By Kevin Doyle, EdD
For those of us who have worked to treat individuals with substance use disorders, the term relapse is one we learned early in our careers. For example, the phrase “relapse is a process not an event,” is one that has been repeated for years, and drilled into the heads of practitioners — rightly so, of course. Twelve Step fellowships, like Alcoholics Anonymous, have long used the term slip, which, although feeling a bit informal and casual, is another way to describe a temporary return to use that does not result in the catastrophic process that sometimes happens when an individual drinks or uses a mood-altering substance after a period of abstinence. These days, “return to use” or recurrence of use” are even better terms than relapse or slip, which carry some moral culpability with them.
Beyond the words, however, it strikes me that the meaning matters most. And the circumstances. Not all returns to use are the same, and we can’t treat them as such.
A situation in which a person recovering from an alcohol use disorder takes a drink, realizes the risk taken, and then calls a person in recovery and re-engages with A.A., for example, is quite different from one in which the same person takes a drink, feels like a failure, and proceeds to go on a two-week bender leading to a hospital emergency room visit for an alcohol overdose.
In many ways, the process of measuring recovery simply by number of days without a drink or drug, while very helpful for many (e.g., receiving chips or tokens recognizing days/months/years of sobriety), can be too simplistic and even counterproductive for others. Who has the stronger recovery: an individual such as the one above who — let’s say — had 10 years of uninterrupted abstinence and immediately reached out for help after the brief return to use, or one with 90 days total in recovery? I would argue the former. As one patient conceptualized in a group I was leading, it may be more helpful to look at recovery like a batting average — the percentage of substance-free days over a period of time. That, in fact, has become one of many ways to measure recovery outcomes.
Don’t misunderstand: for nearly all individuals with a substance use disorder, particularly when moderate or severe, complete abstinence is the gold standard — the way to reduce risk the most. But simply using a linear model to measure what is often a non-linear recovery can be problematic.
Likewise, there is the question of abstinence — from what exactly? Most addiction care professionals advocate for abstinence from all mood-altering chemicals not just the so-called drug of choice or primary drug of use. Makes sense — but what about caffeine, nicotine and prescribed medications (whether for the substance use disorder or another mental health condition)? There is less agreement in the professional community around those substances.
Some will say “a drug is a drug is a drug,” which sounds logical until one considers the importance of psychotropic medications for people with co-occurring mental health conditions such as depression, bipolar disorder, or schizophrenia. Surely, we would not label such people as not in recovery when they are taking legitimately prescribed medications appropriately. With now widespread use of effective medications such as buprenorphine, naltrexone and methadone to treat opioid use disorders, people on a recovery path that includes such medications should also be considered in recovery. Finally, while few professionals seem to consider caffeine consumption as a return to substance use, nicotine is another story. Tobacco use is extremely harmful to one’s overall health, and data exist to show that it interferes with recovery from other substance use disorders as well. But does it constitute a return to active use (a “relapse”)? If one argues that it does, then smoking a cigarette could result in a return to the legal system for individuals mandated to be abstinent.
Clearly, further consideration of not just the term relapse, but its meaning in the context of recovery is needed as we continue to learn how best to help people with substance use disorders, including those in recovery.