Is the relapse concept in studies of substance use disorders a 'one size fits all' concept? A systematic review of relapse operationalisations

Outcomes Among Sober Living House Residents Who Relapse: Role of Recovery Capital

Studies show individuals living in residential recovery homes on average make significant improvements in multiple areas of functioning. Residents who achieve and maintain complete abstinence have particularly good outcomes. Residents who relapse after entering the houses have been studied minimally. The current study examined outcomes for 197 residents who relapsed within six months after entering sober living houses (SLHs), which is one type of residential recovery home that is common in California. Despite having relapsed, these residents made significant improvements between entry into the house and 6-month follow-up on measures of percent days abstinent from alcohol and drugs (PDA), psychiatric symptoms, severity of employment problems, and stable housing. Higher recovery capital predicted higher PDA (coefficient = 0.28, SE = 0.09, p = .001) and lower severity of employment problems (coefficient = -0.00, SE = 0.00, p = .007). Recovery capital showed a significant decrease between baseline and 6-month follow-up among persons who relapsed and were no longer living in the house. SLH providers can draw upon social model recovery principles to enhance recovery capital. However, residents should also seek other sources of recovery capital outside the SLH, which may be particularly important for individuals who leave the home.

Psychological factors predicting patients' risk of relapse after enrollment in drug use treatment: A systematic review

BACKGROUND AND AIMS

Despite high rates of relapse after treatment for drug use, to our knowledge there is no systematic literature identifying psychological factors that predict risk of relapse to drug use (excluding alcohol or tobacco). Our aim was to identify psychological factors that predict risk of relapse to drug use after enrollment in drug use treatment. The identification of such factors can support treatment planning and relapse prevention.

METHODS

We searched for peer-reviewed articles published between 2000 and 2023 in PsycINFO, PsycArticles, Web of Science, and PubMed. The inclusion criteria were: peer-reviewed publications, quantitative studies, in English, adult samples, with a prospective design, and analyses of minimum one psychological factor as predictor of relapse to drug use. All authors were involved in abstract and full-text screening, and in assessing risk of bias. The findings are presented in a narrative synthesis and tables are organized by type of drug.

RESULTS

Of 2226 publications initially identified, 45 were eligible. Twenty-three focused on predicting relapse to stimulants, 15 to opioids, and 7 to unspecified drugs. Substance use at baseline was an important factor predicting risk of relapse to opioids, and possibly stimulants. There was an indication that craving and attention problems potentially predict relapse to use of some drugs. Mental health factors (e.g., psychiatric diagnosis) did not predict relapse. Several psychological factors (e.g., cognition, emotion, personality, motivation) were scarcely examined. Over half of the studies had moderate to high risk of bias.

CONCLUSIONS

Based on the 45 studies, few psychological factors predicted risk of relapse to drug use. Higher comparability between studies and more rigorous methodology are necessary in order to derive more precise recommendations that inform and improve clinical practice.

PRE-REGISTRATION

PROSPERO, CRD42020182839.

"I was already there once": Cumulative attempt capital of marginalized women exiting substance use and street prostitution contributes to their recovery capital

Despite a move to view substance use as a disease of the brain, relapse into drugs is still often viewed as a personal failure. Low recovery capital has been used to explain relapse among certain marginalized populations. Recovery capital is a recent framework that refers to the individual's sum of all internal and external assets that may assist in their recovery process. It includes four categories: physical, human, social, and cultural capital. However, this framework does not relate to the role of actual relapses in the recovery process, despite their common occurrence. To bridge this gap, in-depth interviews with 29 women formerly engaged in substance use and street prostitution in a large urban area were used to probe women about their relapse and recovery experiences. The current study demonstrates the value in repeat recovery setbacks, what I term "cumulative attempt capital": lessons learned from previous recovery attempts. I argue that previous attempts improve women's social and professional networks, help them learn from past mistakes, improve and maintain their health, and provide them with a sense of self-efficacy. This research expands our understanding of the positive role failed attempts play in one's recovery. Such reframing by service providers can alleviate a sense of shame and low self-worth for women in street prostitution and substance use and has implications for policy and program development.

Predicting alcohol relapse post-detoxification: The role of cognitive impairments in alcohol use disorder patients

BACKGROUND

Studies on early abstinence suggest that cognitive function is significantly reduced in the first year of abstinence, which raises the question of whether it is relevant to early relapse in patients with substance use disorders. This study investigates the extent to which impairments in executive function and memory predict alcohol relapse in patients with alcohol use disorder (AUD). Understanding these relationships is crucial for improving therapeutic approaches to prevent relapse in patients with AUD.

METHODS

We selected 116 adult patients (79 male and 37 female) diagnosed with AUD based on DSM-5 criteria, all of whom were undergoing alcohol detoxification treatment. A comprehensive array of neuropsychological tests was administered to assess global cognition, memory, and executive functions. Patients' alcohol use was monitored monthly during a 6-month follow-up period. Logistic regression and Cox regression were used to explore the relationship between cognitive function and the likelihood of alcohol relapse.

RESULTS

Impairments in global cognition, semantic and phonemic fluency, cognitive flexibility, and learning ability during detoxification were significant predictors of relapse in AUD patients, showing similar predictive values at both 3 and 6 months post-treatment. An abnormal Montreal Cognitive Assessment (MoCA) score increased the risk of relapse by 123% (HR: 2.227), and impairments in both semantic and phonemic fluency each increased the risk by 142% (HR: 2.423). Additionally, abnormal performance on the MoCA, Trail Making Test Part B (TMT-B), and California Verbal Learning Test (CVLT) was associated with a higher number of drinking days at 3 months (IRR: 3.764; IRR: 2.237; IRR: 2.738, respectively) and abnormal MoCA and TMT-B scores at 6 months (IRR: 2.451; IRR: 1.859, respectively).

CONCLUSIONS

The MoCA test is a valuable tool for predicting relapse risk in AUD patients undergoing detoxification treatment, with similar predictive value for relapse at 3 or 6 months. Learning ability needs to be assessed and their impairments considered in the treatment of AUD patients. Future research should explore strategies for managing patients with impairments in memory and learning ability to enhance treatment effectiveness and prevent relapse.

The interdependence of substance use, satisfaction with life, and psychological distress: a dynamic structural equation model analysis

Introduction

Longitudinal studies with annual follow-up including psychological and social variables in substance use disorder recovery are scarce. We investigated whether levels of substance use, satisfaction with life, and psychological distress fluctuate across five years in relation to having drug-free friends.

Methods

A prospective naturalistic cohort study of change trajectories in a cohort of people diagnosed with substance use disorder and using multiple substances with quarterly and annual follow-up over five years. Two-hundred-and-eight patients were recruited from substance use disorder treatment in Rogaland, Norway. Out of these, 164 participants fulfilled the inclusion criteria. We used Bayesian two-level dynamic structural equation modelling. The variable 'drug-free friends' was assessed by a self-reporting questionnaire, while psychological distress was assessed using the Symptoms Checklist 90 Revised. Satisfaction with life was assessed using the Satisfaction With Life Scale while drug use was assessed using the Drug Use Disorders Identification Test.

Results

The main findings are that higher-than-average psychological distress at a three-month lag credibly predicts higher-than-normal substance use at the concurrent time point t. Substance use and satisfaction with life seem to have synchronous trajectories over time, i.e. as the first decreases the latter increases and vice versa. During the five years after treatment, the participants mainly experienced a decrease in substance use and increase in satisfaction with life.

Conclusion

Since the participants experienced positive and negative fluctuations for several years after treatment, it seems crucial to establish a dialogue with treatment professionals in order to create functional solutions for maintaining motivation and aiding recovery.

Trait sensitivity to positive feedback is a predisposing factor for several aspects of compulsive alcohol drinking in male rats: behavioural, physiological, and molecular correlates

INTRODUCTION

Alcohol use disorder (AUD) is one of the most common psychiatric disorders and a leading cause of mortality worldwide. While the pathophysiology underlying AUD is relatively well known, the cognitive mechanisms of an individual's susceptibility to the development of alcohol dependence remain poorly understood. In this study, we investigated the theoretical claim that sensitivity to positive feedback (PF), as a stable and enduring behavioural trait, can predict individual susceptibility to the acquisition and maintenance of alcohol-seeking behaviour in rats.

METHODS

Trait sensitivity to PF was assessed using a series of probabilistic reversal learning tests. The escalation of alcohol intake in rats was achieved by applying a mix of intermittent free access and instrumental paradigms of alcohol drinking. The next steps included testing the influence of sensitivity to PF on the acquisition of compulsive alcohol-seeking behaviour in the seeking-taking punishment task, measuring motivation to seek alcohol, and comparing the speed of extinction and reinstatement of alcohol-seeking after a period of abstinence between rats expressing trait insensitivity and sensitivity to PF. Finally, trait differences in the level of stress hormones and in the expression of genes and proteins in several brain regions of interest were measured to identify potential physiological and neuromolecular mechanisms of the observed interactions.

RESULTS

We showed that trait sensitivity to PF in rats determines the level of motivation to seek alcohol following the experience of its negative consequences. They also revealed significant differences between animals classified as insensitive and sensitive to PF in their propensity to reinstate alcohol-seeking behaviours after a period of forced abstinence. The abovementioned effects were accompanied by differences in blood levels of stress hormones and differences in the cortical and subcortical expression of genes and proteins related to dopaminergic, serotonergic, and GABAergic neurotransmission.

CONCLUSION

Trait sensitivity to PF can determine the trajectory of alcohol addiction in rats. This effect is, at least partially, mediated via distributed physiological and molecular changes within cortical and subcortical regions of the brain.

Risk of relapse to non-opioid addictive substances among opioid dependent patients treated with an opioid receptor antagonist or a partial agonist: A randomized clinical trial

BACKGROUND AND OBJECTIVE

First study to assess any compensatory increase in use of non-opioid illicit substances and alcohol in opioid dependent patients randomized to treatment with extended-release naltrexone (XR-NTX) or buprenorphine-naloxone (BP-NLX) and in longer term treatment with extended-release naltrexone.

METHOD

A multicenter, outpatient, open-label randomized clinical trial where patients received intramuscular extended-release naltrexone hydrochloride, 380 mg/month, or daily sublingual buprenorphine-naloxone 8-24/2-6 mg for 12 weeks, and an option to continue with extended-release naltrexone for an additional 36 week follow-up. The study was conducted at five urban addiction clinics and detoxification units in Norway between November 2012, and July 2016.

RESULTS

Among the 143 patients, 106 men and 37 women, there were no significant differences between those randomized to XR-NTX or BP-NLX in the risk of first relapse to alcohol (HR 1.31; 0.68-2.53), amphetamines (HR 0.88; 0.43-1.80), benzodiazepines (HR 1.24; 0.74-2.09) or cannabis (HR 1.55; 0.83-2.89). Also in the 36-week (12-48 weeks) follow-up period we found no significant differences between patients continuing with XR-NTX compared to those switching to XR-NTX after the randomized period in risk of first relapse to any non-opioid substance. In both study periods, the mean time in the study were longer among those relapsing to non-opioid addictive substances than those who did not. There was no significant association between first relapse to illicit opioids and first relapse to non-opioid addictive substances.

CONCLUSION

There was no increase in the risk of relapse to non-opioid addictive substances neither in short term nor longer-term treatment with extended-release naltrexone. Trial registrationclinicaltrials.gov Identifier: NCT01717963.

Equine-assisted therapy effectiveness in improving emotion regulation, self-efficacy, and perceived self-esteem of patients suffering from substance use disorders

Substance Use Disorders (SUD) is a universal overwhelming public health problem and is associated with other psychological and mental health ailments such as emotion regulation, perceived self-esteem, and self-efficacy problems. Complementary and alternative medicine may be beneficial. The aim of this study was to assess the effectiveness of equine-assisted therapy in improving emotion regulation, self-efficacy, and perceived self-esteem among patients suffering from substance use disorders. It was carried out using a randomized controlled trial design at Behman hospital, Cairo, Egypt. It included 100 patients suffering from SUD attending the setting, equally randomized into an intervention group to receive the equine assisted therapy and a control group to receive the regular care. Data were collected using a self-administered questionnaire with standardized tools for assessment of emotion regulation, General Self-Efficacy (GSE), and perceived self-esteem. The intervention group received weekly equine-assisted therapy sessions over 6 weeks in addition to their standard regular therapy. Patients in both groups had similar demographic and SUD characteristics, as well as baseline scores of reappraisals, suppression, GSE and perceived self-esteem. At post-intervention, the intervention group had significant improvements in all these scores in comparison with the control group, as well as their baseline. The multivariate analysis identified the study intervention as a significant positive predictor of the reappraisal and GSE scores, and a negative predictor of the suppression and perceived self-esteem negative score. In conclusion, equine assisted-therapy as a complementary treatment in patients suffering from SUD is effective in improving their emotion regulation, self-efficacy, and perceived self-esteem. A wider use of this approach is recommended in SUD patients along with provision of needed facilities and resources, and training nurses in its administration. Further research is proposed to assess its long-term effectiveness. The clinical trial was registered in the "Clinical Trials.gov Protocol Registration and Results System (PRS);" registration number is (05632185/2022) and the full date of first registration is 10/11/2022.

MANEMOS. The Trigger Situations Inventory. Validation of a Measure Helping Relapse Prevention in the Treatment of Alcohol Use Disorders

Background: Relapse Prevention (RP) is a cognitive-behavioral approach that aims to identify situations at high risk of relapse and to support patients with alcohol use disorders (AUDs) in developing coping strategies for the maintenance of desired behavioral changes. Based on this framework, the present study aims to assess and validate the psychometric properties of the MANEMOS, a 24-item inventory of alcohol relapse triggering situations. Methods: The internal consistency and factor structure of the MANEMOS were analyzed in a sample of 313 (27.7% women) in-patients and out-patients, attending alcohol treatment programs in Italian addiction treatment facilities. Results: The results support the internal reliability and validity of the measure. A confirmative factor analysis has revealed the existence of eight distinct dimensions measuring relapse risk situations: namely, Pleasant emotions, Unpleasant emotions, Craving, Conflicts with others, Occasions, Social Pressure, Personal Control, and Physical Discomfort. The patients' assessment of the riskiness of the situation showed some significant differences depending on gender and on type of treatment received. Conclusions: The findings indicate that MANEMOS is a valid measure for identifying and reflecting on patients' high relapse-risk situations. This easy and flexible assessment measure may have important implications for prevention and clinical intervention.

Performance on Cognitive Screening Tests and Long-Term Substance Use Outcomes in Patients with Polysubstance Use Disorder

INTRODUCTION

Cognitive impairments among patients with substance use disorders are prevalent and associated with adverse treatment outcomes. However, knowledge of the predictive value of broad cognitive screening instruments on long-term treatment outcomes is limited. The present study aimed to examine the predictive value of measures from the Montreal Cognitive Assessment® (MoCA®), Wechsler Abbreviated Scale of Intelligence (WASI), and the Behaviour Rating Inventory of Executive Function - Adult version (BRIEF-A) on self-reported long-term substance use and abstinence in patients with polysubstance use disorders (pSUD).

METHODS

A cohort (N = 164) of patients with pSUD who started a new treatment sequence in the Stavanger University Hospital catchment area were recruited and followed prospectively for 5 years. Participants completed neurocognitive testing with the MoCA®, WASI, and BRIEF-A at inclusion and were categorized as cognitively impaired or non-impaired according to recommended cut-off values. The sum score of the items from the Drug Use Disorders Identification Test Consumption scale (DUDIT-C) was used as a measure of substance use outcome 1 and 5 years after inclusion. We defined substance abstinence (DUDIT-C = 0) and heavy substance use (DUDIT-C ≥7) to determine whether cognitive impairments measured by the respective instruments were associated with and could predict abstinence and heavy substance use 1 and 5 years after baseline.

RESULTS

At the 1-year follow-up, 54% of the total sample reported total abstinence from substances. Conversely, 31% presented heavy substance use. At 5 years, 64% of the total sample reported abstinence from substances, while 25% presented heavy substance use. The results showed a statistically significant association between cognitive impairment defined from MoCA® and higher continuous scores on DUDIT-C at 1-year follow-up. There were no differences in substance abstinence or heavy substance use between patients with and without cognitive impairment at the 1- and 5-year follow-ups. Furthermore, cognitive impairment did not explain substance abstinence or heavy substance use at the 1- and 5-year follow-ups.

CONCLUSION

Generally, individuals with pSUD may be burdened and lack psychosocial resources to such an extent that cognitive functioning plays a subordinate role in long-term recovery. The present study suggests that results on screening tools assessing broad cognitive domains at treatment initiation have limited clinical value in predicting long-term substance use outcomes. There is a need to establish clinically viable instruments to assess cognitive functions with well-established clinical and ecological validity in the SUD population.

Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center

INTRODUCTION

Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel.

METHODS

To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses.

RESULTS

Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment.

CONCLUSIONS

Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.

Factors associated with problematic substance use before and during the COVID-19 pandemic among a drug addiction recovery cohort: A prospective study in the Netherlands, Belgium, and UK

BACKGROUND

The COVID-19 pandemic and measures have placed various burdens on societies and individuals. Emerging evidence suggests that people in drug addiction recovery were negatively affected. This study investigates whether risk and protective factors associated with return to problematic substance use differed between the periods before and during the pandemic for those in recovery.

METHODS

A convenience sample of persons in drug addiction recovery for at least three months completed an assessment at baseline before the pandemic (T0, N = 367) and at two consecutive follow-ups 12 months apart (T1, N = 311; T2, N = 246). The final follow-up took place during the pandemic (2020-2021). We analyzed rates and predictors of problematic substance use in both periods, and whether relations between predictors and problematic use differed between the periods.

RESULTS

Rates of problematic use did not differ significantly before and during the pandemic for those who were followed-up. However, the relationship between problematic use and commitment to sobriety differed between both periods (OR = 3.24, P = 0.010), as higher commitment was only associated with lower odds of problematic use during (OR = 0.27, P < 0.001), but not before, the pandemic (OR = 0.93, P = 0.762). In both periods, persons who were engaged in psychosocial support had lower odds of problematic use.

CONCLUSIONS

The COVID-19 pandemic was not followed by significant return to problematic substance use in a cohort of people who were already in drug addiction recovery for some time before the pandemic. However, with restricted access to environmental resources, they may have been more dependent on internal motivations. Targeting personal recovery resources with interventions could therefore reduce the chances of return to problematic substance use during a pandemic.

Risk of readmission among individuals with cannabis use disorder during a 15-year cohort study: the impact of socio-economic factors and psychiatric comorbidity

BACKGROUND AND AIM

Cannabis use disorder (CUD) is one of the main reasons for seeking substance treatment in the Nordic countries, but there are few studies on readmission to care. We aimed to characterize CUD readmission and estimate the magnitude of how socio-economic factors and psychiatric comorbidity influence the risk of CUD readmission.

DESIGN, SETTING AND PARTICIPANTS

This was a nation-wide cohort study carried out between 2001 and 2016 in Sweden. The participants were individuals with CUD, aged 17 years and above (n = 12 143).

MEASUREMENTS

Information on predictors was obtained from registers and included education, income and psychiatric comorbidity assessed by six disease groups. The outcome measure was readmission, defined as a CUD visit to health-care at least 6 months after initial CUD diagnosis. Hazard ratios (HR) were estimated using Cox survival analyses and flexible parametric survival analyses to assess risk of readmission and how the risk varied with age.

FINDINGS

The vast majority of CUD visits took place in outpatient care (~80%). Approximately 23% of the included individuals were readmitted to care during follow-up. The fully adjusted model showed an increased risk of readmission among those with schizophrenia and other psychotic disorders [HR = 1.54, 95% confidence interval (CI) = 1.29-1.84], low education (HR = 1.40, 95% CI = 1.24-1.57), personality disorders (HR = 1.27, 95% CI = 1.05-1.54) or mood disorders (HR = 1.27, 95% CI = 1.12-1.45). Flexible parametric modeling revealed increased risk of readmission mainly in individuals aged 18-35 years.

CONCLUSIONS

The risk of readmission was highest among those with low education, schizophrenia and other psychotic disorders, mood-related disorders or personality disorders. Individuals aged 18-35 years showed the highest risk of readmission. Our findings highlight individuals with complex health-care needs.

Nondrug reinforcers contingent on alternative behavior or abstinence increase resistance to extinction and reinstatement of ethanol-maintained behavior

The effects of delivering nondrug alternative reinforcement on resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing were evaluated in two experiments. In both, rats self-administered ethanol by lever pressing in a two-component multiple schedule during baseline. In the Rich component, alternative food reinforcement was made available for performing an alternative response (Experiment 1) or according to a differential-reinforcement-of-other-behavior schedule for lever pressing (Experiment 2). In the Lean component, only ethanol was available. Moreover, the frequency of alternative reinforcement was manipulated across conditions in Experiment 1. Following baseline, lever pressing was extinguished in both components by suspending ethanol reinforcement, and alternative food reinforcers were discontinued. Finally, to test for reinstatement, ethanol reinforcers were delivered independently of lever pressing in both components. In both experiments, proportion-of-baseline response rates were higher during extinction and reinstatement testing in the Rich component than in the Lean component (although differentiation was not observed at the lowest frequency of alternative reinforcement in Experiment 1). Thus, alternative nondrug reinforcers increased resistance to extinction and reinstatement of rats' ethanol-maintained lever pressing, even when those reinforcers were delivered contingently on an alternative response or on abstinence from lever pressing.

A review of functional brain differences predicting relapse in substance use disorder: Actionable targets for new methods of noninvasive brain stimulation

Neuroimaging studies have identified a variety of brain regions whose activity predicts substance use (i.e., relapse) in patients with substance use disorder (SUD), suggesting that malfunctioning brain networks may exacerbate relapse. However, this knowledge has not yet led to a marked improvement in treatment outcomes. Noninvasive brain stimulation (NIBS) has shown some potential for treating SUDs, and a new generation of NIBS technologies offers the possibility of selectively altering activity in both superficial and deep brain structures implicated in SUDs. The goal of the current review was to identify deeper brain structures involved in relapse to SUD and give an account of innovative methods of NIBS that might be used to target them. Included studies measured fMRI in currently abstinent SUD patients and tracked treatment outcomes, and fMRI results were organized with the framework of the Addictions Neuroclinical Assessment (ANA). Four brain structures were consistently implicated: the anterior and posterior cingulate cortices, ventral striatum and insula. These four deeper brain structures may be appropriate future targets for the treatment of SUD using these innovative NIBS technologies.

Relapse on the Road to Recovery: Learning the Lessons of Failure on the Way to Successful Behavior Change

Among individuals seeking to change health-related behaviors, relapse is a common experience. Whether it occurs very soon after initiating a change attempt or after several years of sustained changed behavior, it can be discouraging for patients and clinicians alike. Although there is a tendency in healthcare to try to ignore failure, we posit that moving on too quickly results in missed opportunities to learn critical lessons that may promote successful change in the future. In this paper, we use addictive behavior as a lens through which to explore the phenomenon of relapse. We review key insights from the Transtheoretical Model (TTM), including the importance of debriefing failure to promote successive approximation learning while recycling through stages of change. We also offer practical, evidence-based strategies for working effectively with relapse in clinical practice, which we suggest creates a more integrated, client-centered, and personalized approach to care.