I first met 32-year-old Miranda after a drug relapse that followed a stay in a residential addiction treatment facility. She had begun experimenting recreationally with prescription opioids in her early 20s, but her use escalated after she was involved in a car accident a few years later and a doctor began prescribing opioids for pain. Because of her increased use, Miranda decided on her own to enter a 28-day detox and rehab, but relapsed immediately upon discharge. Several months later, she made an appointment with me to discuss opioid agonist treatment. I prescribed buprenorphine, and for the first few months of treatment she appeared to be doing well.
Addiction treatment often begins with high hopes and apparent success, but it’s important to remember that addiction is a disease with a relapse rate of 40%–60% (McLellan et al, JAMA 2000;284(13):1689–1695; Dawson DA et al, Alcohol Clin Exp Res 2007;31:2036– 2045). Be realistic: Expect that patients will go through cycles of relapse and recovery. Learn the warning signs for relapse, the measures you can take to prevent it, and what to do after it has occurred.
There are a number of clues that someone has relapsed—or may be headed that way:
• Reduced eye contact during a session
• A more anxious demeanor than usual
• Less engagement, or a sense of holding back from the treatment process
• Exacerbated emotional distress or worsening co-anxiety or depression
• Vague answers to questions
• Reduced attendance at 12-step programs or therapeutic groups
• Missed visits with a psychiatrist or other caregiver
None of these red flags individually spell impending relapse—instead, it’s the pattern of behavior that tells the story. Your patient may not actually have used yet, but (wittingly or unwittingly) is starting to go down that road. This is known as desire thinking (Martino F et al, Addict Behav 2017;64:118–122), and in 12-step programs, it’s called “drinking thinking.”
After three months of buprenorphine treatment, I began to notice worrisome signs of potential relapse during one of our sessions. Miranda’s answers to my questions were more vague than usual, her eye contact faltered, and she seemed a little more anxious. Before that session, we had started talking about smoking cessation, but that day she didn’t seem interested.
At that point, I told Miranda I would need a urine sample. She hemmed and hawed for a minute, then admitted that she had started using again within the past few days. She had been spending time with her sister, who also abused a variety of illegal and prescription drugs; while there, her sister had told her, “I know you can’t use opioids, but here are some benzodiazepines. Why don’t you try those?” Miranda acquiesced, and that quickly escalated to use of marijuana and finally opioids.
Miranda’s story is fairly typical. Pressure from peers not in recovery, or simply spending time with old friends not in recovery, is cause for concern. In fact, if a patient divulges spending time with past friends to you, this can be a clue that’s just as telling as poor eye contact or unusual jitteriness.
The marijuana Miranda’s sister provided only complicated things more. For many people, using marijuana or alcohol provides a false sense of confidence. They think, “I can smoke some pot or have a couple of drinks because they aren’t my problems, and I can handle them.” But these substances are called gateway drugs for a reason—they can impair judgment and lead people to the very drugs they want to avoid.