatment should focus to some extent on
changing the individual’s outcome
expectancies regarding substance use.
Road to Recovery

40. Road to Recovery

41. Craving
• Defined as a cognitive experience focused on
the desire to use a substance.
• Closely related to outcome expectancies.
• Different from behavioral urges.
• Treatment should also include an evaluation
of cravings and appropriate readjustment
based on outcome expectancies.
Road to Recovery

42. Road to Recovery

43. Motivation
• Gorski: The degree to which a person’s
behavior differs from their ideal behavior
beliefs is the degree of that person’s insanity.
• The person’s desire for self improvement and
commitment to change is a strong predictor
of relapse.
• Ambivalence toward change is the enemy of
recovery.
Road to Recovery

44. Road to Recovery

45. Coping
• “Based upon cognitive-behavioral model of
relapse, the most critical predictor of relapse
is the individuals ability to utilize adequate
coping strategies in dealing with high-risk
situations.”
• One of the most effective coping strategies
available is mindfulness and meditation.
• Foundation of behavioral change.
Road to Recovery

46. Road to Recovery

47. Road to Recovery

48. Emotional States
• Studies show a strong link between negative
affect and relapse to substance abuse.
• It is the cornerstone of effective recovery;
affect is a strong determinant of subsequent
behavior.
• Two things you can control: Attitude and
Behavior. They are intimately associated.
Road to Recovery

49. Road to Recovery

50. Interpersonal Determinants
• Functional support or the level of emotional
support is highly predictive of long term
abstinence and recovery.
• Behavioral therapy which incorporates
partner support in treatment goals is one of
the top three empirically supported
treatment methods for alcohol problems.
• Al-Anon is born.
Road to Recovery

51. Road to Recovery

52. Top 10 ways to Prevent Relapse
• 1) Help patients understand relapse as a
process and event, and learn to identify
warning signs.
Road to Recovery

53. RP
• 2) Help patients identify their high risk
situations and develop effective cognitive and
behavioral coping.
Road to Recovery

54. RP
• 3) Help patients enhance their communication
skills, interpersonal relationships, and develop
a recovery social network.
Road to Recovery

55. RP
• 4) Help patients reduce, identify, and manage
negative emotional states.
Road to Recovery

56. RP
• 5) Help patients identify and manage cravings
and cues that precede cravings.
Road to Recovery

57. RP
• 6) Help patients identify and challenge
cognitive distortions.
Road to Recovery

58. Road to Recovery

59. RP
• 7) Help patients work toward a more balanced
lifestyle.
Road to Recovery

60. RP
• 8) Consider the use of medications in
combination with psychosocial treatments.
Road to Recovery

61. RP
• 9) Facilitate the transition between levels of
care for patients completing residential or
hospital based inpatient treatment programs,
or structured partial hospital or intensive
outpatient programs.
• PRN’s PHP’s RNP’s CM
Road to Recovery

62. RP
• 10) Incorporate strategies to improve
adherence to treatment and medication.
Road to Recovery

63. Susan P. Rx Relapse ?
• Susan is a 35 year old Pharmacist who was treated for alcohol SUD
at the age of 24. After treatment she enrolled in the PRN
monitoring and signed a 5 year monitoring contract.
• After the completion of her five year contract at the age of 29 she
had been very engaged in her peer support recovery program (AA,
Caduceus, Continuing Care, and UDS monitoring) but stopped
going about six months before the end of her contract.
• Three months prior to completion of her contract, Susan
discovered she was pregnant—she had noticed a significant mood
change(depression) and an increase in her anxiety level due to
difficulty with her supervisor at work (Hospital Pharmacy). She also
was increasingly anxious due to her infidelities which occurred with
another coworker who was a 22 year old pharmacy student—which
she ended at 8 months into her pregnancy—after being involved
with him for several months.
Road to Recovery

64. Susan P Rx Relapse ?
• Is Susan P. in Relapse?
• Would she benefit from being in a social recovery
Network?
• How could she be better managing her “negative
emotional state”?
• What emotions are driving that “state”?
Road to Recovery

65. Susan P Rx Relapse?
• She had a child (son) who was born about six months after
completing her monitoring contract(out of meetings for about 1
year. She did have to undergo a C-section and the birth was
complicated with some fetal distress prior to delivery—yet no
anomalies were noted in the infant. Susan received a Rx for
Percocet 10mg after the C-section and took three refills. (when
taking the Percocet—she began to think about a repeated dose
within 1 hour of last dose and could not get it off her mind)
• Susan returned to work after only 8 weeks at home after the C-
section. She had stopped having contact with her sponsor as she
was no longing attending AA meetings (not enough time). Also her
sponsor had advised her to end the previous relationship after
Susan had only one sexual encounter with him at age 33—she did
not follow the suggestions—the relationship continued for several
months. She had been working with a girl in early recovery but
stopped working with her after stopping the meetings.
Road to Recovery

66. Susan P. Rx Relapse
• Is Susan in Relapse?
• What Level?
• What did she not do with her
pregnancy/delivery?
• What could Susan have done with Cravings?
Road to Recovery

67. Susan P Rx Relapse ?
• Susan returned to her habit of smoking cigarettes (she had stopped at age
24) only two weeks after her son was born. Susan also began to
experience recurring episodes of dysphoria within that same time frame,
she also experienced recurring “flash-backs” of early childhood sexual
trauma she experienced at the age of 8 by an “uncle”. She would have
recurrent thoughts of being worthless and not being able to do anything
right—she began to think that her tendency to “gamble” was the reason
for sexual trauma “flash-backs”.
• She was responsible for filling the Pyxis machines with all of the narcotics
when she returned to work from maternity leave—so she progressively
increased her use up to 25 Percocet tablets daily. She took “50 Percocet
capsules” in a “suicide attempt” when her supervisor began to perform
internal Pyxis pharmacy audits. She now presents for an addiction
assessment after getting out of the acute care hospital.
•
Road to Recovery

68. Susan P Rx Relapse?
• 15. Does Cigarette Smoking increase her risk
of relapse?
• 16. What should she do about “flash-backs”?
• 17. What should she do about cognitive
distortions?
• 18. Should she be on MAT? Vivitrol?
• 19. What is most appropriate next step?
Road to Recovery

69. Susan P. Rx Relapse?
True/False?
21. Relapse Prevention plans should always be started at the
middle/end of treatment.
22. Performing a relapse autopsy is always useful.
23. Most HCP’s who relapse, always loose their license and ability to
practice their profession.
24. Many HCP’s who have an early relapse, often are able to achieve
and improved footing/foundation of a recovery program.
25. IDAA. Look us up www.ida.org
Road to Recovery

70. Relapse:
Road to Recovery
Dr. Jay Piland MD
Palmetto Addiction Recovery Center
Pecan Haven Adolescent Addiction Center