Rethinking Relapse

While standing in line at the pharmacy I was approached by a client I worked with at my former position at a small methadone clinic. There is always some discomfort when seeing a client in public because one must balance politeness with protecting the clients confidentiality, this is doubly important with methadone patients. That being said I love it when clients come up to me in public. He asked me about my new job, if I regretted leaving, might I ever work at a methadone clinic again.  He listened to my answers the told me the best news I'd heard in a long time. "I'm doing great" he said, "I've got take homes." I was barely able to pause long enough to ask permission before hugging him. 

He had struggled with heroin addiction for years, had gone to then dropped out of treatment many times over the last few decades.  He had been with my clinic long before I was hired and the year he worked with me had been filled with sincere promises to stop using followed by drug screens reactive for heroin month after month after month, until the last month. I wish I could take credit for it but it was a therapeutic relationship with a nurse on the team that got him to do what I'd been trying to do for a year. He overcame his shame about being on methadone, started to look at it as medicine instead of an extension of his addiction, and adjusted his dose to a level that let him quite heroin use completely.  All I did was keep the powers that be from kicking him out and I refused to threaten to kick him out. In spite of the reactive screening month after month he was making progress. He rarely missed a day, he was addressing health issues that had gone unmanaged for years, and he was learning and applying self care techniques. I knew if he kept on going as he was eventually the heroin would stop too. I was excited to see the nonreactive screen before I left for my new job, I was thrilled to hear that in the following month he continued to improve, but I was not surprised.

I don't like the word relapse. In my opinion true relapse is rare and almost nonexistent with a client who is engaged in treatment and when it does occur it is usually caused by the reaction of the treatment team rather than the continued use.  AA unofficialy recognizes that not every use is a relapse, the term "slip" is often used to differentiate a one time use from a full blown relapse. SMART Recovery distinguishes between a "lapse" which is a short return to substance use usually a single night to a few days and a "relapse" which can last from several weeks to several years. In the clinical setting we are often behind the support groups and treat every use as a relapse. Relapse is loosely defined as a return of all or some of the symptoms of addiction, one of which is problematic substance abuse and when I say it almost never happens I'm not saying people in treatment don't abuse substances, they do.  What I'm saying is, that when they do, it's not relapse. It's not even a "slip" or a "lapse." What I'm proposing is that the substance abuse in most of what we call relapse isn't the return of a symptom, it's a symptom that, like in the example above, just hasn't gone away yet.

The above client wasn't relapsing for most of the year I worked for him. He simply continued to use, regularly, possibly daily. There were many reasons for this, he had inadequate coping skills to deal with anxiety, he had easy access to large amounts of cash, and I near unlimited supply. But the main reason he kept using was he was so ashamed of using methadone to treat his addiction that he wouldn't let the doctors raise his dose to a therapeutic level. When he didn't supplement his methadone dose with street opiates he went into withdrawal and while he could make it a few days he couldn't achieve the sustained  abstinence from heroin that was his goal, so most days he didn't try. While this continued use may have slowed the clients progress and was a blow to his self esteem he did continue to recover. 

It might be argued that his continued use may not fit the strictest definition of relapse, but his continued use certainly put him at risk for it. I agree it is possible, maybe even likely that the client's use would have spiraled out of control and put all his progress at risk. Haven't all of us even those of us who have worked in the field a short time seen it happen over and over again? A client abuses a substance, maybe they tell us, maybe they just get caught. One use leads to another and after a time you see the clients asking for change on the street, read about them in the arrest section of the paper or worse the obituaries. There is one event that has always occurred between that first use and the sad ending, the clients is either kicked or driven out of a treatment program.

In short, if you are working with a client who walks into your office and reports they got drunk over the weekend I would argue they didn't relapse. They just haven't reached their goal of complete abstinence yet. As long as they continue to work towards that goal they almost can't relapse.

 If this happens

Do

Help them take an inventory of their progress, ask questions like "how are you reacting to this use now? How is that different from a year ago?"

Review coping and grounding skills 

Review needs and supports

Don't 

Discharge or threaten to discharge the client

Pressure or scare the client into a higher level of care 

Call it a relapse.