CHAPTER 34
Relapse and Other Problems Frequently Encountered in Substance Rehabilitation
LEARNING OBJECTIVES
After studying this chapter, students should be able to:
•
34.1: Identify the commonly encountered problems in treating individuals
with SUDs
•
34.3: Define and describe concerns with lapse and relapse
•
34.5: Consider the impact of pain on those struggling with SUDs
•
34.7: Understand the use of toxicology testing in treating individuals with SUDs
CHAPTER OUTLINE
Common Problems
Limit Testing by Clients
The Counselor and Treatment “Secrets”
A Double Standard
Treatment Noncompliance
Willpower
Switching Addictions
Lapse and Relapse
“Cravings” and “Urges”
The “Using” Dream
Toxicology Testing
Urine
Hair Sample Testing
Saliva
Sweat
Blood
Funding
Mental Health Parity Laws
CHAPTER OVERVIEW
In this chapter, some of the most common problems encountered by staff involved in the
process of substance rehabilitation are discussed. However, this is not an exhaustive list! Every
time that the author of this text thinks that he has heard it all, a new problem, or variation of a
problem, is brought to him by either a client or by a staff person working with that client.
However, this chapter hopefully does provide an overview of the most commonly encountered
issues in the process of substance rehabilitation.
DISCUSSION QUESTIONS
Break-Out Discussion #1:
Treatment success/treatment failure: The prejudicial manner in which the substance use
disorders (SUDs) are viewed within the world of medicine is perhaps seen in how success is
Another example, cited in your text, is that of the treatment of cancer. Oncology treatment
programs do not require that the patient be cancer-free before admission like many substance
rehabilitation programs do. Of course, insurance company reimbursement policies are different
for substance rehabilitation than they are for the treatment of cancer. Imagine the media frenzy
that would result if an insurance company limited the treatment stay of a liver cancer patient to
Treatment noncompliance is not a problem in just the field of substance rehabilitation. It is just
viewed differently. A patient with hypertension who only takes his or her medication half of the
time is “noncompliant.” A person with an alcohol use disorder who only abstains from alcohol
Questions
1. Do you view the addictions as being the same as other neurological disorders, or are they
behavioral disorders?
2. Do you view the person with an SUD as somehow being dirty, or less than your equal? Why?
Do you think that this image is a problem, and if so, how could be resolved?
3. What should the standards of SUD treatment success or failure be?
4. Do you agree that the above distinction between the treatment of cancer and SUD patients is
unjust? Can you support your argument?
Break-Out Discussion #2:
Health care coverage: The issue of health care coverage, and who is going to pay for it, is quite
controversial at this time. To complicate the debate, it has been discovered that the law of
unintended effects has come into play, in that improved medical care has resulted in a need for
more intensive services. As treatment advances reduce the death rate from heart attacks, a
growing pool of heart attack survivors will require aggressive medical monitoring and
management, placing an unanticipated strain on health care resources. It can be argued that
much of the increase in health care costs in the last half of the 20th century reflects the
successful development of interventions of various disease states, not inefficiency on the part of
health care providers.
Health care insurance providers argue that increased costs reflect inefficiency on the part of the
providers. This ignores the fact that virtually one-third of health care provider costs are now
consumed by the paperwork involved in providing health care to the patient (Keslar, 2008).
Health care provider claims representatives must sort through the multitude of insurance
policies
1
offered by each company to determine which benefits are, or are not, covered under
Another portion of the total expenditure for health care represents the duplicate tests ordered
by a physician not to clarify a diagnosis, but to protect themselves from possible malpractice
claims should the patient file a lawsuit. The physician fears being on the witness stand and
having the plaintiff’s attorney ask scornfully “Do you mean to say that you did not order such–
and-such a test to rule out another condition?” So, a duplicate test, or additional test(s) are
1
A single employer, for example, might have health care policies that offer five or more different
combinations of benefits.
ordered, adding to the cost of health care in this country. This apparently is a direct
consequence of the “tort” system of civil law in the United States.
Lawyers are not paid unless they win a lawsuit, usually accepting a case on the condition that
they will receive a certain percentage of the settlement. Then a lawsuit for a huge amount of
money is filed. Most of these are what are known as “nuisance” lawsuits. The attorney knows
that the malpractice insurance company will want to settle the lawsuit out of court, usually for
Questions
1. What are your views on health care? Is it a right, or a business?
2. Do you agree with the perspectives noted above? Why or why not?
REFERENCES
KEY CONCEPTS AND TERMS
Lapse: When the individual initially uses a compound after a period of abstinence, such as the
first puff of a marijuana cigarette or the first swallow of alcohol
Relapse: When the person falls back into active disease state after a period of remission
Relapse prevention: A self-management program designed to assist the individual in arresting
his or her SUD to the best degree possible
Euphoric recall: Tendency on the part of a person to remember past experiences in a positive
light, while overlooking negative experiences associated with the same event(s). For example, a
heavy drinker might drive by a bar and turn to a companion and say, “Didn’t we have a great
2
In some cases, to limit their liability, health care providers have started to refuse to see patients
with certain conditions or refuse to see certain patients who have filed lawsuits in the past.
Neuroadaptation: The process, once called “tolerance,” and sometimes called pseudo-
addiction, by which the nervous system adapts to the constant presence of a foreign compound.
Craving: An intense, subjective, emotional, and physical experience of desire for a substance,
that varies in intensity between individuals
Acetylcholine: One of the major excitatory neurotransmitters. Acetylcholine activates muscle
cells in response to motor activation commands from the brain, and is also involved in anger,
aggression, and sexual behaviors
Anticipatory guidance: Helping a client to anticipate that certain experience might happen, in
order to mentally prepare for such possibility
Detection threshold: The level of metabolites of a particular substance that must be present in
order for detection to show as positive in toxicology tests
Proteinuria: Presence of abnormal levels of protein in urine, which may indicate kidney damage
or disease
LO/STANDARDS CORRELATION CHART
A-head
LO
Standard 1—CACREP
Common Problems
Willpower
Switching Addictions
34.1: Identify
the commonly
encountered
problems in
treating
individuals
with SUDs
34.2: Review the
concerns related to
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
3f: systemic and environmental factors
that affect human development,
functioning, and behavior
concerns with
lapse and
relapse
34.4: Identify
the most
common
causes of
relapse
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
3f: systemic and environmental factors
that affect human development,
functioning, and behavior
Pain
34.5: Consider
the impact of
pain on those
struggling
with SUDs
3d: theories and etiology of addictions
and addictive behaviors
3e: biological, neurological, and
physiological factors that affect human
development, functioning, and
behavior
Controlled Drinking
34.6: Review
the concept of
controlled
drinking
3d: theories and etiology of addictions
and addictive behaviors
Toxicology Testing
34.7:
Understand
the use of
toxicology
testing in
treating
individuals
with SUDs
3d: theories and etiology of addictions
and addictive behaviors