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Whole Health LibraryMenu Reducing Relapse RiskIntroductionRecovery is a lifelong process that often involves changes across multiple domains of a persons daily life, including physical, behavioral, inter- and intra-personal, psychological, and social spheres.[1] Specific areas of change often include increasing self-awareness, self-care, and life balance; ensuring adequate nutrition, exercise, and sleep; developing healthy relationships with others and self, and a recovery support network; improving coping and communication skills; addressing any existing physical or mental health issues; learning how to manage cravings; and learning relapse prevention skills. All of these changes are crucial for a successful maintenance of recovery and reengaging in life without the use of substances. Each persons progression into and maintenance of recovery is unique. Therefore, it is important to facilitate the patients looking inward to determine the changes that would be important to the successful maintenance of recovery. The process of recovery (and relapse) is often influenced by several relapse risk factors, including:
It is important for clinicians to be aware of the complexities of substance use disorders (SUDs) and recovery, so that they can provide optimal support for the patients progress and maintenance of recovery. What Is Relapse?Relapse is both an event and a process.[1] A lapse is the initial use of a substance after a period of recovery; a relapse is continued use after the initial lapse.[1] The relapse process often begins long before the individual uses the substance. It can start with letting go of some of the changes the individual has made in recovery, and reverting back to old patterns. Early warning signs of the relapse process can include the following:
In addition to these common signs, patients may have their own unique indicators as well that signal they are drifting away from recovery. It is important to help patients learn to identify their own warning signs of the relapse processthis will help them increase self-awareness and strengthen recovery. Within the relapse process, there are many opportunities for the individual to intervene, reengage with recovery-oriented behaviors, and get back on track with recovery. Research indicates that approximately 60% of individuals with substance dependence eventually enter sustained recovery; however, for many of them, it takes more than one cycle of lapserelapsetreatment reentry before achieving sustained recovery. The clinicians should support the patients attempts at recovery regardless of how many times they tried in the past (and relapsed). Multiple treatment episodes may have a cumulative positive effect, leading to a sustained recovery.[1] Early recovery is often the most vulnerable time; approximately half of alcohol-dependent patients relapse within 3 months of detoxification,[1] indicating that relapse preventionoriented treatment should be introduced as early as possible. Because addiction is a chronic relapsing disease, relapse can occur, though, at any time in the recovery processsome people relapse after having been in recovery for years. Therefore, it is important that patients understand that recovery is not an event or a time-limited goal; rather, it is a series of changes across multiple domains of life that need to be maintained lifelong. If a lapse or relapse occurs, the patient should be encouraged and guided by the clinician to explore the relapse itself and the circumstances surrounding it, including any early warning signs of relapse. This knowledge can then be used as a learning experience toward improved understanding and skills for relapse prevention in the future. With relapse, patients may benefit from stepping up the level of treatment they receive for SUDs; for example, a patient in an outpatient aftercare program (weekly individual meetings with a counselor) can be transitioned to an intensive outpatient program (group and individual therapy meetings several times a week). Increasing attendance at mutual self-help group (e.g., Alcoholics or Narcotics Anonymous) meetings and boosting other personal support can exert additional positive effects. OPIOID OVERDOSE WARNINGThose who abstained from opioids, even for a relatively short period of time, are at increased risk for accidental overdose. As part of relapse prevention it is critical to educate patients about the danger of unintentional overdose after a period of staying clean. With abstinence (or even reduced use), the individuals tolerance level for the drug decreases; resorting to using prior (e.g., pre-relapse) doses of opioids can cause overdose and death. Injectable-naloxone kits may help prevent a fatal opioid overdose in active users. Opioid Overdose Prevention Toolkit Relapse Risk FactorsOne of the common reasons for relapse is that the patient is not well prepared for what the process of recovery entails.[1] Many people assume that upon stopping the use of a substance, the worst will be over in a few weeks or months, and then they can ease up on their recovery efforts. This is an incorrect assumption.[1] It is important to educate the patient that recovery requires lifelong and ongoing effort to progress in and maintain recovery.[1] Several psychosocial factors have been identified as relapse risk factors, including the following:
When working with older adults it is also important to consider risk factors that are specific to older populations such as social isolation, loneliness, loss and grief, depression, and co-morbid medical conditions, to name a few.[1] For a successful ongoing recovery, the patient should receive appropriate support and counseling addressing all the risk factors they endorse. There are also more specific daily life factors that can increase the risk for relapse. Some behavioral risk factors include:
Internal risk factors include:
External or environmental risk factors may include:
Triggers (internal or external cues) associated with past substance use can also be risk factors for relapse. These cues or triggers can activate an urge or craving to use that, in turn, can lead to relapse if not appropriately addressed. Triggers are often unique to the individual. Although some may be obvious to identify (e.g., a friend coming over with a bottle of alcohol), others can be subtle (e.g., a memory of pleasure associated with past-use of a substance). With the multitude of possible risk factors for relapse, many of which are unique to the individual, it is important for patients to explore their personal risk factors during treatment. Reducing Relapse RiskRelapse prevention is an essential part of treatment for SUDs and recovery. Relapse prevention involves a complex interplay of environment, history, thoughts, affect, expectations, coping, physical withdrawal, motivation, perception of the situation (and after actions happen), support network, self-efficacy, craving, and self-regulation.[1] While in treatment, it is important for clinicians to closely monitor the patients progress, especially early in recovery when the risk of relapse is highest,[2] as well as assess the patients commitment and motivation to change and help enhance it, if needed, as part of relapse prevention.[1] Motivational interviewing or motivational enhancement approaches can be useful for increasing motivation to change. The clinician and the patient should collaborate together in developing a treatment plan and goals for recovery, as well as identifying any potential barriers to recovery.[2] Treatment plans should be tailored to the patients individual needs and preferences, and take into consideration availability of different treatment modalities (e.g., residential versus outpatient treatment). Smooth and gradual transition from a higher to lower level of care can additionally facilitate recovery, as it gives the patient time to adapt. Relapse prevention is interrelated with many other aspects of recovery. Relapse prevention can be conceptualized as involving two main parts: building the foundation of recovery across multiple life domains (refer to Introduction and Resource Box 1), and learning specific relapse prevention tools (Resource Box 2). Relapse prevention strategies should be tailored to the needs of an individual patient, taking into account the patients sociocultural environment, level of motivation, severity of SUDs, and presence and severity of co-existing medical and mental health problems, to name a few.1 Particular attention must be paid to co-occurring SUDs and mental health conditions. Co-occurrence of mental health conditions is common, and addressing these conditions (e.g., posttraumatic stress disorder [PTSD], depression, anxiety, or insomnia) is critical for the success of SUD recovery.[3] Approximately one-third to a half of patients seeking treatment for SUDs also meet criteria for PTSD, with some studies reporting prevalence of PTSD to be even higher.[4] Relapse prevention strategies can be taught in individual or group therapy formats. The use of experiential learning techniques can make learning a more active process, enhance self-awareness, decrease defensiveness, and encourage behavior change.[1] Some examples of experiential interventions that can be delivered by a trained counselor include role playing, behavioral rehearsal, metaphors, monodramas, psychodrama, bibliotherapy, journaling, interactive videos, and home practice assignments.[1] Meditation-based interventions can be well suited for experiential learning of self-awareness and positive coping skills. Research evidence indicates that mindfulness meditation training and practice can enhance outcomes in SUDs.[5-7] Mindfulness-based relapse prevention is a 8-week program specifically tailored for relapse prevention in SUDs.[8] The American Society of Addiction Medicine describes ten relapse prevention strategies essential for clinicians to be familiar with and implement when treating patients with SUDs throughout the continuum of care (refer to the section below). These strategies can easily be integrated with other therapeutic modalities (e.g., motivational interviewing, contingency management, pharmacotherapy, spirituality, mindfulness meditation, and family-based interventions).[1] Helping Patients: Ten Clinical Relapse Prevention Strategies
*Adapted from American Society of Addiction Medicine[1] Resource Box 1. Building a Whole Health Receovery FoundationPhysical and Emotional Surroundings
Diet
Rest
Support
Self-Care
Physical Health and Exercise
Mental Health
Substance Use Disorder Treatment
Relapse PRevention PlanCreating a written personalized relapse prevention plan can be a very useful tool for reducing relapse risk. Preparing and referring to this plan can help increase awareness of pro-relapse behaviors, and help relapse prevention efforts. Relapse prevention plans often include the following: names and contact information of key people in your recovery support system; description of your internal triggers (e.g., specific thoughts, emotions, behaviors, attitudes related to substance use) and external triggers (e.g., specific people, places, things, situations) to use substances; identification healthy coping skills; your personalized plan on how you can intervene when relapse triggers are activated (e.g., call your sponsor; go for a walk or a run; meditate). Your treatment provider can help you create a relapse prevention plan. Early Recovery Checklist
Resource Box 2. Relapse PRevention ToolsHALT: Ask yourself am I Hungry? Angry? Lonely? Tired? Oftentimes being hungry, angry, lonely, or tired can trigger a desire to use (especially in early recovery), and therefore its important to identify hunger, anger, loneliness, or tiredness and address the underlying need instead of using a substance. Relapse prevention plan: Use your relapse prevention plan in times of needthats what its there for. SOBER: Use the SOBER brief meditation when feeling a desire to use: Stop, Observe, Breathe, Expand, Respond.[8] (Resource Box 3) Recovery wallet card: Create a wallet-size card and outlines your personalized relapse prevention plan. Such a card can contain the following: (1) your top three reasons for not using substances, (2) a list of at least three people or places you could contact when you need support and their phone numbers, and (3) a list of the specific strategies you will use for relapse prevention.[8,19] Play the tape through: When having an urge or craving to use, play the scenario in your thoughts all the way through, thinking not only about the experience of using but also of what might happen due to using (consequences such as legal, personal, emotional, physicalincluding death, financial, job loss, social, etc.) and how you will feel after it is all done. Reach out to your support network: Reach out to someone in your recovery support system when feeling distressed or lonely, or having an urge to use, etc. Call a person who is positive and supportive of your recoverydo not call an old friend you used to use with or who sold you drugs. Recovery self-help groups: Attend a 12-step (e.g., Alcoholics Anonymous, Narcotics Anonymous or SMART Recovery) meeting. (Refer to Alcoholic Anonymous, Narcotics Anonymous, and SMART Recovery) Focus on one day at a time: If cravings or urges to use are happening, make a decision to not use for today or the next hour or the next 5 minutes. When the time period is up, repeat the process and use the relapse prevention tools that you have learned about. Remember: cravings and urges do not last forever; after a while they pass on their own. Urge surfing: This method encourages simply observing a craving or an urge, and noticing the experience of the urge itself, accepting it, and allowing it to pass, rather than attempting to fight it or act on it. With time, a craving or an urge will run its course and spontaneously fade away.[1] Recovery is not a race: Do not try to do too many things at once in early recoveryyour body, mind, and heart need time to heal. Learn to develop healthy balance piece by piece, day by day, and build from there. Resource Box 3. Relapse Prevention Tool: SOBER Brief MeditationSOBER Brief MeditationStop: right here and right now; this pause can allow you to step out of autopilot (instead of automatically reacting to an urge, or distressing situation) Observe: what is happening right now, in this moment whats going on in your mind and body; bring gentle awareness to your thoughts, sensations, and emotions Breathe: bring your attention to the sensations of each breath Expand: expand your awareness to include a sense of the body and mind as a whole Respond: now, try to make a mindful choice what to do next (if anything) Adapted from Mindfulness-Based Relapse Prevention[8] Author(S)Reducing Relapse Risk was written by Aleksandra Zgierska, MD, PhD and Cindy A. Burzinski, MS, LPCT, SACIT (2014). References
What are factors learners should consider when evaluating a teacher?Teacher evaluation matters. Formal education and continuing education.. Experience in the classroom and the education sector.. The ability to foster positive interactions with students.. The ability to create a positive classroom environment.. Successfully using homework and assessments to determine student proficiency.. What are the risk factors for susceptibility to disease in vulnerable populations select all that apply quizlet?Factors associated with vulnerable populations include income and education, age and gender, race and ethnicity, homelessness, chronic illness and disability, and immigration among others. Chronic, not acute, illness is considered as a factor.
Which factor would the nurse include when examining social determinants of health in the community quizlet?Some recognized social determinants of health care include vaccination compliance, family structure, roles of women, and education. Communication patterns often are important to assess in culturally diverse individuals, families, and communities, but this is not considered a social determinant of health care.
What are reasons the Omaha system is highly regarded?The Omaha System was one of the first clinical nomenclatures to be developed, and is so highly regarded because it is: Research based. Created specifically to describe community health care. Designed to be used in electronic documentation systems.
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