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Relapse From Substance Use Disorder

Photograph of a neon BAR sign with an arrow pointing indicating the temptation to relapse from alcohol use disorder.

In yesterday’s post on AddictionNews, we looked at a longitudinal study of 39 persons undergoing substance use disorder treatment as outpatients in Bordeaux, France. The study monitored cravings every few hours for the first 14 days of treatment. Five years later, the researchers looked at who was abstinent and who was still using.

While that study found that 20 of the 39 patients had relapsed — a very typical percentage — it also revealed a strong correlation between low “craving inertia” and the tendency to relapse. Craving inertia is the momentum of craving intensity between checks. Craving intensity decreased more slowly for those with a higher likelihood of relapse. Interestingly, the study did not find a correlation between craving intensity and relapse.

Another small study from Norway sought to uncover similar patterns. This time, 19 patients were tracked, including seven females and 12 males. Participants were in long-term inpatient treatment for substance use disorders. Data was collected three times per week for several weeks, leading to 252 sessions. The study tried to assess the impact of the following factors on the potential for relapse:

  • mental health load
  • self-control
  • craving intensity

Relapse rates for substance use disorder in Norway are estimated at 40-60%, consistent with other studies throughout the world. The relapse rate after one year of inpatient treatment in Norway — something not readily available in most countries — is 30%. The study attempted to find the cause of relapse but instead found an interesting trail:

In this clinical sample, we found that continuous measures of mental health distress predict subsequent cognition, that continuous variability in cognition [predicts] craving, and that continuous variability in craving [predicts] relapse.

It’s not quite clear what the researchers mean by “variability in cognition.” A series of baseline measures were taken, including the Wechsler Adult Intelligence Scale-Fourth Edition (WAIS-IV), The Delis-Kaplan Executive Function System (D-KEFS), and the Conners’ Continuous Performance Test-Third Edition (CPT-3). Follow-up sessions were used to collect the following data:

The Hopkins Symptom Check List 5-item version (SCL-5). This is a quick measure of depression and anxiety with five questions on a five-point scale.

Self-control. This was measured by patients self-rating themselves using a “visual, analog scale.”

Craving. This was also self-reported on a visual, analog scale.

These measures were compared with an actual record of the patient’s substance use based on urine samples. From this data, they derived the following conclusions:

  1. Mental health symptom intensity predicts self-control. The amount of mental health load identified at baseline was correlated with self-reported problems with self-control.
  1. Self-control variability predicts future craving intensity. Swings in self-reported self-control predict a higher intensity of cravings during withdrawal.
  1. Variability in craving intensity predicts later relapse. Large swings in the intensity of cravings correlate with relapse.

In line with the other small study we covered, the intensity of cravings was not correlated with relapse. It is the variability in intensity that is associated with relapse: “a moderate change in craving variability had an important effect,” essentially doubling the chance of relapse. The other study cited craving inertia as a key predictor of relapse. What is going on with craving variability that is driving relapse?

The researchers concluded that “both variability in self-control and baseline inhibitory control are important predictors of craving and subsequent relapse.” Interestingly, it is a sequence the researchers uncovered. A report of an increased mental health load would lead to a subsequent report of a decrease in self-control, and that would lead to a subsequent report of wild swings in cravings.

This would appear to show that stress is driving this sequence of events. An increased mental health load leads to greater anxiety and depression. Those are the ingredients that erode self-control and magnify craving variability. And that is the recipe for relapse. 

Reading the results in reverse, it would appear that care should be taken when entering substance use disorder treatment to avoid increasing the mental health load of the patient. Techniques such as motivational interviewing can help build self-control during the initial treatment phase. A feeling of improving self-control should lead to the stabilization of craving intensity within a manageable range. And that should reduce relapse.

Written by Steve O’Keefe. First published January 28, 2025.

Sources:

“Predicting Relapse in Substance Use: Prospective Modeling Based on Intensive Longitudinal Data on Mental Health, Cognition, and Craving,” Brain Sciences, July 2022.

“Psychometric Properties of Two Brief Versions of the Hopkins Symptom Checklist: HSCL-5 and HSCL-10,” Sage Journals, July 4, 2019.

“Craving changes in first 14 days of addiction treatment: an outcome predictor of 5 years substance use status?,” Translational Psychiatry, December 18, 2024.

Image Copyright: ellepistock.

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