Most addiction recovery professionals understand that relapse is not uncommon on the road to long-term recovery. While staying sober can be tough for those fresh out of recovery, it's even harder when their treatment program didn't really do its job.
Many addicts complete a program only to repeatedly relapse and re-enter the program, a phenomenon known in addiction circles as "revolving door syndrome." This cycle — periods of sobriety followed by relapse and more treatment — can be devastating to addicts and their loved ones.
For family members of people who struggle with addiction, the financial and emotional costs of repeated relapse have a dreary familiarity: money squandered on ineffective treatment and soaring hope followed by the crash of despair and anger. For the addict, the revolving door of treatment and relapse leads to shattered families, lost jobs, destroyed friendships and a profound sense of hopelessness, failure and self-loathing.
For these reasons, a growing number of addiction specialists are beginning to recognize the importance of treating underlying mental health disorders that contribute to or maintain substance abuse problems and using scientifically tested, evidence-based practices to stop the revolving door. That means giving addicts — patients — access to a professional team of physicians, psychiatrists, psychologists, nurses, licensed therapists, registered dieticians and counselors.
When anxiety, depression, bipolar disorder, panic disorder or post-traumatic stress go unrecognized and untreated in people addicted to drugs, alcohol or both, the likelihood of relapse increases sharply, said Anthony Mele, Psy.D., a licensed psychologist with over 25 years in the behavioral health industry and chief clinical officer for Sovereign Health, a San Clemente-based group of addiction and mental health treatment centers with nine facilities in five states.
Traditional substance abuse treatment providers who aren't mental health experts often miss a patient's co-occurring mental and substance use disorders, or what's known as dual-diagnosis status, Mele said. According to a 2014 national survey by the Substance Abuse and Mental Health Services Administration, 20.2 million adults have a substance use disorder. Of these, 7.9 million people, or 39 percent, had both a mental disorder and substance use disorder. Based on his professional experience, the actual percentage of addicts with a dual diagnosis may be as high as 60 percent, Mele said. Among the mental health disorders that co-occur with addiction, bipolar disorder and emotional dysregulation appear most frequently.
Reversing the relapse trend
Mele estimated relapse rates among people addicted to drugs or alcohol at from 50 to 90 percent. He noted that addicts are often aware of these high rates, with some viewing them as a justification for relapsing or something to be expected. Returning to drug and alcohol use is so common that it has almost become institutionalized, Mele said. "You will hear patients ask each other, 'How many times have you relapsed? How many other treatment programs have you attended?"
Rates of readmission to treatment are more readily available and can be more meaningful than relapse rates, Mele said. "We look at who comes back to us," Mele said. Sovereign's rate of readmission is 19.8 percent — lower than a statewide 24.5 percent readmission rate for patients in residential detox programs cited in a 2014 study by the National Institutes of Health.
Successful addiction treatment and lower readmission rates require expert assessment and treatment of co-occurring mental health disorders and, frequently, longer stays in a treatment center than the standard 28-day stint, which often only "patches people up," Mele said.
When asked about the treatment regimen at Sovereign, he said, "We begin our program with an intensive structured psychological evaluation process to address the addiction and the patient's personality style and level of cognitive functioning. Many providers don't understand the personality component of addiction and don't know how to assess it, or assess it very superficially."
Treating only the symptoms of addiction doesn't work, he said. "You have to address the underlying personality contributions to the addiction and identify those cognitive skills which remain relatively intact despite years of substance abuse. Without this information treatment planning will not be individualized and will likely create a good deal of frustration."
Assessing skills and needs
The initial patient assessment at Sovereign includes personality assessment, cognitive and neurological screening.
"We determine which (brain) functioning skills remain intact," Mele said. "In order for the therapist to develop a treatment plan that speaks to and uses the patient's cognitive skills, you have to know which ones are intact and which ones are impaired."
For example, the assessment helps to determine the patient's problem-solving skills, ability to shift attention and capacity to delay gratification. This understanding allows a therapist to create an individualized treatment plan focusing on the patient's specific strengths and needs.
In addition, the Sovereign assessment process examines particular personalities.
"We find out if there's a significant narcissistic or histrionic personality style that leads the patient to continue to feed their brain addiction," Mele said. If these personality styles are not addressed in addiction treatment, either the treatment fails "or the person becomes a desperate sober person for whom every trigger becomes a potentially lethal experience."
A whole picture of the whole person
Sovereign's assessment also evaluates the patient's family history and social system, and the treatment plan considers both.
"We find out what has either supported you or contributed to you looking for a substance," Mele said.
In delving into a person's emotional functioning and history, "it's important to look at what went wrong and what went right," Mele said. "Not everyone with a poor family history becomes an alcoholic, and some people from great families become alcoholics."
Treating the drinking and drug-taking that emerges in a patient's adolescence or adulthood requires looking at the roots of the problem that began many years ago, he said.
Retraining the brain
Aiming to prevent relapse by advising an addict to avoid people, places and things associated with previous drug and alcohol use doesn't go far enough, according to Mele. "You cannot avoid triggers because they're everywhere," he said.
Instead of strict avoidance, the Sovereign program emphasizes retraining the brain to deal with triggers differently. "We teach the brain not to become controlled by those triggers, but to process them differently," Mele said.
The focus on brain wellness and thinking differently empowers patients to face their triggers without responding to them or acting on them. Said Mele: "I can see a bar, but it doesn't mean I have to go into a bar. If I'm about to get off work and I start thinking about having a few beers, I don't have to respond to that thought."
Addiction relapse is a complicated process involving biological, psychological and emotional factors, said Timothy Fong, M.D., professor of psychiatry at UCLA and director of its Addiction Medicine Clinic.
"Like diabetes, hypertension, cancer, asthma or high cholesterol, if you stop addiction treatment, the symptoms come back," he said. "But with addiction, the symptoms come back in more dramatic, visible ways. If you stop your blood pressure meds and your blood pressure goes up, nobody gets too excited or throws you out."
That means addressing the particular ailment of addiction is unlike mitigating any other. "Addiction isn't a disease that's meant to be treated in isolation. There's meant to be a whole village to get you better," Fong said.
Coping with it
When co-occurring mental health disorders are ignored, an attempt at sobriety has the potential to worsen the patient's mental health, Mele said.
"Someone who has felt depressed, sad, scared and alone their entire life may have been numbing those feelings with drugs or alcohol," he said. "If you never get to what is really driving the brain's behavior, getting sober isn't going to address the problems."
Patients who respond to trauma in their lives by using drugs or alcohol never get over horrible events such as the loss of a child, a violent assault or other devastating loss, Mele said. "They can, however, learn to manage the feelings."
Sovereign's treatment model provides patients with new skills to cope with stressful and painful feelings.
Longer stays, better outcomes
Mele said he sees people at Sovereign Health who have sought addiction treatment four or five times or who have been in and out of hospital emergency rooms repeatedly.
"You can keep them for 28 days, get them sober, and patch them up. But that's only one step along the way," he said.
The typical 28-day model that prevails in the addiction treatment industry is flawed, Mele said. Sovereign offers an extended level of care that includes detoxification, subacute care, residential care and an intensive outpatient program.
"We request authorization from the insurance company for each level of care, so stays at Sovereign may be 50 days rather than 28. That contributes to our lower readmission rates, too," he said. "The longer you can keep someone in treatment, the more you can begin to address trauma or other underlying mental health problems."
Understanding the epidemics
President Barack Obama signed the Comprehensive Addiction and Recovery Act in July, authorizing funding to address the national epidemics of prescription opioid abuse and heroin use. And not a moment too soon: Drug overdose is the leading cause of accidental death in the United States, with 47,055 lethal drug overdoses in 2014, according to the American Society of Addiction Medicine.
Along with the national opioid and heroin addiction crisis, two other national epidemics contribute to chemical dependence and deaths, said Rabia Atayee, Pharm.D., associate professor of clinical pharmacy and pain management and palliative care specialist at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.
"We do have a national epidemic of chronic pain," she said, citing a 2011 Institute of Medicine report stating that 100 million adults suffer from the ailment, a persistent pain that lasts from weeks to years. "Even in patients who don't have other mental disorders, chronic pain can cause anxiety and depression.
The other epidemic is serious mental illness, Atayee said. According to the National Institute of Mental health, nearly 44 million American adults and millions of children experience mental health conditions each year.
"Most patients cannot separate physical and emotional pain. To them, it's pain. With a Band-Aid that targets the surface and not the underlying source, you're going to have a vicious cycle of addiction and relapse," she said.
Life after treatment
Addressing co-occurring mental health disorders, helping people understand how their personality affects their behavior, and teaching them to manage triggers and feelings directs Sovereign patients toward a new, healthy lifestyle after treatment.
Sovereign recently rolled out a telehealth program to help patients stay in touch using videoconferencing after they return home. Former patients also get access to continuing support through meetings, continuing education and life skills courses.
"Our patients put the brakes on the slide to the bottom," Mele said. "We help them create a new, positive life that doesn't have to be a replay of their old life."