On Relapse


  (Caution:  Spoilers ahead) 

Well, the production crew on Nurse Jackie isn’t taking any prisoners this season, that’s for sure. This is as realistic (and thus harrowing) a depiction  of the familial ravages of addiction as I have seen portrayed in the popular media, at least since the release of When A Man Loves a Woman.  In Episode 8 of Season 6  Jackie underwent a  grueling  home detox effort facilitated by her sponsor, her boyfriend and a pharmacist colleague from the hospital where she works.  During the worst of it, she  had a feverish and  nightmarish vision of the destructive impact her many lies and betrayals have perpetrated upon her eldest daughter, Grace. The vision concluded with Grace directly accusing Jackie of failing her, saying, “You should have fought harder!”   

I have been a fan of this show since its inception and willingly suspended all disbelief as I watched Jackie struggle with her addiction to pain meds. I devoutly wanted to believe (as I’m sure many others did) that this moment would prove to be Jackie’s rock bottom. And I thought the deal might be sealed when,  in TV reality, Grace, who has been so angry with and so alienated from Jackie, had a hurtful encounter with the mean girls at her school  and came home and threw her arms around her mother and sobbed, “Mommy, I’ve had a really bad day!”  Yes! The universe  was dealing Jackie a second (or actually a 9th or 10th) chance with her severely wounded child. Surely, surely she would seize it and hold on for dear life.  

Sadly art  closely imitated real life in this case.  And it felt like a very real and very  hard punch to the gut when,  within the cinematic half-hour, Jackie snorted opiates yet again. Yeah, I was sucker-punched,  even though I’ve witnessed this kind  of heart-breaking lapse hundreds of times over the course of my career, and even though I explain these falls, on a regular basis to devastated, outraged family members.  So I’ll review the bidding again, for myself, for other members of Jackie’s fanworld, and for family members who are feeling similarly sucker-punched in their own lives.  Then, let’s take a look at how things might have gone differently.  

Here  is what I tell addicts and their friends and family, as a way of helping them to understand the disease they are up against, and as a way of cautioning them  against surrendering disbelief too easily. 

Addiction is a brain disease capable of disrupting functioning in all dimensions of an addict’s life.  Depending on severity, chronicity and individual susceptibility, it can compromise health, distort perception, undermine judgment,  dysregulate emotion. produce highly pathological (including criminal) behavior and destroy relationships and careers. These terrible things happen because drug abuse and addiction  produce  profound changes occur in the reward centers and executive control regions of the  brain.  Again, depending on individual vulnerabilities, this can happen pretty rapidly.
The short version of brain remodeling that occurs as the result of drug and alcohol abuse  is that the brain changes itself to defend against the pleasurable flood of  dopamine it receives every time an addict imbibes, ingests, injects or absorbs psychoactive substances. Very importantly, it begins to produce less dopamine on its own and it becomes less sensitive to  its presence as well.  As addicts develop this “tolerance” to their drug or activity of choice, they need more and more of it to achieve the pleasure they’re used to getting from their habit. Moreover, the brain’s reluctance to produce dopamine on its own means that addicts  also feel less and less pleasure from doing the things and being with people that used to make them happy (and whom, in their right minds, they dearly love). This is  a critical  thing to understand. Sooner or later, drug rewards become more important to addicts than anything else.
Moreover, as I explained in a previous post,  drug abuse and addiction also  weaken  executive control mechanisms in the pre-frontal cortex.  This is the  part of the brain that  helps people to regulate emotions and impulsive behavior.  Heavy drinking (including intermittent binge drinking)  and other drug use undermine the very functions that are needed to make healthy decisions about future use.  This includes the ability to make accurate  calculations about the impact of using on the self and others. These dramatic changes in brain structure and function mean that addicts can transiently, and sometimes for sustained periods, lose any useful awareness of the destruction they are wreaking on themselves and others. As Robin Williams once observed, ” As an alcoholic, you will violate your standards quicker than you can lower them. You will do shit that even the Devil would go… ‘Dude!’

 I was right there with the Devil after Jackie’s latest lapse.  Though it’s probably not accurate to call it a lapse.  Jackie had no sobriety, or even abstinence to lapse from in this case.  Despite the “detox”, she was still a complete wreck.  This is something very important that  the show has an opportunity to teach its audience. The brain takes an extended period to heal after someone abstains from alcohol and other drug use. Two or three days of detox, and even 30 days of residential rehabilitation aren’t nearly enough.  A recent study of current and former cocaine users for example,  found that even after 4 years of abstinencethere were abnormalities in some brain regions involved with reward processing.  

Actress Julie White, who portrays Jackie’s 12-step  sponsor this season, said in an interview that by the end of her stint on the show, she felt like, “… man, I am the worst sponsor ever!” And in fact, home detox was a terrible choice for someone whose addiction is as severe and chronic as Jackie’s.  It’s probably always a terrible choice unless there’s  an extremely strong social , medical and educational structure in place to support ongoing recovery.  Such a structure would  include 90/90 (90 12-step meetings in 90 days), addiction-informed individual and/or group therapy, anti-craving medications, treatment for any co-occurring disorders, and regular, random drug-testing.  Most of this would be aimed at specific brain dysfunctions that stem from drug and alcohol abuse.  The 90/90 guidance, addiction-informed therapy and even the drug testing are all ways of  enhancing the recovering individual’s awareness of information flowing from the more rational, logical centers of the brain about the potentially disastrous consequences of further use.  Intensive 12 step meetings and psychotherapy are also about gradually re-orienting addicts, whose lives have become organized around the pursuit and use of drugs, to the comfort and rewards that are available in constructive and emotionally intimate relationships.  

I am grateful to the cast and crew of Nurse Jackie for delivering the news about the “cunning, baffling and powerful” disease of addiction in a manner that is not only technically, but also emotionally accurate. I hope that they stay in this groove for as long as the show continues, in order to convey to their audience what it really takes to establish stable sobriety…which is…everything you’ve got. 

By the way, you might be interested in this recent article from The Washington Post:  Does “Nurse Jackie” Work in a Hospital Near You? It points out that physicians in recovery “are typically mandated to 90 days of residential treatment, followed by five years of monitoring with random drug tests. As a result, rates of recovery exceed 80 percent, even five years after treatment.”  Good to know.  I wonder if nurses receive  a similar quality of treatment and follow-up? 

————————————————————————————————————————————————RELAPSE AND THE PERSISTENCE OF MEMORY

Salvador Dali:  The Persistence of Memory

“But the thing about remembering is that you don’t forget.”

― Tim O’Brien, The Things They Carried

While addiction is viewed in most corners of the treatment and recovery communities (including the American Society of Addiction Medicine)  as a chronic and relapsing brain disease,  as I have pointed out in previous posts, this is usually a  difficult idea for families and friend of addicts to accept.  It is particularly hard when relapse occurs after a long period of sobriety.  Loved ones wonder how   a loss of control can  occur when life has been normal and predictable   for an extended period of time.  It seems as though the addict made a terrible choice, with no thought at all about the impact such an eventful decision would have on everyone else.  Is that the case?   Yet another complicated question, but it is important to understand that, even after extended periods of sobriety and stability,  brain structure and brain chemistry still matter.

Animal studies and imaging studies of the human brain have taught us that all natural reinforcerssuch as food and sex, and all psychoactive drugs  increase the production of dopamine in the nucleus accumbens, which is a structure in the basal forebrain sometimes referred to as the brain’s“pleasure center”.  When this part of the brain receives  a massive  hit of dopamine from the ingestion of a drug, the user feels high, and the experience of this huge reward constitutes  a powerful learning experience. Repeated experiences of intense reward eventually make other parts of life far less interesting and important to the brain than the pursuit and use of addictive substances and activities. Moreover  and very importantly, the flow of dopamine to the nucleus accumbens  increases not only when the addict is using a drug, but when the addict’s brain anticipates receiving it because it is coming into contact with cues that are associated with use.  This is why 12-step programs remind people in recovery to avoid “slippery people places and things”. Those slippery entities are paving the way to relapse by priming the brain with a dopamine rush.

But a publication by Harvard Health makes the important point that changes in the brain’s reward circuitry don’t make addiction inevitable. Rather:

What makes permanent recovery difficult is drug-induced change that creates lasting memories.

What are these changes?

The Role of  Delta FosB  in addiction and relapse

The article, Addiction and the Problem of Relapse, explains that addiction involves many of the same brain circuits that control learning and memory  and that, “Long-term memories are formed by the activity of transcription factors.”  A transcription factor   is a protein that binds to specific DNA sequences and controls “the flow (or transcription) of genetic information from DNA to messenger RNA”. In this manner it establishes new neural connections and strengthens old ones. The Harvard report  notes that:

All rewards increase the concentration of the transcription factor delta FosB in the nucleus accumbens. An excess of this transcription factor can heighten the risk of relapse in addicts long after they have stopped taking the drug. Even after levels (of the factor) return to normal, addicts may remain hypersensitive to the drug and the cues that predict its presence. *

Again, all rewards induce delta FosB in the nucleus accumbens, including drugs of abuse such as cocaine,  amphetamines, morphine, nicotine and phencyclidine.  Another article, a piece in  Scientific American  about The Addicted Brain , explains that delta FosB is an extraordinarily stable protein.  It accumulates and  remains active in nerve cells for weeks to months after someone ingests a drug.  It is believed that the lingering presence of delta FosB in the nucleus accumbens and other brain regions enables it to  “maintain changes in gene expression long after drug taking ceases”.  It may do so by causing neurons to induce the dendrites, or signal-receiving branches of the nucleus accumbens, to grow additional buds (dendritic spines) that heighten the ability of these cells to communicate with other neurons.  This sprouting of additional buds has been seen in rodents for months after the animals stop receiving drugs.  Authors Eric Nestler and Robert Malenka note that while extrapolation from animal studies is speculative, this finding nontheless,

raises the possibility that the extra connections generated by delta FosB activity amplify signaling between the linked cells for years and that such heightened signaling might cause the brain to overreact to drug-related cues. The dendritic changes may, in the endbe the key adaptation that accounts for the intransigence of addiction.

In sum, neuroscientists seem to be coming to the conclusion that changes to the reward circuitry induced by repeated drug use are important factors that compel addicts while they are actively using drugs, and that they continue to be key  for some time after  people stop using.   However,  after people abstain from drug use for longer periods,  other drug-induced changes in brain activity may become bigger players in making them vulnerable to relapse. The action of delta FosB may be a change that is of particular importance, making addicts more sensitive to a drug’s effects when it is used again after a long break and creating extremely powerful responses to “memories of past highs and to cues that bring those memories to mind”.

What is the takeaway for family members and friends of addicts, and for addicts themselves? As Tim O’Brien notes in The Things They Carried, “…you don’t forget”.  Not only that, but in some important respects, even when addicts stop using, they still have the brain they had when they were active in their addictions.  Slippery entities remain slippery entities even after long periods of sobriety because the brain responds to them in the same way it responded to them during active addiction.  This at least reduces the capacity for choice.   There may one day be medicines that block such responses.  In the meantime, addicts can make the choice to avoid the slippery entities and to  strengthen their resistance to relapse by engaging in  activities that strengthen the part of the brain that exercises executive control over powerful and primal responses.  “Push-ups” for the pre-frontal cortex, that is,  activities that increase focus and the ability to regulate strong feelings include regular 12-step attendance, psychotherapy, meditation and exercise.  Neuroscience is teaching us that the need for some combination of  these interventions is ongoing.  Even a sober  brain is busy remembering the rewards of drug and alcohol use for a very long time.  So it is necessary for most people in recovery to be equally busy remembering and addressing the “cunning, powerful and baffling” impact of psychoactive substances for a very long time as well.

 *In another article, Dr. Nestler notes that “drug induction of ΔFosB in … is more dramatic in adolescent animals, a time of greater addiction vulnerability”.


The Fall From the Wagon
For Alcoholics, Relapses Can Occur Just When Things Seem to Be Going Well
Washington Post/Health/April 3, 1985

By Barbara L. Wood, Ph.D.

Angela’s parents were deeply discouraged, and more than a little angry.
Their daughter had been a heavy drinker for the past 10 years, and they had spent a good portion of that time smoothing over her scrapes with school authorities, the law and various angry employers.

Although Angela often promised to get her drinking under control, and had even attended a few Alcoholics Anonymous meetings here and there, the drinking never really stopped for more than a few weeks at a time. The fresh hope her parents would feel when she seemed to regain control was always destroyed by the onset of a new crisis.

When she was finally arrested for driving while intoxicated they borrowed heavily to pay for her care at a private hospital specializing in the treatment of alcoholism. Angela was hospitalized for 30 days .During that time, her parents participated in several programs offered by the hospital to educate them about alcoholism and to help them cope more effectively with their daughter’.s problem They also attended some meetings of Al-Anon, a self- help group for families and friends of alcoholics. When Angela was released from the hospital, her parents were understandably apprehensive.

They were very afraid that without the constant support of the hospitaL staff, Angela would drink again. She surprised and pleased them by remaining sober for 51/2 months after her release from the hospital.

She was able to get a job and tn move out of their house and take an apartment with a friend. She even enrolled at the local university in an effort to complete the bachelor’s degree she had abandoned years before. Everything seemed fine But just when her parents began to feel that the long struggle might be behind them, Angela fell off the wagon, and badly.

She left school the day before her mid-term exams were to begin, stole her roommate’s car and some cash, and drove to a motel in West Virginia. At the motel, Angela drank steadily for three days before calling her roommate to apologize and beg for help The roommate called Angela’s parents, who drove to West Virginia, collected their daughter, returned home and contacted a therapist. Angela’s recovery, which had been so costly in emotional as well as financial terms, appeared to be in a shambles. Her parents wanted to know what to do. More to the point, they wanted to know whether it was still worthwhile to try to do anything at all. “Every bit of that hard work has come to nothing,” her father said with tears in his eyes. “I feel like giving up.”
“Angela” is a pseudonym and some details have been changed to protect the privacy of the family. Every event actually occurred, however , and the anger and despair that this woman’s father expressed are agonizingly real to the millions of people in this country who live with, and love, alcoholics.

They are also familiar feelings to medica1 and mental health professionals who treat alcoholics and to alcoholics themselves, whose own fragile hopes for a stabte recovery are threatened by repeated periods of relapse.

The question that inevitably rises in the aftermath of a renewed bout of drinking is “Why?” When everything was finally going so well and there has been so much misery on account of the drinking, why? The search for an answer leads directly to a complicated and heated controversy concerning the nature of alcoholism itself.

Though the great majority of people who use alcohol do so without significant emotional or physical cost, approximately 10 percent of drinkers use liquor in ways that are harmful io themselves, their families and their communities. Throughout the years, philosophers. physicians. prophets– and alcoholics and their families-have wondered and fought about the causes of harmful drinking. Today we are still trying to discover what it is in the personality or physical makeup of alcoholics that make them so different from other drinkers. The problem is seen by some as a mora! failing, by others as a disease that may have genetic underpinnings, and by still others as a problem of learning or a defense against psychic pain. Few therapists believe it is a moral failing, but rather argue heatedly over the genetic versus learning viewpoints.

The disease concept of alcoholism is the basis for thousands of treatment programs across the country, including the recovery program advanced by Alcoholics Anonymous. It includes the idea that the alcoholic is different from the non-alcoholic physiologically, psychologically or both; that the alcoholic suffers from an irreversible, progressive disease process characterized by a loss of control over drinking, and that while disease cannot be cured, it may be arrested by total abstention from alcohol. This view has been strengthened by the observation that alcoholism tends to run in families, as if inherited, and by recent research that seems to confirm the role of genetic factors in certain cases of alcoholism.

For example, two studies have shown that children whose biological parents are alcoholic, who are adopted at birth, had a much higher incidence of diagnosed alcoholism than do children, also adopted at birth, whose biological parents are not alcoholic. And the development of alcoholism in the children was independent of the drinking practices of the adoptive parents.

Proponents of the disease model believe that since alcoholism is a chronic illness, relapse is a more or less inevitable feature of recovery. They point out that, as with some other chronic diseases, relapse in alcoholism tends to occur when individual is exposed to unaccustomed stress. They believe that most instances of relapse can handled, just as crises in diseases like diabetes or hypertension are dealt with, by adjusting the treatment regimen to accommodate the additional stress.

The disease hypothesis is challenged by those who say that there is little experimental evidence to support the idea that alcoholism is irreversible or that it involves an absolute loss of control. Such critics favor psychological explanations of compulsive drinking. Some see it as a learned behavior that can be modified by “retraining” alcoholics–teaching them, for example, to sip rather than gulp their drinks.

Others who favor a psychological model point to e feelings of low self-esteem and fear of failure that seem to torment many alcoholics. They argue that the use of alcohol and other drugs is actually an effort to drown these severe psychic pains.

In this view, compulsive drinking is a defense against other “deeper” psychological problems, Psychological theories are bolstered by studies that claim to have helped heavy drinkers to establish control over their drinking. Such research is considered inconclusive because it is difficult to establish whether the subjects were truly alcoholic to begin with, and since authorities disagree as to what constitutes “controlled” drinking, (Some studies allowed their subjects to consume as much as six ounces o liquor a day.) Because the evidence is so unclear, nearly all treatment programs encourage alcoholics to abstain from alcohol rather than try to establish control.

Psychological models of alcoholism usually relate relapse to either a failure of new learning or to a return of painful emotions and a regression to destructive ways of coping with psychic distress, It signals that treatment was ineffective, or that it is still incomplete, Some authorities favor an integrated, “multi-variate” explanation of alcoholic drinking. This approach incorporates the idea of genetic vulnerabilities without discarding the unshakeable impression of most clinicians that learning and environmental stress also play crucial roles in this problem, It emphasizes that there are many patterns of alcohol abuse and dependency and suggests that relapse, like harmful drinking itself, means different things in different cases This view holds that the relative importance of physical and psychological factors may vary from individual to individual, and that the same person may relapse for different reasons on different occasions.

Though relapse often triggers feelings of intense disappointment and even hopelessness in alcoholics and their friends and family members, it should be noted that none of the major theoretical perspectives on the problem regards relapse as a sign of hopelessness. Rather, relapse is seen today as related to the complexity and chronic nature of alcoholism. Specialists in alcoholism treatment expect that it will frequently be a part of the process of recovery. A treatment strategy will be viewed as successful if the number of relapses declines steadily over time, and if the periods of sobriety grow progressively longer .

Alcoholics and their families are told that relapse a common occurrence during recovery , and need not signal a return to active alcoholism as away of life. They are warned that relapse is most likely to occur on holidays and occasions that disrupt the normal daily routine, and under conditions of special stress such as a job crisis or an illness or death in the family.

Though alcoholics usually feel ashamed when they “slip,” they are encouraged to fight their shame and to talk about relapse and other problems with fellow AA members and sympathetic friends and family members. Many find that such sharing relieves the intense internal pressure that can trigger a resumption of drinking.

Family members who enter treatment learn that the possibility of relapse is only heightened if they create a punitive or fearful atmosphere in which feelings of stress and the temptation to drink cannot be shared.

Treatment programs now attempt to use relapse and near-relapse as an opportunity tn uncover and remedy the flaws in a particular treatment plan. There is widespread agreement that relapse should be greeted by a redoubling of treatment efforts rather than a surrender to compulsive drinking.

Angela’s parents had discussed the possibility of relapse with hospital staff and ALAnon members, but they lost touch with these sources of help during the period that Angela was sober. Their perspective on her problem began to be shaped more by their hopes than by a realistic understanding of the nature of alcoholism.

After her relapse, they were encouraged to return to AI-Anon, and with the help of that program and counseling, they were ultimately able to take heart from the fact that their daughter had achieved several months’ sobriety after ten long years of active alcoholism.

They discovered that, prior to her relapse, Angela had abandoned her AA meetings in order to study for exams, and they surmised that the loss of contact with supportive friends in the program, as well as heightened pressure at school, were probably responsible for triggering her binge. Once Angela’s parents overcame their feelings of despair and analyzed the relapse, they were able to help her regain her own hope for a stable recovery.. Most important, they helped her to return to AA, where she is now in her second year of sobriety.