Relapse prevention

Triggers

What are triggers?

Triggers are things that initiate or spark off a certain action or behaviour. Examples could be:

• Using drugs or alcohol
• Offending
• Anger
• Depression
• Suicide/self harm

The desire to use again, even after a long period of abstinence, can be extremely intense. This desire to use can be triggered by many things.Once the desire to use takes hold, it can be very difficult to stop it—like a train without brakes. That is why it is important to learn and practice relapse prevention skills. They give you brakes to help you avoid a crash.

What triggers us

Triggers can be broken down into four main categories:

• People e.g friends, family, partners
• Places e.g pubs, clubs, jail, hostels, friends houses
• Emotions e.g guilt, disappointment, stress, depression
• Things e.g times of the day, health problems, celebrations or parties

Christmas time is a high trigger point for people in recovery. Looking at the list above it is easy to see why. There may be certain people that can stress us out, places we try and avoid the rest of the year, emotions like stress and loneliness play a big part too.

How triggers work:

Triggers > cravings > relapse
When we experience a trigger this automatically leads to drug thoughts. Drug thoughts often lead to drug craving and obsession. Drug craving and obsession can lead to relapse.

Different types of triggers

Internal triggers are emotional states that people may experience prior to, during, or after drug use.

• People may feel euphoric, depressed, anxious, or sexually aroused in drug-related situations.
• Later, these feelings can remind them of drug use.

External triggers include external events, places, things, or times that the user has learned to associate with prior drug use.

• For instance, these triggers might include the neighborhood where drugs were routinely purchased, a dealer’s apartment, a payday,or weekend evenings.
• External triggers also include specific people who were involved in the transaction. Drug paraphernalia can also serve as a strong trigger for drug thoughts and cravings.

Sensory triggers are related to the senses of sight, sound, smell, taste, and touch.

• Sensory triggers may include seeing drugs or alcohol, types of music or specific songs, certain smells and tastes, and sexual experiences.

Defusing Triggers

Identify triggers. Learn to recognise and identify triggers. Become aware of what people, places, and things trigger thoughts of drugs.


Avoid triggers. Whenever possible, people should avoid all high-risk situations, high-risk people, and other triggers. Triggers are red flags that signal danger.


Interrupt triggers. Some triggers, such as specific days of the week, certain times of the day, or specific feelings, cannot be avoided. These triggers can be interrupted, however, by engaging in a healthy activity that can break the power of the trigger, such as attending an AA/CA/NA/SMART meeting right after work on Fridays.

Talk about them- By talking about triggers you can better understand what’s going on and reduce their power. This can prevent them turning in to a craving.


Think about creating a trigger action plan


Consider these points:

• Are there people that I need to break ties with? If so, what do I need to do to avoid them?
• Are there people I know who use or supply alcohol/drugs? If so, what do I need to do to avoid them?
• Are there things that remind me of alcohol/drug use? If so, what do I need to do to get rid of them?
• Are there places that remind me of alcohol/drug use? If so, what do I need to do to avoid them?
• How much money should I carry out with me in order to reduce the possibility of buying alcohol/drugs?
• How can I protect myself against certain people/feelings that may trigger my alcohol/drug use?

The best time to stop a trigger from leading to relapse is

(1) before a specific trigger is experienced or
(2) before a trigger leads to cravings.

Thus, one of the best relapse prevention techniques is to avoid high-risk trigger situations.Placing yourself in a high-risk trigger situation usually does not happen by accident. It happens by making a series of small decisions that lead you into that situation.

Another way to deal with triggers for relapse is to work on your refusal skills. Refusal skills are how you say “no”. It is often helpful to run through situations in your head where you will have to say “no” and practice the responses you will give.


Remember:

• You do not have to respond immediately
• Assess whether you think that the other person’s request is something you want to do
• Assert your right to ask for more time or information
• If you decide the request is something you don’t want to do say “No” followed by:statements like…I would prefer not to...I would rather …...I don’t want to

If you say no:

• Try to give an honest reason …
• Don’t make excuses
• Try not to sound abrupt
• Speak slowly & steadily
• Repeat and reiterate if necessary

Cravings

If your triggers do lead you to experience a drug craving, they come in many intensity levels, some more easier to manage than others, but they are not static and can often intensify and then lessen over the course of a few hours.

Four common misconceptions about cravings

• Cravings are excruciating or unbearable.
• They compel you to use.
• They will not go away until you drink or use.
• They will drive you crazy.

There is no evidence to support the four common misconceptions.You can resist them and they will get weaker over time.When you realise you can stand a little discomfort, you will be back in control and part of your problem will be solved immediately.

• Accept your cravings as a normal part of changing instead of treating them as catastrophes.
• You make yourself feel crazy by thinking…“I can’t stand this; it’s awful to feel this way”; “this is too much for me”; “I’m losing control of my emotions and I must be in control.”

Ask yourself: Am I somehow entitled to be able to give up using, without strong urges to go back to using?

Answer: No! It may be unpleasant to resist some of my urges, but no one gave me a 'get out of unpleasantness free' card. Cravings are a normal part of giving up substances and there are various strategies to manage them.

Coping with cravings

Distraction

• Find something to take your mind off the craving.
• Make a list of the things that are possible to do

Talking about cravings

• A very effective way of getting through a craving is to make contact with someone who understands what you are going through. Do you know someone you can trust and talk to? Can you phone someone? Can you contact your support or Key Worker?

Going with the craving

• It can be a very empowering, positive experience to let the craving occur, peak and pass.
• In other words, experience it without fighting or giving in to it.
• Imagine you are walking over a hill. Its tough going up but you know you will shortly reach the top and come down the other side.Listen to the craving, focus on how intense it is and where it occurs in your body. If you find it useful, fill this information into a Craving Diary.

Think about the negative consequences of using drugs or alcohol again..

• Many people tend to remember only the positive effects : they often forget the problems that using drugs or alcohol brings with it.
• Make a list of the problems you were experiencing with drugs or alcohol. Remind yourself, very strongly, of the negative consequences of using again.

Lapse vs relapse

Change is difficult, and it is unreasonable to expect anyone to be able to modify a habit perfectly without any slips.

A lapse or relapse can be used to learn new coping strategies. The lapse is not the problem – the lack of recovery is. When people recover from lapses/relapses, they become stronger than they ever were before.

Lapse

What is a lapse?

• A lapse is a temporary return to “old” behaviours, thoughts or feelings. In addiction, it is an initial episode of drug or alcohol use after a period of abstinence.
• A lapse is often a “blip” in the recovery process, it can end quickly or it may lead to a more extensive relapse
• A lapse can be used as a warning sign and can be learnt from…

Relapse

What is relapse?

• Relapse is a full return to the “old” way of life or behaviour. In addiction it is a return to drinking/using after a period of abstinence
• A relapse often happens after a string of lapses and is triggered from the guilt over the first lapse
• Like a lapse it is often partof the recovery process and can be learned from in order for the next attempt to be successful

There are often warning signs of a lapse or relapse where it may be possible to stop it

• Examples? e.g poor decisions, ignoring triggers (people, places, emotions, things)
• When a person lapses they often feel guilty and that a little bit is just as bad as a lot and turn the lapse in to a full scale relapse
• It is easier to correct the relapse process early rather than later, a slip does not necessarily lead to a relapse, and a relapse is not the end of recovery.

Common warning signs for relapse

Changes in attitude e.g not caring about yourself, becoming negative about your recovery, life or how things are going

Going back to old ways of thinking e.g thinking you deserve a reward for a period of abstinence, that you could just have 1 drink, 1 line etc and it will be ok, believing you are cured and no longer need to think about managing your triggers

Changes in moods or feelings e.g feeling unusually stressed, worried, anxious, depressed or angry. Even feeling extremely happy can be a sign if you begin to feel invincible and unusually positive about managing your drug/alcohol use.

Changes in behaviour e.g hanging out with people you know will be using substances, dropping out of support groups or treatment, taking other substances even if it’s not your “problem drug”, arguing or picking fights with people for no apparent reason, being dishonest or secretive with those around you, lying to yourself “rationalisation”,self destructive behaviours (engaging in criminal activity, spending time with people who cause you to feel low), not going out to normal social activities, not filling your time, spending most of your time feeling bored.

If you lapse or relapse

• Discuss what happened with a supportive friend, family member or your keyworker
• Lapses are not a point to start over, but a point to get back on the horse and keep riding.
• We don’t start over at day zero – we’ve learned too much to say we’re starting from scratch.
• For many, change looks more like an upward spiral than a straight line.

Difficult emotions at Christmas

Coping with negative emotions is a challenge for everyone. It can be even more of a challenge during recovery and this can often be exacerbated at times of the year like Christmas.Learning to tolerate negative emotions and deal with them in a healthy way is critical to success in recovery.

Loneliness

People may experience loneliness at different points in their life, it can be described as an unbearable feeling of separateness, at a deep level. Loneliness can trigger emotions such as sadness, anxiety and feelings of being abandoned, unloved and insecure.

Loneliness can be triggered by various things

• Loss and grief. In addiction we can lose many things, bereavement is very often a feature.
• Modern lifestyles-living within the modern world where people more commonly live separately and to some extent can lead more isolated lives due to things like work commitments, divorce or separation for example.
• Social exclusion-Inequalities run across our society, where people experience stigma or exclusion. This could be due to gender, race, sexuality, disabilities, mental health or drug use.
• Feeling unwelcome-Where someone has experienced stigma or exclusion in the past, it may lead them to feel unwelcome when in company whether this is actual or perceived.

Who are the most likely people to feel lonely?

• People with addictions
• Homeless
• People with mental health issues
• People with physical disabilities
• Older people without close family
• Bereaved people
• Lone carers
• Single parents

How can it be overcome?

• Learning to be alone and value some time alone.
• Learning how to socialise effectively. When we spend a lot of time alone, it can become more difficult to know how to interact with people, especially in large groups. Take advantage of any social opportunity e.g responding to a fellow passenger on a Volunteering- This can be a wonderful way to meet like minded people and also to give something back to a cause which interests you
• Joining groups or classes-there are many local initiatives to bring communities together, this could be a recovery group, walking group, a choir, book club etc. Likewise attending evening or adult education classes will create opportunities to meet people and learn new skills. These are often available for free if you have low income or are on benefits.

Managing loneliness at Christmas time

• Get in touch with any family of friends in advance of festive period. Consider explaining this is a difficult time for you and maybe make arrangements to meet up or talk on the phone regularly.
• Plan the festive period as much as you can. Keeping busy can be helpful so arrange things like going for a walk, watching your favourite film, visiting a neighbour, shopping, cooking etc.
• Be aware of your triggers for loneliness- sometimes being around happy families, using substances or television programmes can trigger, even the word Christmas is enough for some people. Some people manage this by not celebrating it at all and going away for a break or getting stuck into work or household chores. Do what works for you.
• Volunteering over xmas- if you are the sort of person who needs something to keep them busy, considering volunteering in the short term over xmas. This could be helping out at a shelter, soup kitchen or hospital. Just keep yourself safe within this and don’t do anything which you feel would put further stress on you.
• Get support if it all gets too much. Make use of telephone helplines like Samaritans, Breathing Space.
• If you are religious or indeed just feel drawn to something spiritual around this time, attend church or pray. There are many Christmas services where you can simply attend the service and spend some time reflecting.

Stress

Planning Christmas for a family can be very stressful. Attending family Christmas celebrations can be equally as stressful especially if you have addictions or are in recovery. Even the run up to Christmas can be stressful, shopping, managing finances, managing warring relatives, organising the day.

Stress is the awareness of threat: real or false- an expectation of future discomfort or disaster

Sources of stress:

• Environment
• The way we see situations, life events and circumstances
• Our physical and psychological reactions to situations, life events and circumstances

Recognising stress

Emotions and feelings:

• Distress
• Upset
• Anger
• Anxiety
• Irritability
• On edge
• Fear

Physical symptoms:

• Insomnia and disturbed sleep
• Sweaty palms
• Palpitations
• Chest pains
• Weight loss
• Poor concentration and memory

Thoughts:

• Repetitive
• I can't do this
• I am a failure
• It's going to be terrible
• Something bad is going to happen
• I can't cope
• Things will never get better

Behaviour

• Use drugs or alcohol
• Kick off or lash out at people
• Avoid situations
• Outbursts of anger
• Not eating
• Become emotional

Managing stress at Christmas

Shopping

This is one of the most universally stressful areas for people, do I have money for presents? have I bought the right gifts? Then there’s the actually battling through swarms of other frantic Christmas shoppers.


Here are some tips:

• Don’t wait to the last minutes to buy gifts- try and spread the costs and buying bits here and there is arguably less stressful. Be one of those smug people that says I’ve finished all my shopping in October!
• If you find crowds difficult, buy online
• Make presents where you can, it saves money and people almost always appreciate a personal gift.

Stress on the day

Know when enough is enough. Stay only for as long as you feel you can manage when in a stressful environment. This may mean planning ahead for ways to excuse yourself early. Leaving is better than arguing and certainly better than triggering a lapse or relapse. Another option is to consider taking a buddy along with you, this cold be a close friend or someone else in recovery that can be there to help take the pressure off.

Eat well

At Christmas, it’s nice to indulge in a few treats but be aware of certain foods that can trigger anxiety and zap your energy. Caffeine and high salt are ones to keep to a minimum, eat plenty of fresh and veg, which contain vital antioxidants.

Sleep well

People naturally feel more stressed and anxious when they are not sleeping well. At Christmas, it’s easy to get into an unhealthy sleeping pattern but try and avoid this where possible. Visit the sleep management wiki for more tips on how to have a healthy sleep routine.

Drinking

If you are deciding to drink over the festive period, drink safely. Recommended amounts are 3-4 units (equivalent to a pint and a half of beer) per day for men and 2-3 units (equivalent to a 175ml glass of wine) per day for women.

Don’t forget that alcohol is really calorific so if you are trying to keep your weight down, this is something to consider.

What’s in your festive drinks?

Champagne
Units: 1.5 units in a 125ml glass
Calories: 95
Equivalent to: 2 cheese straws or 3 Hershey's kisses.

Eggnog
Units: Eggnog can be made with or without alcohol. If you make it with alcohol (typically rum or brandy), there will be one unit in every 25ml of 40% spirits you put in your mixture.
Calories: 343 in a 250 ml (8 1/2 0z) glass
Equivalent to: a chocolate biscuit or 5 Oreos with a cup of milk

Sherry
Units: 0.9 units in a small (50ml) thimble glass (17.5% strength)
Calories: 62
Equivalent to: A 20g pork sausage.or 1 slice of salami

Mulled wine
Units: 2.3 units in a 175ml (6 0z)glass
Calories: 134
Equivalent to: three pieces of chocolate orange.

Irish cream liqueur
Units: 0.9 units in 50ml measure
Calories: 175
Equivalent to: two mini mince pies

Brandy
Units: One per (25ml) measure of 40% brandy
Calories: 61
Equivalent to: two sausages on a stick.

Beer
Units: 1 pint of 5% beer 2.8 units
Calories: 244
Equivalent to: a large slice of pizza

Whisky
Units: one per (25ml) measure of 40%
Calories: without mixer-56 calories with mixer-111 calories

Most importantly you should aim to have at least 2 days without alcohol to let your body recover. So take a break off drinking between Christmas and New Year.

If Christmas is a stressful time for being around family, try and limit your drinking in social situations as you are much more likely to quarrel or fall out where drink is in the mix.

Cutting down your drinking

Ways to cut down your drinking:

• If you drink lager, try pints of shandy or lager tops, if you drink wine try drinking spritzers- you will still have a long drink but with less alcohol
• You can also try opting for half pints, or bottled beers or drinking a low strength beer
• Use spacers in between alcoholic drinks
• Try using fruit juices instead of carbonated mixers as fizzy drinks help you absorb the alcohol more quickly.
• If drinking at home, avoid free pouring spirits, measure them out you can use a small egg cup if you don’t have a shot glass

Drinking and driving

If your are drinking- don’t drink and drive

In UK the legal limit is 80mg per 100 millilitres of blood. This cannot easily be broken down into how many units is safe as we all process alcohol differently. A very rough guide is that 3-4 units will bring most men to the limit and 3 for most women. This basically means 1 drink (low strength) should keep one under the limit. People should always wait at least an hour after a drink before driving or operating any machinery.


There is no foolproof way of drinking and staying under the limit. The amount of alcohol you would need to drink to be considered drink driving varies from person to person. It depends on:

• Your weight
• Your gender (men tend to process alcohol faster than women)
• Your metabolism
• Your current stress levels
• Whether you've eaten recently
• Age (younger people tend to process alcohol more slowly

Bear this in mind when driving the following day. If you have had a heavy session drinking, you may still be over the limit although you may feel sober. A general rule of thumb is that it takes us roughly 1 hour to process 1 unit of alcohol, if you go to sleep this slows down to about 1 ½ hours per unit. This is again affected by the factors in the list above.

So if you drink 6 pints of Becks lager (5%) at 2.8 units per pint, this will take about 17 hours to be back down to nothing and longer if you have went to sleep for a few hours!