Researchers Seek to Predict Stress-Induced Substance Abuse Relapse

With more than two thirds of people relapsing after starting treatment for substance use disorders, researchers are looking for ways to predict a person’s susceptibility to return to drug or alcohol use. Researchers at the Yale Stress Center in New Haven, CT, are developing biological markers of recovery to predict who will relapse, and when.

Having validated markers to measure a person’s risk of relapse could help doctors better predict who is at highest risk and tailor treatments for them, says Rajita Sinha, PhD, Director of the Yale Stress Center. For instance, a doctor might recommend an extended stay in residential treatment, or more intense behavioral treatment for patients who are likely to relapse.

While much is known about the effects of stress on addiction, much less is understood about how stress affects a person’s risk of relapse and jeopardizes recovery, according to Dr. Sinha. “When the regions of the brain involved in regulating stress are not working well, it increases a person’s vulnerability to relapse,” she says. “We want to find those neural and biological measures that predict whether this will occur.”

She and her colleagues are testing a number of biological measures of stress in people with various substance use disorders, including cocaine addiction and alcoholism. They are studying patients who are discharged from inpatient substance abuse treatment, to see if and when they relapse. The researchers are looking for links between relapse and biological markers including high levels of the chemical cortisol and high blood levels of a protein called brain-derived neurotrophic factor (BDNF), as well as brain atrophy in specific regions of the brain.

In a recently published study in the Archives of General Psychiatry, Dr. Sinha found several markers of increased risk of alcohol relapse, including high morning levels of the hormone corticotrophin. Another recent study, published in Biological Psychiatry, found high levels of BDNF in cocaine-dependent patients was predictive of an early relapse.

Dr. Sinha’s lab is also studying treatments to reduce stress-induced substance abuse. One recent pilot study found an older drug for hypertension called prazosin appears to decrease stress-induced alcohol craving. “We are also identifying newer drugs that could help those most susceptible to stress,” she notes. “But first we need to validate biological markers so we know who will benefit from these treatments.”

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    Lisa Frederiksen –

    January 11, 2012 at 3:45 PM

    Developing a solid “Continuing Care Plan” to follow the acute detox/rehab treatment period can help reduce the stress that leads to relapse. There is the perception that after a 28-day residential and/or intensive care treatment program, for example, “all is well” and life can go back to “normal.” What is missing is the understanding that addiction, like other diseases, requires continuing care. According to the ASAM’s 2009 Principles of Addiction Medicine Fourth Edition, “…effective treatment attends to multiple needs of each individual, not just his or her alcohol or drug use. To be effective, treatment must address any associated medical, psychologic, social, vocational, legal problem, and environmental problems” (ASAM, Principles…, p. 389). Additionally, the Principles cites one of the key components of “the best treatment programs” is “continuing care” (ASAM, Principles…, p. 351).

    Because addiction is a brain disease, there is no way all aspects of healing the brain can be completed in 10, 28 or even 60 days. Yes, a great start can be made, but a continuing care (a.k.a. an after care) plan that extends “treatment” for at least a full year is critical. The addict/alcoholic’s embedded addiction-related neural networks will be triggered by any number of cues – sound, sight, memory, the smell of alcohol, an emotion, a stressful person or situation. Therefore, planning how to prevent and/or handle such cues is critical. Let’s face it, treatment for a heart disease patient or diabetic doesn’t stop after the person is stabilized, nor is it assumed a patient’s diabetes or heart disease goes away after the rehabilitation effort. Instead, those patients are counseled, provided education and behavioral modification strategies, and then they are given a continuing care plan and follow-up with further modifications, if necessary. This same approach must be used with treating addiction. For as you can imagine by now, healing, developing and changing neural networks takes time.

    To be effective a Continuing Care Plan needs include a specific strategy that outlines how the drug addict/alcoholic is going to maintain abstinence. They must go far beyond the “typical” drug testing and 12-step meeting attendance monitoring. They must include plans for how to integrate with the family; for how to deal with the fall-out of not dealing with “life” while in their addiction (e.g., credit destruction, parenting issues, relationships problems, foreclosure, lost jobs, lost friendships — the “life” situations than can trigger a person who is in early recovery (day 29, 30, 45 or 72, for example); for identifying strategies to handle relapse (stress) triggers; for what the family needs in order to help themselves and in that process, help their loved one. Just as a person with diabetes, heart disease or cancer has a continuing care program/plan to help them continue their recovery once the acute care treatment (e.g., surgery, radiation, chemo) is complete, so too must the alcoholic / addict AND the family member/friend.

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    Ben House

    January 11, 2012 at 1:20 PM

    Maria’s comments about insurance paying for what might actually solve the problem is valid, not only because they suspect the bigger problems will show up later with alternate coverage, but also because they still make a percentage of the gross. We also live in a short term thinking society in many ways that seeks immediate gratification (sound like addiction?). We must look at payment for problems that effect the larger society in a bigger picture perspective.

    I am pleased to see these markers identified, but fear they will only justify more medications. Behavioral interventions can have powerful effect on cortisol levels and we can teach people how to get their endorphins in positive addictions rather than negative addictions. See. W. Glasser’s book from the 1970″s.

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    Maria Shaffer-Gordon

    January 10, 2012 at 1:20 PM

    I like the idea of “an extended stay in residential treatment, or more intense behavioral treatment for patients who are likely to relapse”, but how can we persuade public and private insurers to pay for better treatment, which pays dividends in the long run rather than the short-term? My understanding is that some private insurers won’t pay for more than round of smoking cessation therapy, which is clearly less expensive than treatment for drug or alcohol abuse, per year – they figure that by the time a smoker experiences serious health problems from smoking, some other company will be insuring the smoker, so they’re not highly motivated to pay for more cessation treatment. I believe that more effective (longer or more intense) treatment can save money compared to multiple rounds of treatment that is too brief or not intense enough because the success rate will be higher, but health insurers seem more interested in profits that they can make now, and both public and private insurers are always looking for ways to save money now.

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