Relapse Prevention and Management

Relapse is a common challenge in alcohol treatment; approximately 60 percent of patients return to problematic drinking within the first month of treatment. In this respect, the difficulty of maintaining sustained reduction of alcohol consumption resembles the challenges of maintaining other kinds of behavioural change. 

Various internal and external factors (often those associated with drinking in the past) can contribute to relapse risk: 

• persisting desire to drink with the belief that consumption can be controlled;
• positive emotional states (e.g. celebration); 
• negative emotional states (such as frustration, anxiety, depression or anger); 
• interpersonal conflict (such as relationships with partner, work colleagues, friends); and
• direct or indirect social pressure to drink. 

Relapse prevention and management strategies are a set of strategies that aim to help the patient maintain treatment gains (see Chapter 9). Relapse prevention and management teach patients cognitive and behavioural strategies that help prevent an initial lapse and prevent lapses becoming relapses. These strategies focus on development of coping skills and the self-efficacy to implement these skills, and the attainment of perceived gains for the effort of changing drinking behavior as part of the maintenance of change. 

Relapse prevention and management can be assisted through use of medication (including alcohol pharmacotherapies such as naltrexone, acamprosate, disulfiram) for reducing alcohol use or medication for addressing psychological problems, such as anxiety or depression (see Chapter 10). 

Biased decision making is a feature of alcohol dependence whereby stimuli, such as tastes, smells, visual cues, and physical and social contexts are increasingly paired to the rewarding effects of alcohol via the brain’s reward system. This may result in alcohol-related cues triggering automatic tendencies to resume consumption of alcohol. This process occurs, in part, outside of conscious awareness, which could make it difficult to address. These cognitive biases can be dampened through a computerised cognitive training intervention known as cognitive bias modification (CBM). Over a few sessions (typically 4-6), individuals with alcohol dependence practise repeatedly “avoiding” alcohol cues (e.g., pictures of alcoholic beverages) and “approaching” neutral cues (i.e., non-alcohol-related images). There is some evidence from recent Australian and international studies that CBM delivered as part of inpatient alcohol withdrawal treatment may reduce relapse risk. However, there is not yet sufficient evidence to recommend routine use of CBM in alcohol dependence. More research in a variety of clinical contexts with longer-term follow-up is required.