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Relapse prevention: plan, triggers, stages, and the 5 rules of recovery

Reading time: 14 mins
different narcotics

Relapse prevention refers to the ways to keep people away from the use of drugs or harmful behaviors. It focuses on recognizing and dealing with situations that make them want to go back to those behaviors. The plan has two main goals: to stop a relapse from happening and to manage it if it does. 

Relapse triggers are situations, feelings, thoughts or conditions that increase the chance of a relapse or return to substance use. These triggers are internal, such as emotions, neutral, positive or negative feelings and external triggers are people, places, objects, or situations.

Stages of relapse prevention include emotional, mental and physical relapse. Emotional relapse involves behaviors and emotions that set the stage for potential relapse, even without active thoughts of substance use. Mental relapse is characterized by an internal struggle between the desire to use substances and the determination to abstain. Physical relapse is the final stage where individuals start using substances again.

The 5 rules of recovery include changing your life, being completely honest, asking for help, practicing self-care and by not bending the rules. Following these rules help individuals stay on track with their recovery journey and avoid potential relapse triggers.

What is a relapse?

depressed woman

Relapse refers to the resumption of substance use after a period of abstinence or significant reduction in its use. It indicates a return to the previous pattern of substance consumption, often accompanied by a loss of control over its use. It is considered a common part of the recovery process for many individuals with substance use disorders, and managing relapse is an important aspect of addiction treatment.

There is a common misconception that relapse happens suddenly and without warning. However, the truth is that relapse is often preceded by warning signs. Understanding and effectively managing these warning signs helps prevent an addiction relapse. Preventing relapse necessitates a deliberate commitment to adopting positive lifestyle changes.

Addiction relapse is not an indication of treatment failure. If someone in recovery from addiction experiences a relapse, they should seek advice from their doctor to resume, adjust, or consider alternative treatments. Although relapse is a common occurrence in recovery, it is perilous or even deadly with certain drugs due to the risk of overdose as highlighted in the article titled “Drugs, Brains, and Behavior: The Science of Addiction” under Treatment and Recovery section published by the National Institute on Drug Abuse (NIDA) in 2023.

Why does addiction relapse happen?

Addiction relapse happens as a result of its chronic nature and a variety of contributing factors. Research indicates that factors such as stress, negative feelings and thoughts, temptations, boredom, job instability, and poor support systems contribute to addiction relapse vulnerability, as outlined in the article “New Findings on Biological Factors Predicting Addiction Relapse Vulnerability” by Rajita Sinha, published in the journal Current Psychiatry Reports in 2011.  

 The article ”Public Policy Statement: Definition of Addiction” published by the American Society of Addiction Medicine (ASAM) on August 15, 2011, describes the relationship between drug addiction and relapse. It defines addiction as a chronic brain disease affecting the brain’s reward, motivation, and memory functions, leading to issues in various aspects of life such as physical, mental, social, and spiritual. Drug addiction leads to cycles of relapse and remission, similar to other chronic illnesses. Without treatment, it worsens and even leads to disability or death. Relapse, or returning to substance use after stopping, is common and is triggered by exposure to substances, stress, or cues. These cues can be anything from being in places where one previously used drugs, encountering people associated with past drug use, or experiencing stressful situations that trigger the desire to escape or numb emotions.

What is relapse prevention?

Relapse prevention refers to strategies and techniques used to prevent a return to substance use or addictive behaviors after a period of abstinence. It involves identifying and managing triggers, developing coping skills, enhancing self-efficacy, building a support network, and implementing lifestyle changes to maintain sobriety and avoid relapse. Relapse prevention is a key component of addiction treatment and recovery programs, helping individuals develop the skills and mindset needed to sustain long-term recovery.

In the article “Relapse prevention: An overview of Marlatt’s cognitive-behavioral model”  authored by M.E. Larimer et al., published in the journal Alcohol Research and Health in 1999, Marlatt and Gordon’s model underscores various ways to prevent relapse. Specific interventions help identify risky situations and improve coping skills. They boost self-confidence, correct misconceptions about alcohol, manage lapses, and change how the client sees relapse. Global strategies help balance the client’s life, create positive habits, use control and urge-management techniques, and make plans for relapse.

The concept of the abstinence violation effect (AVE) is a key aspect of relapse prevention, as discussed in the article “Relapse prevention” by Jayakrishnan Menon and Arun Kandasamy in the Indian Journal of Psychiatry in 2018. AVE is a phenomenon in which individuals respond to a relapse by blaming themselves, leading to a perceived loss of control. This effect occurs when individuals believe there is no intermediary step between a minor slip-up (lapse) and a complete return to heavy substance use (relapse). Essentially, they feel that since they have already broken their abstinence, they might as well continue using.

What is a relapse prevention plan?

man says no to drugs with hand

A relapse prevention plan is an individualized strategic plan for people recovering from addiction, helping them anticipate, avoid, and cope with triggers. It includes identifying triggers, developing coping strategies, building support, and setting goals.

The article “Relapse Prevention and the Five Rules of Recovery” by Steven M. Melemis, published in the Yale Journal of Biology and Medicine in 2015, outlines four key concepts in relapse prevention. Firstly, it emphasizes that relapse is a gradual process with identifiable stages, and effective treatment aims to help individuals recognize these early stages when success rates are highest. Secondly, it suggests that recovery is a journey of personal growth marked by specific milestones, each stage carrying its own risks of relapse. Thirdly, it highlights cognitive therapy and mind-body relaxation as crucial tools for relapse prevention, as they help change negative thought patterns and foster healthy coping mechanisms. Lastly, the article suggests that most relapses are understood through a few fundamental rules, and educating individuals about these rules help them prioritize their recovery efforts.

How to create a relapse prevention plan?

To create a relapse prevention plan, start by setting clear goals and motivations for your recovery. Think about why staying sober is important to you and what you hope to achieve in the long run. Next, identify your triggers—these are situations, emotions, objects or people that tempt you to use substances. Knowing your triggers will help you develop strategies to cope with them.

Once you’ve identified your triggers, brainstorm healthy ways to cope with them. This includes practicing relaxation techniques like mindful yoga, meditation or exercises, spending time with supportive people, or engaging in physical activities. Build a strong support system of people who motivate you in your journey to recovery. 

Prioritizing activities that make you happy, practice self-compassion, and regularly review your progress and update your relapse prevention plan to ensure it stays relevant and effective for your recovery journey. Lastly, don’t hesitate to seek professional help if you need it.

To ensure the effectiveness of your relapse prevention plan, it’s essential to keep it accessible. Whether you choose to write it down, store it on your phone, or create a digital document, easy access will help you stay committed. Additionally, setting realistic and achievable goals is crucial. Avoid overwhelming yourself with unrealistic expectations, as this leads to frustration. Lastly, remember to reward yourself for sticking to your plan. Positive reinforcement helps maintain motivation and reinforce your commitment to recovery.

What are relapse triggers?

Relapse triggers refer to the situations, feelings, or conditions that heighten the likelihood of a relapse or a return to substance use.

The relapse triggers are listed below.

  • Internal relapse triggers
  • External relapse triggers
cocaine bag

1. Internal relapse triggers

Internal relapse triggers are emotions, thoughts, or feelings that lead a person to use substances again. Highly stressful situations and chronic stress increase vulnerability to addiction and risk of relapse, as highlighted in the article “Chronic Stress, Drug Use, and Vulnerability to Addiction” by Rajita Sinha, published in the journal Annals of the New York Academy of Sciences in 2009. Stress exacerbates internal triggers, heightening the risk of developing addiction and relapse.

Neutral feelings, such as boredom or emptiness, serve as internal triggers for relapse. These emotions prompt individuals to seek out substances or addictive behaviors to alleviate the sense of emptiness. Unlike intense emotions, neutral feelings are subtle and are overlooked, making them challenging to manage. Nevertheless, if not addressed, these neutral emotions perpetuate the cycle of addiction and relapse.

Positive emotions act as internal triggers for relapse. When individuals experience positive emotions, such as excitement or happiness, they associate these feelings with past substance use or addictive behaviors. This creates a craving or desire to recreate those pleasurable experiences, leading to a relapse. It’s important for individuals in recovery to be aware of how positive emotions trigger cravings and to develop healthy coping strategies to manage these triggers.

Negative thoughts and self-criticism are powerful internal triggers. When individuals experience these negative thoughts, they feel overwhelmed by emotional distress. To cope with these difficult feelings, they turn to their past addictive behaviors to escape or numb their emotions. This pattern of using substances to cope becomes deeply ingrained, making it challenging to resist the urge to relapse. 

Emotions, whether positive or negative, serve as triggers for relapse. Simply avoiding these emotions is not an effective strategy for preventing relapse. The study “Emotional triggers and their relation to impulsive and compulsive psychopathology” by Adrienne Abramowitz and Howard Berenbaum, published in the journal Personality and Individual Differences in 2007, highlights how individual differences in emotional experiences predict impulsive-compulsive (I-C) psychopathology. They described the significance of emotional triggers in understanding and predicting I-C psychopathology. Therefore, it is important to address and manage these challenging emotions to reduce the risk of relapse.

 Another research paper, “Relapse Triggers for Drug Addiction” authored by Kaylyn Farris and published in the 2017 issue of the journal Integrated Studies, discusses how emotional factors like stress, fear, frustration, depression, and anxiety contribute to relapse. For individuals, drugs serve as a coping mechanism, making them more susceptible to relapsing.

2. External relapse triggers

External relapse triggers are environmental, social, or situational factors that  prompt someone in recovery to relapse. These triggers include people, places, objects, or situations that evoke memories or cravings associated with past substance use.

People trigger relapse in addiction recovery for different reasons. Just being around someone from the past who used drugs brings back memories and cravings, stirring up a mix of emotions and sensations that are overwhelming and challenging to navigate. People associated with substance use, such as friends, family members, colleagues, or former drug dealers, encourage the person in recovery to use substances again, increasing the risk of relapse. Witnessing others using drugs normalizes the behavior, making it harder to stay sober. Stressful interactions or conflicts lead someone to seek comfort in drugs. Friends or acquaintances who pressure someone to use substances don’t understand their struggles triggers. Additionally, not having enough support makes someone feel isolated and more likely to relapse.  

Places that are familiar provokes potential risk of relapse. Places like worksites, bathrooms, schools, former drug stash locations, friends’ houses, bars, concerts, neighborhoods, and hotels are common triggers for relapse and should be approached with caution. Avoiding these places altogether or finding alternative routes is beneficial to reduce the risk of relapse.

Objects that trigger external relapse by evoking memories or associations with past substance use are often referred to as “cue-induced cravings” or “relapse triggers” for example, how seeing a beer bottle reminds someone of the pleasure they once derived from drinking. Objects associated with drug use, such as a pipe or a syringe, trigger cravings and thoughts of using drugs again. These objects serve as visual cues that activate the brain’s reward system, making it more likely for someone in recovery to relapse.

Situations like parties, holidays, lack of routine, financial issues, work related pressure, uneventful happenings in family, all trigger relapse. Individuals with poor coping mechanisms feel stressed and are unable to cope up with the challenging situations. Managing these situations without drugs becomes difficult and overwhelming, increasing the risk of relapse.

The article “A QUALITATIVE EXPLORATION OF DRUG ABUSE RELAPSE FOLLOWING TREATMENT” by Manirul Islam, published in the Journal of Ethnographic & Qualitative Research in 2012, explores how individuals experience relapse due to various situational factors such as emotional issues like boredom, stress, or the influence of friends who use drugs. It highlights the availability of drugs in the community as a significant contributor to relapse, noting that easy access to drugs increases the likelihood of relapse, particularly in environments where drug use is prevalent. Additionally, the article discusses how situational factors, including the lack of recreational facilities and negative community attitudes towards drug users, play a role in relapse. It further examines how the cyclical nature of relapse leads to broken families, perpetuating the cycle of treatment and relapse.

What are the stages of relapse?

The stages of relapse are listed below.

  • Emotional relapse
  • Mental relapse 
  • Physical relapse
depressed man

1. Emotional relapse

Emotional relapse involves behaviors and emotions that create conditions for a potential relapse, even without active thoughts of substance use. Individuals’ actions, emotions, and feelings inadvertently lead them back to substance use. Recognizing these emotions is challenging, leading to ignorance or denial.

The chapter “Relapse Prevention for Alcohol and Drug Problems” by G. Alan Marlatt and Katie Witkiewitz, published in the book “Relapse Prevention, Second Edition, Maintenance Strategies in the Treatment of Addictive Behaviors” in 2005, identifies negative emotional states as a key predictor of emotional relapse.

Emotional relapse is identified by signs such as isolation, which manifest as neglecting support group meetings or attending but not sharing, as well as exhibiting poor self-care, including unhealthy eating and sleeping habits.

Neglecting these signs of emotional relapse results in individuals feeling restless, irritable, and discontent over time. This eventually leaves individuals experiencing them to contemplate using substances to alleviate these negative emotions. Early recognition and intervention prevent further progression into relapse stages.

2. Mental relapse

Mental relapse is characterized by an internal struggle where individuals find themselves at odds with their desire to use substances and their determination to abstain. Willpower to stay sober weakens, and the urge to escape reality gets stronger as mental relapse progresses.

The article “Addiction Relapse Prevention” authored by Nicholas Guenzel and Dennis McChargue, published by StatPearls last updated in 2023, details the signs of mental relapse. These include craving drugs or alcohol, reminiscing about past substance use triggers, downplaying or glorifying past use, bargaining with oneself, being dishonest, attempting to control use, seeking opportunities to relapse, and planning to resume substance use.

In the bargaining stage, individuals justify situations where using drugs or alcohol would be considered casual, like during holidays or vacations. Individuals actively consider the possibility of controlled relapses, thinking about allowing themselves to use substances once or twice a year or even pondering the idea of switching to a different addictive substance.

3. Physical relapse

Physical relapse is the last stage of relapse where individuals start using substances again. In the article “Lapse and Relapse Rates in Narcotics Anonymous versus Methadone Maintenance Treatment: A 12-Month Prospective Study” by Fahimeh Mohseni et al., published in the Iranian Journal of Psychiatry in 2022, researchers distinguish between two stages: the “lapse” stage and the “relapse” stage. A lapse is a brief and isolated instance of drug use, while relapse involves more intense and continuous drug use. Lapse is considered the first stage leading to full relapse, representing the initial step in the path toward relapse. 

Understanding the importance of even a minor lapse is important as it rapidly escalates into uncontrolled substance use. Furthermore, a lapse stimulates obsessive thoughts about using the substance, making it harder to resist.

What are the relapse warning signs?

The relapse warning signs are listed below.

  • Isolation: Isolation is a warning indicator of relapse since it implies a loss of social support and healthy activities, as well as a decrease in accountability and good influences. Increased loneliness as a result prompts substance abuse. Devoid of outside support, isolation breeds pessimistic attitudes and desires. To avoid recurrence, it’s critical to identify the warning symptoms of isolation and get help.
  • Behavior changes: Behavior changes like compulsive behaviors is a warning sign of relapse. These behaviors include developing new compulsive habits related to substance use, seeking out friends who use substances, revisiting places where they used to use, or engaging in risky behaviors. Recognizing these behaviors and seeking support is important to prevent relapse. 
  • Negative emotions: Negative emotions like feeling overwhelmed, stressed, or inability to cope with emotions, is a warning sign of relapse. These negative emotions trigger the desire to use substances as a way to cope or escape. When individuals are unable to manage these negative emotions effectively, they turn to substance use as a temporary relief solution. 
  • Defensiveness: Becoming defensive and avoiding discussions about substance use or recovery, is a warning sign of relapse. When individuals become defensive or avoid conversations about their substance use, it indicates that they are struggling with their recovery or feeling guilty about their behavior. This defensiveness is a way to protect themselves from facing the reality of their situation or from feeling judged by others.
  • Neglecting responsibilities: These include missing work, skipping classes, or neglecting family duties. This change suggests that someone in recovery is struggling and is at a risk of relapse. 
  • Reappearance of withdrawal symptoms: Withdrawal symptoms such as sweating, shaking, or nausea, returning after a period of detox and recovery is a warning sign of relapse. These symptoms resurface as the body expects the substance it relied on, indicating a possible relapse. Recognizing these physical signs early and seeking help is crucial in preventing relapse and maintaining recovery.

What are the 5 rules of recovery and relapse prevention?

The 5 rules of recovery and relapse prevention are listed below.

  • Change your life
  • Be completely honest
  • Ask for help
  • Practice self-care
  • Don’t bend the rules

1. Change your life

Changing your life takes more than just stopping substance use. It requires modifying your general lifestyle. This entails forming new, healthy routines, such as engaging in enjoyable activities, pursuing interests, and hanging out with supportive and motivating individuals. determining the high-risk variables, such as individuals, locations, items, circumstances, or feelings from the past, that operate as triggers. In addition, therapy is utilized to address underlying emotional or psychological difficulties in order to decrease recurrence and increase recovery.

Recovering from addiction is challenging, often bringing up self-doubt and fears about staying clean and transitioning to a new lifestyle. However, it’s important to replace these negative thoughts with positive ones. Changing negative thinking patterns is key, involving challenging and reframing negative thoughts, fostering a positive outlook, and focusing on solutions. View recovery as a chance to assess your life, make positive choices, and prioritize self-love and care.

Avoid high-risk situations in recovery, such as associating with drug-using peers and rationalizing one-time indulgences. These scenarios involve intense emotions and lead to relapse. Prioritize rational thinking and honesty in risk assessment to maintain recovery.

Determine the symptoms of H.A.L.T., an acronym for Hungry, Angry, Lonely, and Tired. These emotional states frequently serve as catalysts for relapses in addiction rehabilitation. Hunger causes our body to run low on energy, which makes us agitated, tired, and unable to focus, which increases our susceptibility to cravings. Anger impairs judgment, isolates us, and encourages impulsive behavior, making it a powerful relapse trigger. Feeling isolated or indifferent contributes to relapse, as strong social connections are significant for overall well-being. Fatigue not only affects judgment but makes one more prone to desires and is a sign of underlying health problems that require medical treatment.

By recognizing these emotions and states and taking proactive steps to address them, you reduce the risk of relapse and maintain your recovery.

2. Be completely honest

Be completely honest with your ideas, thoughts, feelings and behaviors. It involves being honest about the difficulties in recovering and seeking assistance when needed. Having an open communication with the therapists, support system and sponsors allows for appropriate advice and support during challenging times. Being truthful with professionals about the progress or any potential relapses enables you to adjust your treatment plan as needed.

3. Ask for help

Ask for help when you feel intense cravings, or you feel weak. Recovery is rarely a solo journey. Reaching out for help demonstrates strength and commitment to your well-being.  Therapy provides tools to manage cravings, address underlying issues, and develop healthy coping mechanisms. Support groups offer encouragement, shared experiences, and a sense of belonging. Connecting with others who understand your struggles help incredibly. Surround yourself with positive and supportive loved ones who will encourage your recovery journey.

4. Practice self-care

Practice self-care by rewarding yourself with small acts of kindness and creating a healthy routine that you stick to. This includes making sleep a priority, maintaining a healthy diet and lifestyle, and getting regular exercise to enhance overall wellbeing and help control cravings and stress. Using stress-reduction methods including yoga, meditation, and deep breathing help to reduce the risk of relapse. Taking part in enjoyable activities, like going on nature hikes or taking up a hobby, are important to your emotional health and healing process.

5. Don’t bend the rules

Don’t bend the rules of recovery by convincing yourself occasional drug use is acceptable. Testing yourself in this way increases the risk of relapse and undermines your progress. To stay clean for the long-term, maintain strict adherence to your short-term and long-term goals. Recognize that occasional use leads back to addiction, even after years of sobriety. Stay vigilant against temptations and remember that recovery is a process with its challenges. Set boundaries to avoid triggering situations, focus on staying abstinent one day at a time, and celebrate your progress to reinforce positive behavior and motivation.

What are the coping skills for relapse prevention?

group therapy session

The coping skills for relapse prevention are listed below.

  • Identifying triggers: Identifying triggers is a coping skill that involves becoming aware of the specific people, places, objects or situations that lead to cravings or urges to use substances or engage in harmful behaviors. By recognizing these triggers, individuals take proactive steps to avoid or manage them more effectively. 
  • Setting goals: Setting goals involves establishing realistic and achievable objectives for short term and long term to maintain focus and motivation in recovery. These goals are around physical, mental, interpersonal, and occupational growth and well-being. Setting SMART (specific, measurable, achievable, relevant, and time-bound) goals creates an easy roadmap to recovery by tracking progress.
  • Mindfulness and relaxation techniques: These techniques involve practicing mindfulness meditation, deep breathing exercises, or yoga to help manage stress and reduce cravings. Mindfulness meditation involves focusing on the present moment without judgment, which helps individuals become more aware of their thoughts and feelings and reduce the risk of relapse.
  • Healthy lifestyle: Maintaining a healthy lifestyle involves prioritizing habits such as eating a balanced diet, engaging in regular physical activity, and ensuring an adequate amount of sleep. These practices not only improve physical health but enhance overall well-being and reduce the risk of relapse.
  • Support system: Having a support system involves surrounding yourself with individuals who provide encouragement, guidance, and understanding during challenging times. This support comes from friends, family members, support groups, or mental health professionals. Having a strong support system helps individuals feel less alone in their struggles and provides them with the resources and encouragement needed to stay motivated and focused on their recovery journey.
  • Identifying HALT symptoms: HALT stands for Hungry, Angry, Lonely, and Tired, emotional states that trigger cravings. Addressing these needs through healthy means, such as eating balanced meals, managing anger constructively, building relationships, and ensuring adequate rest, helps reduce cravings and supports recovery by replacing harmful behaviors with positive alternatives. By recognizing HALT symptoms, individuals take proactive steps to avoid or manage them more effectively. 
  • Practice journal writing: Practicing journal writing involves regularly writing down thoughts, feelings, and experiences in a journal. This practice helps individuals to process their emotions, gain insight into their behavior patterns, and track their progress in recovery. 
  • Seeking professional help: Seeking professional help involves reaching out to trained mental health professionals, such as therapists, counselors, or psychiatrists, for support and guidance in managing mental health challenges or addiction recovery. These professionals provide therapy, medication management, and treatments to help individuals cope with their difficulties and work towards healing and recovery.