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Relapse among Physicians with Substance Use Disorders

Studies have reported that the relapse rate of physicians with substance use disorders over a 5-year period following commencement of a monitoring agreement with a Physician Health Program (PHP) is about 20%.  This is an impressive but overly simplistic statistic. What is relapse? Are there different severities of relapse? Should relapse be considered a failure or can relapse sometimes be beneficial? There are many other questions to consider regarding relapse and its appropriate management.

The most practical and common way to define substance use disorder relapse is “return to illicit use of an addictive substance(s).” It is clear, however, that relapse exists on a broad continuum. Prior to actual substance use there are often behavior changes, changes in adherence to one’s recovery program. This can be subtle, such as discontinuing sharing at mutual support group meetings, discontinuing phoning recovery associates or a sponsor, telling lies or omitting the truth. (For a more detailed list of recovery behaviors see Table 1 below.) Any of these changes can signal the beginning of a relapse. Regarding return to illicit substance use there is also a broad continuum of severity. Substance use can be as subtle as inappropriate use of over-the-counter medications that have mood altering properties or carelessness in avoiding foods or products that contain alcohol or drugs (i.e. poppy seeds). Substance relapse itself can be limited to a “one off” use of an illicit substance. Or relapse can be severe, i.e. returning to a pattern of chronic progressive use with all the trappings of addiction, e.g. dishonesty, denial, illegal behavior, impairment etc. (See Table 2 for a list of some further examples of the progression of illicit substance use.) Since relapse exists on broad continuums it makes sense that the response to relapse should likewise be on a continuum. (See Table III) Can understanding that relapse is a process rather than event help identify it earlier? Can specific therapeutic responses to relapse target the needs of an individual to help them regain and maintain long-term recovery?

When relapse does occur, it is important to look at it as an opportunity to make correction, to figure out what was missing that led to relapse, to ultimately achieve a better recovery. Of the 20% of physicians who relapsed in one large study of over 900 physicians, over two thirds of those who relapsed only had a single relapse over the five-year period, i.e. following the relapse, which often occurred in the first year, the subsequent success rate was high. It almost seems that sometimes people have to suffer a relapse to start taking their recovery seriously.

Achieving long-term recovery is difficult and takes significant commitment. Like any other behavioral change, it is challenging and is best accomplished by changing lifestyle. There is no quick fix. In recovery circles there is a silly but poignant saying “Only one thing needs to change, everything.”

One thing is certain, having the overly simplistic view that all relapses are the same is blatantly wrong. So, organizations that have the “one strike – you’re out” approach will find that it is often difficult because relapse is so variable. People like to think in binary terms, i.e. either someone is in recovery or relapse. The truth is that recovery is an ongoing journey, always with ups and downs, and relapse is a progressive process culminating with illicit substance use, and the use pattern can be fairly benign or quite serious.

Criminal and administrative law organizations sometimes have little tolerance for relapse. Stigma regarding these disorders can be significant. Substance use disorders can be treated as crimes rather than recognizing them as illness and this discourages early reporting. Early intervention with high functioning doctors provides better patient protection than punitive interventions based on worn out stigmatization.

Table 1: Partial list of recovery behaviors – lapse of any of these can be the beginning of a relapse

  • Regular frequent attendance at mutual support groups
  • Self-disclosure, i.e. sharing the truth about one’s life
  • Calling sponsor and others
  • Asking for help and being willing to accept help
  • Keeping commitments – being reliable
  • Meditation or prayer
  • Regular exercise
  • Reading meaningful literature
  • Honesty
  • Emotional honesty – properly identifying feelings and expressing them in healthy ways
  • Humility – empathy, caring about others, service
  • Courage to try new things – responsive to suggestions
  • Assertiveness – avoiding “people pleasing” and/or aggressive behavior
  • Trust
  • Perseverance – continuing after setbacks
  • Forgiveness
  • Spontaneity
  • Enthusiasm
  • Acceptance – ability to tolerate the things that cannot be changed
  • Surrender – no longer struggling
  • Avoiding process addictions (i.e. pornography, compulsive overeating, gambling, etc.)

Table II: Examples of substance use relapses – examples of the continuum of severity

  • Use of over-the-counter medications in excess (i.e. Sudafed, Benadryl, dextromethorphan, etc.)
  • Use of designer drugs that are hard to detect (i.e. kratom, bath salts, spice, etc.)
  • Use of an addictive substance that was not the drug of choice (i.e. opioid addict having a beer)
  • Use of drug of choice
  • Illegally obtaining drug of choice (i.e. diversion, doctor shopping, dealer, internet, etc.)
  • Brief use that is self-reported, without risk to others (i.e. drinking a beer or glass of champagne over a weekend)
  • Chronic progressive use with dishonesty and denial, etc.

Table III: Appropriate responses to relapse

  • Renewed commitment to recovery behaviors with monitoring
  • “Relapse autopsy” to take a close look at what went wrong
  • Address troublesome personality issues
  • Treatment (or improved treatment) of co-occurring disorders
  • Addressing “process addictions,” i.e. sex, gambling, eating disorder, etc.
  • Addressing relationship issues
  • Psychotherapy
  • Reenter treatment
  • Discontinue work

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