“People, places, and things” is a phrase heard in Alcoholics Anonymous to summarize common environmental cues that can trigger cravings leading to relapses – a full return to substance use that can be extremely discouraging to people struggling with recovery from substance use disorders.
My general recommendation is to avoid environmental triggers as much as possible. Many people in early recovery, however, have a difficult time with that. Our patients often are tempted to test themselves, or they mistakenly believe that their recovery is strengthened by exposing themselves to bars, neighborhoods, or friends associated with their previous use. Some medications, such as acamprosate, can reduce the power of these cues.
Coming into minimal contact with an addictive substance, either intentionally or accidentally, is a second trigger that can often lead to a full return to use. Medications such as disulfiram (Antabuse), buprenorphine (Suboxone), or naltrexone (Vivitrol) can be useful in reducing cravings and the tendency to act on them.
Stress is a third trigger. The mnemonic “HALT” is often repeated in 12-Step circles to warn newcomers to be on guard for a relapse when they feel hungry, angry, lonely, and tired. Many people would add boredom, guilt, sadness, and physical pain to that list. Introspection, prayer, distraction, or psychotherapy can help people defuse these triggers.
Our approach at Kolmac is to establish abstinence from addictive substances at the beginning of treatment and then work to prevent a relapse. As more is learned about them, better strategies can be developed to prevent relapses. We now know that the mechanisms underlying these three paths to relapse involve different brain areas and neurotransmitters. For instance, a person’s stress system can be sensitized by the addictive use of substances, making them more vulnerable to stress-induced relapses.
A group of medications, used for many years to treat hypertension, has been found to reduce PTSD nightmares. These “alpha-2 agonists” (clonidine, guanfacine) appear to work by reducing norepinephrine hyperactivity in the brainstem. Recent research suggests that these medications, which are not addictive and have a good safety profile, may also be useful in reducing stress-induced relapses.
We are starting to use them at Kolmac on a pilot basis for patients struggling with stress-induced relapses. I will update you about their actual usefulness as we get more experience with them.