Why Do People Relapse on Alcohol?
From a clinical standpoint, vulnerability to relapse is associated with an intense craving or desire to drink. Events potentially triggering relapse are tied to exposure to small amounts of alcohol, alcohol-related cues (e.g., environmental settings like bars or sporting events) and stress. Clinical laboratory studies indicate alcohol-dependent people are more sensitive to stimuli and events that evoke craving and negative affect, presumably driving an increased desire to drink.
A 1980 retrospective analysis of more than 500 alcoholism outcome studies reported that more than 75% of individuals relapsed within one year of treatment. More recent studies indicated 65-70% of individuals relapsed within one year, especially within the first three months of abstinence.
A 2013 study found a significant percentage (40-80%) of individuals receiving treatment for alcohol use disorder (AUD) had at least one drink within the first year after treatment. About 20% returned to pretreatment levels of alcohol use. It’s essential to understand the individualized, often complex factors underlying alcohol addiction to uncover and prevent relapse triggers.
Alcohol Relapse Causes
A 1996 study utilizing Marlatt and Gordon’s Reasons for Drinking Questionnaire revealed negative emotions were associated with blood alcohol level on the first day of relapse, the duration of relapse and occurrence of a second relapse. The negative emotions factor was also associated with client reports of alcohol dependence, trait anger and depression. This research suggests different relapse triggers occur together, therefore training focusing on specific relevant coping skills should be considered as a preventive measure.
Studies indicate relapse is a complex, multifactorial phenomenon. A small 2017 study comparing alcohol and opioid relapse in men being treated for alcoholism indicated the most common reasons for relapse were a desire for positive mood, sleep difficulties and negative affect.
Emotional state was a relapse trigger in 76-80% of individuals in both the alcohol and opioid groups. Perceived criticism and craving were significantly associated with negative affect in the alcohol group. Although relatively small, this study revealed negative affect in only 20% of alcohol-dependent individuals.
Other studies found unpleasant negative effects such as anger, frustration, sadness and boredom were the most common cause of relapse. Sleep problems have been reported in other studies as a cause of relapse. In this study, 30% of the alcohol group reported sleep issues, but only 10% experienced associated cognitive issues such as concentration difficulties.
The Role of Co-Occurring Disorders
Individuals struggling with AUD often have co-occurring psychiatric disorders such as mood and anxiety disorders. Failure to adequately address co-occurring disorders is an obvious cause of relapse and adverse clinical outcomes. For example, if a person has comorbid bipolar disorder and AUD, they often use alcohol to cope with symptoms. Moreover, research indicates alcohol use in individuals with bipolar increases the risk of suicide attempts, hospitalization and crime rates.
Relationships and Socialization Issues Tied to Relapse
Family dysfunction can sabotage treatment and lead to alcoholic relapse. Interpersonal problems with a partner and family conflict or criticism reflect a lack of bonding and act as stressors.
Individuals who perceive their spouse or partner as more critical and hostile toward them when admitted to treatment experience a higher rate of relapse and a shorter time to relapse. Individuals engaged in greater social participation and integration in conventional activities have a lower likelihood of relapse compared to individuals who are socially isolated.
Many studies suggest abstinence is unlikely if the individual does not enroll in alcohol rehab, which may include detox, individual counseling and therapy, mutual support groups like Alcoholic Anonymous (AA) and long-term medications to reduce the risk of relapse. Groups such as AA provide ongoing monitoring, reflected in 24-hour availability and goal direction, modeling substance use refusal skills, suggesting how to avoid relapse-inducing situations and providing advice for staying sober.
Psychosocial interventions are the mainstay of AUD treatment. Unfortunately, psychosocial interventions alone are associated with higher relapse rates than multimodal treatment incorporating pharmacotherapy and psychotherapeutic approaches.
A 2018 study analyzed the efficacy of the FDA-approved AUD drugs naltrexone and acamprosate, second-line agents such as disulfiram, and a wide array of off-label drugs including topiramate, gabapentin and baclofen. Researchers concluded pharmacotherapy for AUD is effective, cost-efficient and evidence-based and should be combined with evidence-based psychosocial treatment to improve outcomes and help reduce relapse.
Although AUD relapse rates tend to be high, an integral component of prevention is being aware of triggers and avoiding them, as well as recognizing the warning signs of relapse.