The road to recovery is a lifelong endeavor for those struggling with alcohol use disorder.

People relapse an average of five times before achieving sustained sobriety — and stumbles can happen even after years of abstention, according to John Kelly. 

Kelly, the Elizabeth R. Spallin Professor of Psychiatry at Harvard Medical School, is the first author of a new study that explores some warning signs for relapse, especially in those who have had long stretches of success.

In an interview with the Gazette, which has been edited for clarity and length, Kelly discussed the lack of research surrounding long-term relapse, and what clinicians and patients in recovery should look out for.

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Could you explain what some of the markers look like in day-to-day life?

There were four domains we looked at — biological, psychological, social, and changes in treatment/recovery support services.

Biological factors are things like sleep, appetite, or pain. The psychological are things like anxiety, depression, boredom, or stress. Social factors are loneliness, isolation, or engagement with high-risk others and environments where alcohol or other drugs may be present.

And then treatment and recovery support services would be things like people changing their medication use, if they’re on an anti-relapse, anti-craving medication, or changing their going to meetings, or stopping counseling.

From a biological standpoint, the things that were most notable were pain and recreational drug use. They occurred more rarely, but when they did occur, they were very strong predictors of recurrence of the disorder.

What sparked the decision to do this study?

We’ve got a ton of information — theoretical and empirical data — on short-term relapse. So we’re all quite familiar with the cues and triggers that can lead to relapse after a cessation attempt in these early days, weeks, and months. But there’s almost nothing that is known or was known about longer-term relapse once all of that so-called deconditioning has occurred — the unlearning of the conditioned cues that arouse the craving and the neurophysiological response when people become addicted to alcohol or other drugs.

We were able to uncover and discover some of the dynamics and content areas that were associated with longer-term relapse.

That’s what I think is very important from a disease-management perspective.

We talk about these illnesses as being chronically relapsing conditions, particularly in the first five years. It means that people, particularly in that first five years of their recovery, are still not out of the woods. They’re still susceptible to recurrence of the disorder, and yet we have no protocols in place for disease management in primary care or other clinical settings.

So what I wanted to do here was to try to see if we could uncover some of these warning signs that occur before people have a recurrence of the disorder, to monitor these kind of sobriety-based warning signs, or recovery vital signs that that can be monitored in primary care or other clinical settings.

Because we don’t have good biomarkers that will predict relapse or recurrence of an alcohol or other drug disorder, we have to rely on self-report and the kinds of psychosocial factors and environmental risk factors that can precipitate and increase risk.

In a clinical setting, how do we design the best screening questions to elicit the most useful responses?

I don’t think there’s any reason why people would be defensive about questions about pain, sleep, appetite, social-network changes, going to meetings, medication use. And so what we did is, we delineated a checklist, which is available in the paper as the appendix.

What that is, is a documentation and listing of all the things that people reported that precipitated relapse in the year. It provides a nice way for a clinician to broach the subject and then talk about some of these warning signs.

These signs are coming from people who have relapsed, who didn’t know that the relapse was coming. These people were, on average, in recovery for five or more years. What can happen is that imperceptibly, under the radar and insidiously, people don’t realize that they’re moving toward a relapse.

A good clinician can therefore talk about these things as risk factors, and make the patient more aware of them and even show them that these are potent risk factors for relapse, so pay attention to them.

Why is it so important to catch this behavior as early as possible? How much more difficult is it to get back to sobriety after a relapse?

It can be, yes, because there’s a lot more shame and self-stigma that occurs in later relapses when people have been in recovery. So it’s very important to intervene before the recurrence of the disorder, to be proactive about it, rather than wait for some kind of disaster to happen — to end up in the emergency department, or overnight stays in the hospital, or some other thing that’s happened because of the recurrence of the disorder.

It can minimize the mortality rate and morbidity rate, as well as all the other aspects — the social ramifications and the negative ripple effects that occur in the families of people who relapse as well.

Was there anything that you found that was particularly surprising?

I think those biological factors, particularly physical pain. Even though that was a rare one, it was a potent one.

Also recreational drug use, especially with this kind of California sober idea — when if you have a certain type of drug use disorder, like alcohol use disorder, then you use something like cannabis as a kind of a harm-reduction or coping tool. But a lot of these people using something like cannabis relapsed on their primary drug, which was alcohol.

For me, a lot of it was really underscoring potent factors, which we’ve known about for a long time, like cognitive vigilance — the idea of making sure you don’t forget that you’re in recovery from this potentially deadly disorder, and making sure that regardless of how many days, months, years you have behind you, it doesn’t necessarily guarantee that you’re cured and that you still have to maintain vigilance.

So a very frequent, potent marker of relapse risk was when people reprioritized other things above their recovery.