Alcohol Relapse and Cravings

Recent evidence has shown that 50% to 90% of people with an alcohol use disorder will likely relapse at least once during the four-year recovery period following their treatment. The relapse rate for alcohol is similar to those for nicotine and heroin addiction.

Some researchers believe the high rate of relapse for alcohol and drug addicts is due to impaired control caused by chemical changes that have taken place in the brains of alcoholics and addicts, changing the brain's reward system.

Some researchers believe this impaired control is responsible for an alcoholic picking up the first drink of a relapse, while others believe impaired control kicks in after that first drink, making it difficult for the alcoholic to stop drinking once they start.

For severe alcoholics, it can be impossible to stop drinking after the first drink. When an alcoholic stops drinking, withdrawal symptoms and alcohol cravings can set in.

The Role of Craving in Relapse

The concept of drug and alcohol craving is somewhat controversial, with some investigators believing that environmental stimuli play a larger role in relapse than physiological urges.

But research in 1974 by Arnold M. Ludwig and LH Stark found that the best way to determine if alcohol craving actually exists is to simply ask alcoholics. They asked study participants if they felt a need for alcohol, in the same manner as you would ask if someone was hungry.

Further research by Ludwig found that alcoholics display classic Pavlovian conditioning to internal and external stimuli to the reinforcing effects of alcohol. For example, driving past a familiar bar or experiencing a negative mood, could both set off a craving for alcohol.

Euphoric Recall and Appetitive Urges

Internal and external cues that evoke the memory of the euphoric effects of alcohol set off an appetitive urge, similar to hunger, in the alcoholic. Similarly, the memory of the discomfort of alcohol withdrawal could also produce a craving for alcohol.

Other studies have found that exposure to alcohol, without consumption, can stimulate a salivary response in alcoholics. A 1987 study by Zelig S. Dolinsky found that alcoholics had significantly greater and more rapid insulin and glucose responses to the consumption of a placebo beer, compared to nonalcoholics.

Expectations Play a Role in Relapse

Other researchers have theorized that relapse prevention depends on the alcoholic's expectations about his or her ability to cope with alcohol cues. One theory posited in 1999 suggests whether or not the first drinks leads to an excessive-drinking relapse may depend on the alcoholic's:

• Skills to cope with high-risk situations
• Level of perceived personal control
• The anticipated positive effects of alcohol

High-Risk Situations

Investigators who analyzed 48 relapse episodes found that most were prompted by the following high-risk situations:

• Frustration and anger
• Social pressure
• Interpersonal temptation

Assuming an Active Role in Relapse Prevention

To overcome these high-risk situations, some ways that alcoholics could take a more active role in changing their behavior include:

• Modify lifestyle to enhance the ability to cope with stress and high-risk situations
• Identify and respond appropriately to internal and external cues that serve as relapse warning signals
• Implement self-control strategies to reduce the risk of relapse in any situation

One study found that teaching alcoholics how to identify certain coping skills needed to deal with high-risk situations could help reduce relapse rates. Another approach focuses on cue elimination. Many different strategies have been proposed, but in the end, 50% to 90% of people with an alcohol use disorder experience at least one relapse.

Medications That Reduce Craving

Relapse prevention made great strides with the advent of medications that would reduce cravings. Naltrexone hydrochloride, sold as the brand name Revia and Depade and in an extended-release form under the trade name Vivitrol, was the first medication approved for the treatment of alcoholism that reduced the craving for alcohol.

Naltrexone seems to work by decreasing the reinforcing effects of alcohol in the neural pathways of the brain by blocking opiate receptors which then block the effect of endorphins.

According to the Sinclair Method, which stipulates using naltrexone one hour before any drinking occurs, the medication can also block the euphoric effects of alcohol and subsequent excessive consumption once drinking starts. Over time, the effect of naltrexone to block this euphoric effect can result in pharmacological extinction and the elimination of craving for alcohol.

Some researchers have found that a combination of pharmaceutical treatment and behavioral therapy, along with participation in mutual support groups, is the most effective effort to prevent drug and alcohol relapse.