HEALTH : Why Do Those Who Undergo Substance Abuse Treatment Suffer Relapses?

It happened recently to Kitty Dukakis and Drew Barrymore. It plagued Elizabeth Taylor for years. And it has sent hundreds of less well-known folks into a similar downward spiral, one that for some has ended in death.

The problem is relapse, the reoccurrence of an addiction. It is a surprisingly common experience among recovering drug addicts and alcoholics. It is not well understood by the public or by many clinicians in the field.

No Superior Treatments

According to experts on chemical dependencies, no treatment methods have been proven superior in preventing an addiction’s return.

But they do know that relapse is experienced by most recovering alcoholics and drug addicts--as many as four out of five of them experience it, estimates one researcher in Washington state--and that it can occur as long as decades after the initial successful treatment.

Moreover, experts say, it does not necessarily mean a return to the same addictive substance: A pill abuser could relapse with alcohol, for example, or an alcoholic could switch to marijuana.

“People assume there is a ‘fix’ that happens in treatment, and that isn’t so,” said Ellsa Sorenson, a counseling supervisor at the Hazelden Foundation, a renowned drug and alcohol rehabilitation clinic in Minnesota. “Part of the disease (of substance addiction) is a relapse for some people. . . . The disease can be arrested, but never cured.”

Elizabeth Taylor’s bouts with drugs and booze are legend. But Kitty Dukakis’ recent disclosure that she had an alcohol problem surprised the public as well as many of her close friends.

Post-Election ‘Letdown’

The wife of Massachusetts Gov. Michael Dukakis successfully ended a 26-year addiction to diet pills at Hazelden in 1982. But on Feb. 6, the governor called a press conference to announce that his wife was entering Edgehill, a private rehabilitation clinic in Newport, R.I., because the post-election “letdown” of his presidential campaign defeat by George Bush caused her to start drinking “excessive quantities” of alcohol.

According to his prepared statement, his wife voluntarily sought treatment because she knows she is “chemically dependent” and that her recovery is “always at risk.”

Drew Barrymore, the actress who at age 6 enraptured movie audiences with her portrayal of Gertie in “E.T.,” disclosed in a People magazine interview last month that she underwent treatment for drug abuse twice last year at the ASAP Family Treatment Center in Van Nuys.

In the interview, the actress, now 13, blamed her addiction and relapse on the pressures of life in the fast lane, an array of family problems and an inability to stay away from friends who abused drugs and alcohol. She abused a series of substances, beginning with alcohol at age 9, then moving on to marijuana at 10 and cocaine at 12.

Clinicians who treat people with addictions say celebrities are no more likely to develop a dependency--or a relapse--than average people. Although average folks don’t suffer under the glare of the media spotlight when they seek help, the pain of acknowledging that they failed to stay clean of drugs or alcohol cuts just as deep, they say.

Growing Up a ‘Loner’

In a recent interview, Tina T.--a 31-year-old account executive for a San Fernando Valley manufacturing company who asked that her full name not be used--described herself growing up as a “loner.” She kept upsetting feelings bottled up inside. To mask the uncomfortable feelings, she turned to sniffing glue and paint when she was 9, eventually switching to marijuana, then alcohol.

In retrospect, Tina T. said she believes that she set herself up for a relapse while still in the hospital undergoing counseling. She sought alcoholism treatment at St. Joseph Medical Center in Burbank in 1986 and again in 1988.

During her first stay, “I didn’t (drink) anything, but I was isolating (myself),” she said. “With alcoholics and addicts, the reason you go to meetings is to share where you’re at. I just didn’t share. I was afraid of getting hurt . . . of putting (my)self on the line and someone not liking (me) for what (I am). I don’t think I could admit I was an alcoholic.”

A week after she left the hospital, she got high on marijuana. “But I didn’t drink,” she said, “so I thought that was OK.”

A month later, she started taking diet pills, eventually consuming as many as eight a day. She rationalized her use of the amphetamines by telling herself “it’s OK because it’s over the counter” and must be safe.

‘I Was So Sick’

In September, 1987, she went on a business trip to pitch her company’s line at a trade show. It was the first time she represented the company at a show and the first time she had ridden a jet--two ample causes, she thought, to feel nervous. In her hotel room the first night, she ordered a bottle of wine to relax, but thought better of it and called Alcoholics Anonymous for moral support.

The next night was even tougher. That is when she drank a margarita, her first alcohol in months.

By December, she was stashing bottles at home and imbibing a fifth to a quart of tequila a day, besides taking the diet pills.

“I was so sick,” she said.

She found that drinking no longer helped to relieve the nausea she awoke with every morning or the hurt and angry feelings that she kept pent-up inside.

“I felt spiritually dead,” she said. Luckily, “(I had a) moment of clarity where I couldn’t take it anymore, and I said, ‘God, get me out of this one.’ ”

A feeling of “incomprehensible demoralization” finally drove her back into treatment, she said.

She claims to recognize now where her mistake was: when she smoked that first joint after her 1986 hospitalization and thought she was safe as long as she stayed away from alcohol. “That is where the fallacy is. . . . Once you’re addicted to something,” she said, “you’re addicted to everything.”

New Cycle of Addiction

The National Institute on Drug Abuse reports that almost 2 million people were treated for alcohol or drug abuse in 1987, the last year for which figures are available. Estimates of the occurrence of relapses among people who have undergone treatment vary, but all are discouragingly high.

G. Alan Marlatt, a clinical psychologist at the Addictive Behaviors Research Center at the University of Washington in Seattle, estimates that four out of five patients will experience one or more relapses. For most, the risk is highest in the first 90 days after completing a treatment program.

“Most will have some setbacks along the way,” he said. “It’s a rocky road that leads to a successful outcome, (but) for many it will take five or six times. Some can do it the first time. It’s hard to tell who is going to perform (well) and who isn’t.”

James Conway, director of St. Joseph Medical Center’s alcohol and chemical dependency program, said he has seen patients return for help with a new addiction after decades of freedom from a substance dependency.

He said he has found that about a third of patients in a treatment group experience “a continuous, long-term, uninterrupted recovery without relapse.” But another third will have a major relapse and a third will go through a series of relapses. “I’ve seen people recover who had multiple, serial relapses, some with horrible consequences, who eventually made it,” he said, adding, “I’ve seen some who die in relapse.”

Warning Signs of Relapse

Experts agree on signs that a recovering addict is on the verge of drinking or taking drugs again, such as withdrawing from or avoiding support group meetings, overeating, severe mood swings, isolation from friends who are recovering addicts or increased irritability.

But the causes of a relapse--physiological factors or an addictive personality--is as much a matter for debate as what causes an addiction in the first place.

“The whole area of relapse has not been well studied,” noted Dr. Ernest Noble, Pike professor of alcohol studies at UCLA.

He said stress, as in Kitty Dukakis’ case, often reactivates an addiction. On the other hand, however, some studies have shown that cigarette, alcohol or drug dependency can cause chemical imbalances in the brain that can predispose individuals to abuse a substance again.

“That imbalance,” he said, “creates a situation where other kinds of mind-altering agents are looked for to take care of behavioral problems.”

Marlatt said research on various treatment methods has not shown strong links between a particular approach and a lower relapse rate. That, he noted, “raises the interesting question of what does treatment really do? There is no clear evidence that the more treatment you have, the better you’re going to be.”

Dr. Matoi Hayashida, a University of Pennsylvania psychiatry professor, said addiction prevention “is still pretty much filled with certain dogmatic beliefs,” such as that treatment programs requiring residence in a facility are more effective than those that don’t.

In a paper published this month in the New England Journal of Medicine, Hayashida and a team of Penn researchers reported finding no significant difference in relapse rates between those hospitalized for treatment and those whose treatment did not require a hospital stay. The study found less than a 50% success rate after six months among 164 male veterans surveyed, achieved “irrespective of the setting in which (patients) had been detoxified.”

Thus, he said, he would advise individuals considering addiction treatment that outpatient therapy, which is far less costly, appears to be just as effective as programs requiring long hospitalization. He and his colleagues found the costs of inpatient programs ranged from $3,319 to $3,665 per patient, while non-residential programs cost $175 to $388 per patient.

An Ounce of Prevention

Marlatt--co-author of the 1985 book “Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors”--and other experts believe that relapses can be prevented.

The goal of relapse treatment, Marlatt said, should be to find out “what will throw a person off course,” then focus on strategies to avoid risk situations: “We map out the areas where a person is going to have a problem. (For example,) ‘If I’m alone on a business trip and no one knows me, I get most tempted there.’ So how are you going to handle that? We say, for the first year, cut out those trips.”

Marlatt said most treatment programs “don’t deal with those types of things. . . . They don’t tell (patients) how not to drink or use drugs, what to do in tempting situations.”

Father Leo Booth, an Episcopal priest and addiction counselor, teaches a weekly class in relapse prevention at Presbyterian Intercommunity Hospital of Whittier. In the course, he shows family members how to recognize symptoms that a relapse is imminent--overeating, mood swings, avoidance of friends who are recovering from an addiction or inappropriate expressions of anger, sarcasm or violence. “Family awareness of this can stop people from relapsing fully,” he said.

Tina T. said now she attends meetings of a relapse support group faithfully and writes in a journal regularly as an emotional outlet. She has been free of drugs and booze for a year.

“By all rights, I should be dead, and by God’s grace, I’m not. But I’m working hard (to stay sober),” she said emphatically. “I’m feeling a lot better about my recovery.”