Relapse
Encyclopedia
Relapse, in relation to drug misuse, is resuming the use of a drug
or a dependent substance after one or more periods of abstinence
. The term is a landmark feature of both substance dependence
and substance abuse
, which are learned behaviors, and is maintained by neuronal adaptations that mediate learning and processing of various motivational stimuli. An important aspect of drug use
is the propensity for repeated use and dependence, tendencies that are influenced by the nature of the drug itself and thus vary from substance to substance. Those substances that are cleared from the body most quickly, those with the highest pharmacological efficacy, and those that induce the highest tolerance
elicit the most severe tendencies in users. Drug dependence can lead to increased tolerance to the substance in question, cravings, and withdrawal
if the drug use ceases.
and nervous system
.
(DEA) has categorized controlled substances into 5 major categories based on the drug’s addictive potential and intended use. Drugs with the highest addictive potential are listed in DEA Schedules I and II. Schedule I drugs are those with no accepted medical or therapeutic use whereas Schedule II drugs are those that can be used therapeutically but may lead to severe physical or psychological dependence
.
The addictive potential, also sometimes called abuse potential, varies greatly between substances and is based on both the pleasurable effects associated with the drug and the likelihood that the drug will induce dependent behavior. The system for quantifying addictive potential based on scientific knowledge was first established by Professor David Nutt
in 2007. The addictive potential for the 14 substances examined in this study was derived by scoring the drugs on a four-point scale in 9 different parameters. The parameters were established by dividing the three categories of harm into 3 further subgroups.
. The following chart shows these categories and the further division into the nine parameters of harm.
The first category can be further divided into three parameters of harm: acute physical harm, chronic physical harm, and intravenous harm. Acute harm is defined as the immediate effects associated with use of the given drug such as respiratory depression or cardiac crises. Chronic harm is the consequence of continued and repeated use such as psychosis
or lung disease. Lastly, intravenous harm refers to problems associated with the route of administration such as the spread of blood-borne pathogens like HIV
.
The second parameter of harm is subdivided into three smaller categories: the pleasurable effects of the drug, the induced physical dependence, and the induced psychological dependence. The intensity of pleasure experienced is influenced by the initial rapid effect, called the rush
, and the subsequent lasting euphoria, called the high
.
This category is subdivided into the last three parameters: intoxication, other social harms, and healthcare costs. These parameters attempt to rate a drug’s impact on families, communities, and societies.
plays a role in self-administration and the reinforcing effects of cocaine
and other stimulants. The D2 receptor availability has an inverse relationship
to vulnerability to the reinforcing effects of the drug. That is, as D2 receptors become limited the user becomes more susceptible to the reinforcing effects of cocaine. It is currently unknown if a predisposition
to low D2 receptor availability is possible; however, most studies support the idea that changes in D2 receptor availability are a result, rather than a precursor, of cocaine use. It has also been noted that D2 receptors may return to the level existing prior to drug exposure during long periods of abstinence
, a fact which may have implications in relapse treatment
.
, re-exposure to the drug called drug-priming, and environmental cues. These factors may induce a neurochemical response in the drug taker that mimics the drug and thus triggers reinstatement. These cues may lead to a strong desire or intention to use the drug, a feeling termed “craving” by Abraham Wikler in 1948 to describe the desire elicited in the opioid
addicts he studied when they were returned to their drug-taking environments. The propensity for craving is heavily influenced by all three triggers to relapse and is now an accepted hallmark of substance dependence
. Stress
is one of the most powerful stimuli for reinstating drug use because stress cues stimulate craving and drug-seeking behavior during abstinence. Stress-induced craving is also predictive of time to relapse. Comparably, addicted individuals show an increased susceptibility to stressors than do non-addicted controls. Examples of stressors that may induce reinstatement include emotions of fear, sadness, or anger, a physical stressor such as a footshock or elevated sound level, or a social event. Drug-priming is exposing the abstinent user to the drug of abuse, which will induce reinstatement of the drug-seeking behavior and drug self-administration. Stimuli that have a pre-exisiting association with a given drug or with use of that drug can trigger both craving and reinstatement. These cues include any items, places, or people associated with the drug.
because relapse itself is a treatment failure; however there exist three main approaches that are currently used to reduce the likelihood of drug relapse. These include pharmacotherapy, cognitive behavioral techniques, and contingency management. The main goals of treating substance dependence and preventing relapse are to identify the needs that were previously met by use of the drug and to develop the skills needed to meet those needs in an alternative way.
Various medications are used to stabilize an addicted user, reduce the initial drug use
, and prevent reinstatement of the drug. Medications can normalize the long-term changes that occur in the brain
and nervous system
as a result of prolonged drug use. This method of therapy is complex and multi-faceted because the brain target for the desire to use the drug may be different from the target induced by the drug itself. The availability of various neurotransmitter receptors, such as the dopamine receptor D2
, and changes in the medial prefrontal cortex are prominent targets for pharmacotherapy to prevent relapse because they are heavily linked to drug-induced, stress-induced, and cue-induced relapse. Receptor recovery can be upregualted by administration of receptor antagonists, while pharmacotherapeutic treatment for neruoadaptations in the medial prefrontal cortex are still relatively ineffective due to lacking knowledge of these adaptations on the molecular and cellular
level.
, characterized by positive reinforcement and negative reinforcement in order to alter the cognitions, thoughts, and emotions associated with drug taking behavior. A main approach of CBT is cue exposure, during which the abstinent user is repeatedly exposed to the most salient triggers without exposure to the substance in hopes that the substance will gradually lose the ability to induce drug-seeking behavior. This approach is likely to reduce the severity of a relapse than to prevent one from occurring altogether. Another method teaches addicts basic coping mechanisms to avoid using the illicit drug. It is important to address any deficits in coping skills, to identify the needs that likely induce drug-seeking, and to develop another way to meet them.
Relapse prevention
attempts to group the factors that contribute to relapse into two broad categories: immediate determinants and covert antecedents. Immediate determinants are the environmental and emotional situations that are associated with relapse, including high-risk situations that threaten an individual’s sense of control, coping strategies, and outcome expectancies. Covert antecedents, which are less obvious factors influencing relapse, include lifestyle factors such as stress level and balance, and urges and cravings. The relapse prevention model teaches addicts to anticipate relapse by recognizing and coping with various immediate determinants and covert antecedents. The RP model shows the greatest success with treatment of alcoholism but it has not been proven superior to other treatment options.
In contrast to the behavioral approaches above, Contingency management
concentrates on the consequences of drug use as opposed to its precursors. Addict behavior is reinforced, by reward
or punishment
, based on ability to remain abstinent. A common example of contingency management is a token or voucher system, in which individual abstinence is rewarded with tokens or vouchers that they can redeem for various retail items.
, anatomy
of the prefrontal cortex
, social behavior, and life span
. Other advantages to studying relapse in non-human primates include the ability of the animal to reinstate self-administration, and to learn complex behaviors in order to obtain the drug. Animal studies have shown that a reduction in negative withdrawal symptoms is not necessary to maintain drug taking in laboratory animals; the key to these studies is operant conditioning and reinforcement.
The stimulus may be the drug itself, the visual stimulus that was initially paired with the drug intake, or a stressor such as an acoustic startle or foot shock .
(PET), which uses radiolabeled ligand
tracers to measure neurochemistry in vivo
and single-photon emission tomography (SPET). ). Functional magnetic resonance imaging
(fMRI) is widely used in human subjects because it has much higher resolution and eliminates exposure to radiation.
settings there are some limitations to the validity
of the procedures as a model of craving and relapse in humans. The primary limiting factor is that in humans, relapse rarely follows the strict extinction
of drug-seeking behavior. Additionally, human self-reports show that drug-associated stimuli play a lesser role in craving in humans than in the laboratory models. The validity of the model can be examined in three ways: formal equivalence, correlational models, and functional equivalence. There is moderate formal equivalence, or face validity
, meaning that the model somewhat resembles relapse as it occurs outside of the laboratory setting; however, there is little face validity for the procedures as a model of craving. The predictive validity
, which is assessed by correlational models, has yet to be determined for the procedures. There is sound functional equivalence for the model, which suggests that relapse in the laboratory is reasonably similar to that in nature. Further research into other manipulations or reinforcements that could limit drug taking in non-human primates would be extremely beneficial to the field.
, and higher responsiveness to drug-related cues in women as compared to men. One study suggests that the ovarian hormones, estradiol
and progesterone
, that exist in females at fluctuating levels throughout the menstrual cycle
(or estrous cycle
in rodents), play a significant role in drug-primed relapse. There is a marked increase in progesterone levels and a decrease in estradiol levels during the luteal phase
. Anxiety
, irritability, and depression
, three symptoms of both withdrawal
and the human menstrual cycle, are most severe in the luteal phase. Symptoms of withdrawal not associated with the cycle, such as hunger, are also enhanced during the luteal phase, which suggests the role of estradiol and progesterone in enhancing symptoms above the naturally occurring level of the menstrual cycle. The symptoms of craving also increase during the luteal phase in humans (it is important to note that the opposite result occurs in female subjects with cocaine addiction suggesting that cyclic changes may be specific for different drugs of abuse). Further, the drug-primed response is reduced during the luteal phase suggesting a time in the cycle during which the urge to continue use may be reduced. These findings implicate a cyclic, hormone-based timing for quitting a drug of abuse and preparing for magnified symptoms of withdrawal or susceptibility to relapse.
Drug
A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. There is no single, precise definition, as there are different meanings in drug control law, government regulations, medicine, and colloquial usage.In pharmacology, a...
or a dependent substance after one or more periods of abstinence
Abstinence
Abstinence is a voluntary restraint from indulging in bodily activities that are widely experienced as giving pleasure. Most frequently, the term refers to sexual abstinence, or abstention from alcohol or food. The practice can arise from religious prohibitions or practical...
. The term is a landmark feature of both substance dependence
Substance dependence
The section about substance dependence in the Diagnostic and Statistical Manual of Mental Disorders does not use the word addiction at all. It explains:...
and substance abuse
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
, which are learned behaviors, and is maintained by neuronal adaptations that mediate learning and processing of various motivational stimuli. An important aspect of drug use
Drug use
Drug use may refer to any drug use; or:* Drug abuse* Drug addiction* Entheogenic drug use* Medication* Performance-enhancing drug use* Recreational drug use* Self medication...
is the propensity for repeated use and dependence, tendencies that are influenced by the nature of the drug itself and thus vary from substance to substance. Those substances that are cleared from the body most quickly, those with the highest pharmacological efficacy, and those that induce the highest tolerance
Tolerance
Tolerance or toleration is the practice of permitting a thing of which one disapproves, such as social, ethnic, sexual, or religious practices.Tolerance, tolerant, or toleration may also refer to:...
elicit the most severe tendencies in users. Drug dependence can lead to increased tolerance to the substance in question, cravings, and withdrawal
Withdrawal
Withdrawal can refer to any sort of separation, but is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation/separation or a decrease in dosage of the intake of medications, recreational drugs, and alcohol...
if the drug use ceases.
Causes
Substances that may cause dependence or abuse can be classified based on their given effects on the brainBrain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
and nervous system
Nervous system
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
.
- Stimulants increase activity in the cerebral cortexCerebral cortexThe cerebral cortex is a sheet of neural tissue that is outermost to the cerebrum of the mammalian brain. It plays a key role in memory, attention, perceptual awareness, thought, language, and consciousness. It is constituted of up to six horizontal layers, each of which has a different...
leading to increased motor activity.- CocaineCocaineCocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
- Selective Serotonin Reuptake Inhibitors (i.e.: Prozac)
- Amphetamines
- Methamphetamines
- CaffeineCaffeineCaffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
- Cocaine
- Depressants slow down neuronal activity.
- Benzodiazepines (i.e.: Xanax)
- Opioids activate or block opioid receptors in the brain typically to reduce the affect of pain. Some common opioids are:
- MorphineMorphineMorphine is a potent opiate analgesic medication and is considered to be the prototypical opioid. It was first isolated in 1804 by Friedrich Sertürner, first distributed by same in 1817, and first commercially sold by Merck in 1827, which at the time was a single small chemists' shop. It was more...
- MethadoneMethadoneMethadone is a synthetic opioid, used medically as an analgesic and a maintenance anti-addictive for use in patients with opioid dependency. It was developed in Germany in 1937...
- OpiumOpiumOpium is the dried latex obtained from the opium poppy . Opium contains up to 12% morphine, an alkaloid, which is frequently processed chemically to produce heroin for the illegal drug trade. The latex also includes codeine and non-narcotic alkaloids such as papaverine, thebaine and noscapine...
- Heroin
- Morphine
- NicotineNicotineNicotine is an alkaloid found in the nightshade family of plants that constitutes approximately 0.6–3.0% of the dry weight of tobacco, with biosynthesis taking place in the roots and accumulation occurring in the leaves...
is neither a stimulant nor a depressant but rather a chemical that is absorbed by the skinSkin-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
and mucous membranes and activates the nicotinic acetylcholine receptors. - AlcoholAlcoholIn chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
produces disinhibitionDisinhibitionDisinhibition is a term in psychology used to describe a lack of restraint manifested in several ways, including disregard for social conventions, impulsivity, and poor risk assessment. Disinhibition affects motor, instinctual, emotional, cognitive and perceptual aspects with signs and symptoms...
in the nervous system, which depresses the frontal cortex while speeding up the rest of the brain. This can lead to a sense of riskRiskRisk is the potential that a chosen action or activity will lead to a loss . The notion implies that a choice having an influence on the outcome exists . Potential losses themselves may also be called "risks"...
, poor judgment, and other characteristics known to accompany what is commonly known as intoxicationIntoxicationSubstance intoxication is a type of substance-induced disorder which is potentially maladaptive and impairing, but reversible, and associated with recent use.If the symptoms are severe, the term "substance intoxication delirium" may be used.-Classification:...
.
DEA schedules of controlled substances
The Drug Enforcement AdministrationDrug Enforcement Administration
The Drug Enforcement Administration is a federal law enforcement agency under the United States Department of Justice, tasked with combating drug smuggling and use within the United States...
(DEA) has categorized controlled substances into 5 major categories based on the drug’s addictive potential and intended use. Drugs with the highest addictive potential are listed in DEA Schedules I and II. Schedule I drugs are those with no accepted medical or therapeutic use whereas Schedule II drugs are those that can be used therapeutically but may lead to severe physical or psychological dependence
Psychological dependence
In the APA Dictionary of Psychology, psychological dependence is defined as "dependence on a psychoactive substance for the reinforcement it provides." Most times psychological dependence is classified under addiction...
.
Addictive potential
- Related article: Substance dependenceSubstance dependenceThe section about substance dependence in the Diagnostic and Statistical Manual of Mental Disorders does not use the word addiction at all. It explains:...
The addictive potential, also sometimes called abuse potential, varies greatly between substances and is based on both the pleasurable effects associated with the drug and the likelihood that the drug will induce dependent behavior. The system for quantifying addictive potential based on scientific knowledge was first established by Professor David Nutt
David Nutt
David John Nutt is a British psychiatrist and neuropsychopharmacologist specialising in the research of drugs that affect the brain and conditions such as addiction, anxiety and sleep. He was until 2009 a professor at the University of Bristol heading their Psychopharmacology Unit...
in 2007. The addictive potential for the 14 substances examined in this study was derived by scoring the drugs on a four-point scale in 9 different parameters. The parameters were established by dividing the three categories of harm into 3 further subgroups.
Categories of harm
The three main categories to determine addictive potential are the physical harm of the drug to the user, the drug’s tendency to cause dependence, and effects of the drug on societySociety
A society, or a human society, is a group of people related to each other through persistent relations, or a large social grouping sharing the same geographical or virtual territory, subject to the same political authority and dominant cultural expectations...
. The following chart shows these categories and the further division into the nine parameters of harm.
Physical harm
The first category can be further divided into three parameters of harm: acute physical harm, chronic physical harm, and intravenous harm. Acute harm is defined as the immediate effects associated with use of the given drug such as respiratory depression or cardiac crises. Chronic harm is the consequence of continued and repeated use such as psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
or lung disease. Lastly, intravenous harm refers to problems associated with the route of administration such as the spread of blood-borne pathogens like HIV
HIV
Human immunodeficiency virus is a lentivirus that causes acquired immunodeficiency syndrome , a condition in humans in which progressive failure of the immune system allows life-threatening opportunistic infections and cancers to thrive...
.
Dependence
The second parameter of harm is subdivided into three smaller categories: the pleasurable effects of the drug, the induced physical dependence, and the induced psychological dependence. The intensity of pleasure experienced is influenced by the initial rapid effect, called the rush
Rush
- United States :* Rush, Colorado* Rush, Kentucky* Rush, New York* Rush, Ohio* Rush City, Minnesota-People:* Rush, a nickname for Canadian mixed martial artist Georges St...
, and the subsequent lasting euphoria, called the high
High
- Science, technology and economics :* Height* High , a high pressure area* High , a quality of a Turing degree, in computability theory* High , or top, an event in market-price fluctuations of a security...
.
Social harm
This category is subdivided into the last three parameters: intoxication, other social harms, and healthcare costs. These parameters attempt to rate a drug’s impact on families, communities, and societies.
| Category of harm HARM HARM or H.A.R.M. may refer to:* AGM-88 HARM, a high-speed anti-radiation missile* Historic Aircraft Restoration Museum, a museum in Creve Coeur, Missouri, United States... | Parameter | Subgroup |
|---|---|---|
| Physical harm | 1 | Acute Acute Acute may refer to:* Acute accent* Acute angle* Acute * Acute * Acute toxicity... |
| 2 | Chronic Chronic Chronic may refer to:* Chronic , a disease that is long-lasting and reoccurring.* Chronic toxicity, a substance with toxic effects after continuous or repeated exposure* The Chronic, a 1992 album by Dr. Dre... |
|
| 3 | Intravenous harm | |
| Dependence | 4 | Intensity of pleasure |
| 5 | Psychological dependence Psychological dependence In the APA Dictionary of Psychology, psychological dependence is defined as "dependence on a psychoactive substance for the reinforcement it provides." Most times psychological dependence is classified under addiction... |
|
| 6 | Physical dependence Physical dependence Physical dependence refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction... |
|
| Social harm | 7 | Intoxication Intoxication Substance intoxication is a type of substance-induced disorder which is potentially maladaptive and impairing, but reversible, and associated with recent use.If the symptoms are severe, the term "substance intoxication delirium" may be used.-Classification:... |
| 8 | Other social harms | |
| 9 | Health-care costs |
Dopamine D2 receptor availability
The availability of the Dopamine receptor D2Dopamine receptor D2
Dopamine receptor D2, also known as D2R, is a protein that, in humans, is encoded by the DRD2 gene.- Function :This gene encodes the D2 subtype of the dopamine receptor. This G protein-coupled receptor inhibits adenylyl cyclase activity...
plays a role in self-administration and the reinforcing effects of cocaine
Cocaine
Cocaine is a crystalline tropane alkaloid that is obtained from the leaves of the coca plant. The name comes from "coca" in addition to the alkaloid suffix -ine, forming cocaine. It is a stimulant of the central nervous system, an appetite suppressant, and a topical anesthetic...
and other stimulants. The D2 receptor availability has an inverse relationship
Inverse relationship
An inverse or negative relationship is a mathematical relationship in which one variable, say y, decreases as another, say x, increases. For a linear relation, this can be expressed as y = a-bx, where -b is a constant value less than zero and a is a constant...
to vulnerability to the reinforcing effects of the drug. That is, as D2 receptors become limited the user becomes more susceptible to the reinforcing effects of cocaine. It is currently unknown if a predisposition
Predisposition
Predisposition may refer to:* Genetic predisposition, a genetic effect which can identify individuals who may be predisposed to certain health problems* Predispositioning Theory, mathematical term in the field of decision theory...
to low D2 receptor availability is possible; however, most studies support the idea that changes in D2 receptor availability are a result, rather than a precursor, of cocaine use. It has also been noted that D2 receptors may return to the level existing prior to drug exposure during long periods of abstinence
Abstinence
Abstinence is a voluntary restraint from indulging in bodily activities that are widely experienced as giving pleasure. Most frequently, the term refers to sexual abstinence, or abstention from alcohol or food. The practice can arise from religious prohibitions or practical...
, a fact which may have implications in relapse treatment
Treatment
Treatment may refer to:* Treatment, therapy used to remedy a health problem* Treatment, a process or intervention in the design of experiments* Treatment group, a collection of items or individuals given the same treatment in an experiment* Water treatment...
.
Social hierarchy
Social interactions, such as the formation of linear dominance hierarchies, also play a role in vulnerability to drug abuse. Animal studies suggest that there exists a difference in D2 receptor availability between dominant and subordinate animals within a social hierarchy as well as a difference in the function of cocaine to reinforce self-administration of cocaine in these animal groups. Socially dominant animals exhibit higher availability of D2 receptors and fail to maintain self-administration.Triggers
Drug taking and relapse are heavily influence by a number of factors including the pharmacokinetics, dose, and neurochemistry of the drug itself, as well as the drug taker’s environment, and drug-related history. Reinstatement of drug use after a period of non-use or abstinence is typically initiated by one or a combination of the three main triggers: stressStress
- Mechanical :* Stress , the average amount of force exerted per unit area* Compressive stress, the stress applied to materials resulting in their compaction...
, re-exposure to the drug called drug-priming, and environmental cues. These factors may induce a neurochemical response in the drug taker that mimics the drug and thus triggers reinstatement. These cues may lead to a strong desire or intention to use the drug, a feeling termed “craving” by Abraham Wikler in 1948 to describe the desire elicited in the opioid
Opioid
An opioid is a psychoactive chemical that works by binding to opioid receptors, which are found principally in the central and peripheral nervous system and the gastrointestinal tract...
addicts he studied when they were returned to their drug-taking environments. The propensity for craving is heavily influenced by all three triggers to relapse and is now an accepted hallmark of substance dependence
Substance dependence
The section about substance dependence in the Diagnostic and Statistical Manual of Mental Disorders does not use the word addiction at all. It explains:...
. Stress
Stress
- Mechanical :* Stress , the average amount of force exerted per unit area* Compressive stress, the stress applied to materials resulting in their compaction...
is one of the most powerful stimuli for reinstating drug use because stress cues stimulate craving and drug-seeking behavior during abstinence. Stress-induced craving is also predictive of time to relapse. Comparably, addicted individuals show an increased susceptibility to stressors than do non-addicted controls. Examples of stressors that may induce reinstatement include emotions of fear, sadness, or anger, a physical stressor such as a footshock or elevated sound level, or a social event. Drug-priming is exposing the abstinent user to the drug of abuse, which will induce reinstatement of the drug-seeking behavior and drug self-administration. Stimuli that have a pre-exisiting association with a given drug or with use of that drug can trigger both craving and reinstatement. These cues include any items, places, or people associated with the drug.
Treatment
Relapse treatment is somewhat of a misnomerMisnomer
A misnomer is a term which suggests an interpretation that is known to be untrue. Such incorrect terms sometimes derive their names because of the form, action, or origin of the subject becoming named popularly or widely referenced—long before their true natures were known.- Sources of misnomers...
because relapse itself is a treatment failure; however there exist three main approaches that are currently used to reduce the likelihood of drug relapse. These include pharmacotherapy, cognitive behavioral techniques, and contingency management. The main goals of treating substance dependence and preventing relapse are to identify the needs that were previously met by use of the drug and to develop the skills needed to meet those needs in an alternative way.
Pharmacotherapy
- Related article: Drug rehabilitationDrug rehabilitationDrug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines...
Various medications are used to stabilize an addicted user, reduce the initial drug use
Drug use
Drug use may refer to any drug use; or:* Drug abuse* Drug addiction* Entheogenic drug use* Medication* Performance-enhancing drug use* Recreational drug use* Self medication...
, and prevent reinstatement of the drug. Medications can normalize the long-term changes that occur in the brain
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
and nervous system
Nervous system
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
as a result of prolonged drug use. This method of therapy is complex and multi-faceted because the brain target for the desire to use the drug may be different from the target induced by the drug itself. The availability of various neurotransmitter receptors, such as the dopamine receptor D2
Dopamine receptor D2
Dopamine receptor D2, also known as D2R, is a protein that, in humans, is encoded by the DRD2 gene.- Function :This gene encodes the D2 subtype of the dopamine receptor. This G protein-coupled receptor inhibits adenylyl cyclase activity...
, and changes in the medial prefrontal cortex are prominent targets for pharmacotherapy to prevent relapse because they are heavily linked to drug-induced, stress-induced, and cue-induced relapse. Receptor recovery can be upregualted by administration of receptor antagonists, while pharmacotherapeutic treatment for neruoadaptations in the medial prefrontal cortex are still relatively ineffective due to lacking knowledge of these adaptations on the molecular and cellular
Cellular
Cellular may refer to:*Cellular automaton, a model in discrete mathematics*Cellular , a 2004 movie*Cellular frequencies, assigned to networks operating in cellular RF bands*Cellular manufacturing...
level.
Cognitive behavioral techniques
The various behavioral approaches to treating relapse focus on the precursors and consequences of drug taking and reinstatement. Cognitive behavioral techniques (CBT) incorporate Pavlovian conditioning, characterized by associations, and operant conditioningOperant conditioning
Operant conditioning is a form of psychological learning during which an individual modifies the occurrence and form of its own behavior due to the association of the behavior with a stimulus...
, characterized by positive reinforcement and negative reinforcement in order to alter the cognitions, thoughts, and emotions associated with drug taking behavior. A main approach of CBT is cue exposure, during which the abstinent user is repeatedly exposed to the most salient triggers without exposure to the substance in hopes that the substance will gradually lose the ability to induce drug-seeking behavior. This approach is likely to reduce the severity of a relapse than to prevent one from occurring altogether. Another method teaches addicts basic coping mechanisms to avoid using the illicit drug. It is important to address any deficits in coping skills, to identify the needs that likely induce drug-seeking, and to develop another way to meet them.
Relapse prevention
- Main article: Relapse preventionRelapse preventionRelapse prevention, or RP for short, is a cognitive-behavioral approach with the goal of identifying and preventing high-risk situations such as substance abuse, obsessive-compulsive behavior, sexual offending, obesity, and depression.-Underlying Assumptions:...
Relapse prevention
Relapse prevention
Relapse prevention, or RP for short, is a cognitive-behavioral approach with the goal of identifying and preventing high-risk situations such as substance abuse, obsessive-compulsive behavior, sexual offending, obesity, and depression.-Underlying Assumptions:...
attempts to group the factors that contribute to relapse into two broad categories: immediate determinants and covert antecedents. Immediate determinants are the environmental and emotional situations that are associated with relapse, including high-risk situations that threaten an individual’s sense of control, coping strategies, and outcome expectancies. Covert antecedents, which are less obvious factors influencing relapse, include lifestyle factors such as stress level and balance, and urges and cravings. The relapse prevention model teaches addicts to anticipate relapse by recognizing and coping with various immediate determinants and covert antecedents. The RP model shows the greatest success with treatment of alcoholism but it has not been proven superior to other treatment options.
Contingency management
- Main article: Contingency managementContingency ManagementContingency management is a type of treatment used in the mental health or substance abuse fields. Patients are rewarded for their behavior; generally, adherence to or failure to adhere to program rules and regulations or their treatment plan...
In contrast to the behavioral approaches above, Contingency management
Contingency Management
Contingency management is a type of treatment used in the mental health or substance abuse fields. Patients are rewarded for their behavior; generally, adherence to or failure to adhere to program rules and regulations or their treatment plan...
concentrates on the consequences of drug use as opposed to its precursors. Addict behavior is reinforced, by reward
Reward
A reward may refer to:*Bounty , reward, often money, offered as an incentive*Reward website, website that offers rewards for performing tasks-Science:...
or punishment
Punishment
Punishment is the authoritative imposition of something negative or unpleasant on a person or animal in response to behavior deemed wrong by an individual or group....
, based on ability to remain abstinent. A common example of contingency management is a token or voucher system, in which individual abstinence is rewarded with tokens or vouchers that they can redeem for various retail items.
Animal Models
There are vast ethical limitations in drug addiction research because humans cannot be allowed to self-administer drugs for the purpose of being studied. However, much can be learned about drugs and the neurobiology of drug taking by the examination of laboratory animals. Most studies are performed on rodents or non-human primates with the latter being most comparable to humans in pharmacokineticsPharmacokinetics
Pharmacokinetics, sometimes abbreviated as PK, is a branch of pharmacology dedicated to the determination of the fate of substances administered externally to a living organism...
, anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
of the prefrontal cortex
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
, social behavior, and life span
Life span
Life span or lifespan may refer to:*Maximum life span, the maximum lifespan observed in a group*Life expectancy, the average lifespan expected of a group*Longevity, the average lifespan expected under ideal conditions...
. Other advantages to studying relapse in non-human primates include the ability of the animal to reinstate self-administration, and to learn complex behaviors in order to obtain the drug. Animal studies have shown that a reduction in negative withdrawal symptoms is not necessary to maintain drug taking in laboratory animals; the key to these studies is operant conditioning and reinforcement.
Self administration
To self-administer the drug of interest the animal is implanted with an i.v. catheter and seated in a primate chair equipped with a response panel. The animal is seated in a ventilated chamber and trained on a schedule of drug self-administration. In many studies the self-administration task begins with presentation of a stimulus light (located near the response panel) that may change colors or turn off upon completion of the operant task. The change in visual stimulus is accompanied by an injection of the given drug through the implanted catheter. This schedule is maintained until the animals learn the taskExtinction
Extinction in non-human primates is analogous, with some limitations, to abstinence in humans. In order to extinguish drug-seeking behavior the drug is substituted with a saline solution. When the animal performs the task it has been trained to perform it is no longer reinforced with an injection of the drug. The visual stimulus associated with the drug and completion of the task is also removed. The extinction sessions are continued until the animal ceases the drug-seeking behavior by pressing the leverReinstatement
Reinstatement is the animal equivalent to relapse in humans. After the animal’s drug-seeking behavior is extinguished a stimulus is presented to promote the reinstatement of that same drug-seeking behavior. For example, if the animal receives an injection of the drug in question it will likely begin working on the operant task for which is was previously reinforced.The stimulus may be the drug itself, the visual stimulus that was initially paired with the drug intake, or a stressor such as an acoustic startle or foot shock .
Neuroimaging
Neuroimaging has contributed to the identification of the neural components involved in drug reinstatement as well as drug-taking determinants such as the pharmokinetics, neurochemistry, and dose of the drug. The neuroimaging techniques used in non-human primates include positron emission tomographyPositron emission tomography
Positron emission tomography is nuclear medicine imaging technique that produces a three-dimensional image or picture of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide , which is introduced into the body on a...
(PET), which uses radiolabeled ligand
Ligand
In coordination chemistry, a ligand is an ion or molecule that binds to a central metal atom to form a coordination complex. The bonding between metal and ligand generally involves formal donation of one or more of the ligand's electron pairs. The nature of metal-ligand bonding can range from...
tracers to measure neurochemistry in vivo
In vivo
In vivo is experimentation using a whole, living organism as opposed to a partial or dead organism, or an in vitro controlled environment. Animal testing and clinical trials are two forms of in vivo research...
and single-photon emission tomography (SPET). ). Functional magnetic resonance imaging
Functional magnetic resonance imaging
Functional magnetic resonance imaging or functional MRI is a type of specialized MRI scan used to measure the hemodynamic response related to neural activity in the brain or spinal cord of humans or other animals. It is one of the most recently developed forms of neuroimaging...
(fMRI) is widely used in human subjects because it has much higher resolution and eliminates exposure to radiation.
Limitations
Although the reinstatement protocols are used frequently in laboratoryLaboratory
A laboratory is a facility that provides controlled conditions in which scientific research, experiments, and measurement may be performed. The title of laboratory is also used for certain other facilities where the processes or equipment used are similar to those in scientific laboratories...
settings there are some limitations to the validity
Validity
In logic, argument is valid if and only if its conclusion is entailed by its premises, a formula is valid if and only if it is true under every interpretation, and an argument form is valid if and only if every argument of that logical form is valid....
of the procedures as a model of craving and relapse in humans. The primary limiting factor is that in humans, relapse rarely follows the strict extinction
Extinction
In biology and ecology, extinction is the end of an organism or of a group of organisms , normally a species. The moment of extinction is generally considered to be the death of the last individual of the species, although the capacity to breed and recover may have been lost before this point...
of drug-seeking behavior. Additionally, human self-reports show that drug-associated stimuli play a lesser role in craving in humans than in the laboratory models. The validity of the model can be examined in three ways: formal equivalence, correlational models, and functional equivalence. There is moderate formal equivalence, or face validity
Face validity
Face validity is a property of a test intended to measure something. It is the validity of a test at face value. In other words, a test can be said to have face validity if it "looks like" it is going to measure what it is supposed to measure...
, meaning that the model somewhat resembles relapse as it occurs outside of the laboratory setting; however, there is little face validity for the procedures as a model of craving. The predictive validity
Predictive validity
In psychometrics, predictive validity is the extent to which a score on a scale or test predicts scores on some criterion measure.For example, the validity of a cognitive test for job performance is the correlation between test scores and, for example, supervisor performance ratings...
, which is assessed by correlational models, has yet to be determined for the procedures. There is sound functional equivalence for the model, which suggests that relapse in the laboratory is reasonably similar to that in nature. Further research into other manipulations or reinforcements that could limit drug taking in non-human primates would be extremely beneficial to the field.
Differences between sexes
There exists a higher rate of relapse, shorter periods of abstinenceAbstinence
Abstinence is a voluntary restraint from indulging in bodily activities that are widely experienced as giving pleasure. Most frequently, the term refers to sexual abstinence, or abstention from alcohol or food. The practice can arise from religious prohibitions or practical...
, and higher responsiveness to drug-related cues in women as compared to men. One study suggests that the ovarian hormones, estradiol
Estradiol
Estradiol is a sex hormone. Estradiol is abbreviated E2 as it has 2 hydroxyl groups in its molecular structure. Estrone has 1 and estriol has 3 . Estradiol is about 10 times as potent as estrone and about 80 times as potent as estriol in its estrogenic effect...
and progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
, that exist in females at fluctuating levels throughout the menstrual cycle
Menstrual cycle
The menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human menstrual cycle....
(or estrous cycle
Estrous cycle
The estrous cycle comprises the recurring physiologic changes that are induced by reproductive hormones in most mammalian placental females. Estrous cycles start after puberty in sexually mature females and are interrupted by anestrous phases or pregnancies...
in rodents), play a significant role in drug-primed relapse. There is a marked increase in progesterone levels and a decrease in estradiol levels during the luteal phase
Luteal phase
The luteal phase is the latter phase of the menstrual cycle or the estrous cycle . It begins with the formation of the corpus luteum and ends in either pregnancy or luteolysis...
. Anxiety
Anxiety
Anxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
, irritability, and depression
Depression
Depression or depress may refer to:-Medicine:* Depression , a state of low mood and aversion to activity** Mood disorder, a class of mental illnesses featuring depressed mood...
, three symptoms of both withdrawal
Withdrawal
Withdrawal can refer to any sort of separation, but is most commonly used to describe the group of symptoms that occurs upon the abrupt discontinuation/separation or a decrease in dosage of the intake of medications, recreational drugs, and alcohol...
and the human menstrual cycle, are most severe in the luteal phase. Symptoms of withdrawal not associated with the cycle, such as hunger, are also enhanced during the luteal phase, which suggests the role of estradiol and progesterone in enhancing symptoms above the naturally occurring level of the menstrual cycle. The symptoms of craving also increase during the luteal phase in humans (it is important to note that the opposite result occurs in female subjects with cocaine addiction suggesting that cyclic changes may be specific for different drugs of abuse). Further, the drug-primed response is reduced during the luteal phase suggesting a time in the cycle during which the urge to continue use may be reduced. These findings implicate a cyclic, hormone-based timing for quitting a drug of abuse and preparing for magnified symptoms of withdrawal or susceptibility to relapse.
See Also
- Substance abuseSubstance abuseA substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
- Substance dependenceSubstance dependenceThe section about substance dependence in the Diagnostic and Statistical Manual of Mental Disorders does not use the word addiction at all. It explains:...
- Drug and Alcohol Dependence (journal)
- Controlled Substances ActControlled Substances ActThe Controlled Substances Act was enacted into law by the Congress of the United States as Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970. The CSA is the federal U.S. drug policy under which the manufacture, importation, possession, use and distribution of certain...
- Cognitive behavioral therapy
- Drug rehabilitationDrug rehabilitationDrug rehabilitation is a term for the processes of medical or psychotherapeutic treatment, for dependency on psychoactive substances such as alcohol, prescription drugs, and so-called street drugs such as cocaine, heroin or amphetamines...
- National Institute on Drug AbuseNational Institute on Drug AbuseThe National Institute on Drug Abuse is a United States federal-government research institute whose mission is to "lead the Nation in bringing the power of science to bear on drug abuse and addiction."-History:...