Relapse and Stress 

The #1 reason people relapse** to alcohol or drugs or other unhealthy coping is stress. It’s a complicated and multidirectional relationship that we are going to break down and understand through the science.

Stress is a known and quantified challenge and trigger in sobriety. Evidence strongly suggests that the neural circuits involved in stress and emotions overlap substantially with the brain systems involved in drug reward, creating craving, and the development of the crave, use, recovery, and tolerance cycle. 

A study from my research reports that “Acute stress exposure stimulates the autonomic, endocrine, and brain emotion and motivation regions that process and regulate negative emotion and distress responses.” (Sinha 2022)

The Science of Stress

Stress is the body’s reaction to change involving mental, emotional, and physical adjustment. This momentum of changes is known as a “stress cascade.” It can emerge from mood states such as feeling frustrated, angry, nervous, or overwhelmed. Stress is a perceived threat to wellbeing or status quo – or to the feeling of “too much.” 

 A stress cascade involves several physiological systems including the limbic, nervous, and the prefrontal cortex of the brain. Including the prefrontal cortex suggests that cognitive and behavioral coping are also involved. 

Alcohol and Stress

Regarding alcohol, what research has found is that repeated “success” with psychoactive substances in responding to stress is correlated with more use of psychoactive substances. The action of stress on the body coactivates stress circuits and reward circuits. 

One quote from my research: “The transition from moderate to compulsive alcohol drinking is driven by increasingly dysfunctional reward and stress systems.” (Sinha 2022)

It appears that more than 50 % of people with substance use disorder relapse immediately after formal treatment. Between 3 weeks and 6 months estimates range 40-75%. (Kabisa et al, Sinha 2008)

One study explains “Exposure to repeated stress and trauma also contributes to changes in the brain and body’s responses to stress and emotions as well as to changes in alcohol motivation and adaptive coping responses.“ (Tunstall et al)

Additional research reports “The consumption of alcohol is a habitual response to stressful situations in people with. Stress plays an important role at all levels of alcohol consumption, beginning with facilitation of initial use through early stages of transition to regular use and from regular to excessive use . In AUD, alcohol use also represents a habitual response to stressful situations.” (Wittgens et al)

Formal substance abuse treatment typically covers triggers and has clients build a relapse prevention plan, but I’ve seen few, if any, treatment settings that address stress with a holistic, comprehensive, and informed care in a way that makes a stress management plan as important as a relapse prevention plan.

How important is a stress management plan?

In spite of all we’ve learned about substance use disorder in the last 25 years, relapse rates are still alarming. Relapse and untreated substance use disorder causes pain to the individual, families, business, employers, and communities. 

One study estimated that 76% of the research participants relapsed due to a reported “stressful experience.” (Kabisa et al)

The multidirectional relationship between stress, substance abuse, and relapse begins with the reasons a substance use disorder happens to begin with. We talked about this last week when we discussed the reasons a substance use disorder develops. Of those 6 reasons 4 are involved here: trauma, reward insufficiency, learned behavior, and co-occurring mental health disorders each have their own bidirectional relationship with stress.

When I was reviewing my research for this video, it confirmed that interacting regularly with drugs and/or alcohol changes the structure of the brain in ways that reduce stress resiliency, increase anxiety, and increase the experience of stress. As tolerance to alcohol or other drugs increases, the rewarding effects of the substance decrease. However, changes to the complicated neuro chemical structure of the brain result in the felt experience of stress as being enhanced, more intense, and less tolerable. 

Stress and Professionals

The challenge for executives, professionals, and other high achievers is that their roles often come with specific stressors.

And, as yet another study said “These analyses using multiple approaches across different samples of individuals with AUD found that stress exposure increased alcohol craving. This response was accompanied by higher emotional, mood, and anxiety symptoms and lower ability to regulate emotions and control alcohol cravings.“ (Sinha 2022)

What happens when people relapse due to stress is that craving incubates and grows and a relapse often means the consumption of alcohol or drugs beyond the previous level. 

In alcohol use disorder, this has a name: alcohol deprivation effect (ADE).

Other multidirectional mechanisms for stress are that alcohol and drugs increase inflammation and lower immunity, impair sleep, and slow organic healing. It’s common for people with a diagnosable problem to have relationship, financial, health, or employment impact all of which are stressful. These do not go away quickly or in the early stages of recovery and need to be faced by the person in recovery at the precise time their stress resources are least, their former stress mitigator (alcohol/drugs) removed, and they do not have the neural pathways of healthy stress management.

It’s also possible that the best mitigator – social connectedness – has been disrupted. Many people in recovery are rightfully instructed to make strategic changes to people, places, and things in order to structure a safe sobriety but that can leave people with a paucity of a friend group. Guess what happens? You guessed it – stress.

Is There a Way to Optimize Prevention Tools?

So, what’s the solution? I am going to suggest a few multidimensional categories of interventions to support the building of a recovery stress management plan. What I mean by multidimensional is that the suggestions have documented benefits for substance use disorder, mental health, and general wellness making the habits have synergy.

Remember that the reinforcement of drugs and alcohol involve the neurotransmitters (the feeling and mood chemicals.) Repeated interaction with drugs and alcohol change the neurotransmitters and limit the effectiveness of their organic functioning. Lasting solutions need to include resetting the reward system to improve mood and stress resiliency. 

The 3 tools I recommend:

1. Healthy peer support – this does not need to be 12-Step, and I endorse people in recovery to find a peer network that works for them. 
2. Move your body -In addition to the effect on consumption and craving, exercise has also been proven effective as a method to improve mental disorders such as stress reduction, anxiety  and depression.
3. Mindfulness – There is a formal program called Mindfulness Based Relapse Prevention. It was created in the early years of the mindfulness trend and modeled after the proven Mindfulness based Stress Reduction that was created and is still being used for cardiovascular health and recovery.

Results support the effectiveness of mindfulness in substance use disorder, especially in reducing cravings, decreasing the frequency of use, and improving depressive symptoms. 

Combining mindfulness and exercise was addressed in many studies. One quote says “Body–mind activities and programs based on improving physical conditions produced similar results in mental disorders and quality of life. Available evidence indicates that physical exercise, both body–mind and physical fitness programs, can be effective in improving mental disorders, craving, and quality of life in drug-dependent patients.” (Giménez-Meseguer et al)

Support and Resources

Here is a  link to Mindfulness based relapse prevention book, the original structured program that was modeled after Mindfulness Based Stress Reduction written for cardiovascular healing. 

Another option that would increase mindfulness would be to attend Dharma Recovery.

For more information, content, support, and tools on how to manage executive stress, and enjoy life without drugs, alcohol, or over-relying on unhealthy coping, check out my Instagram or YouTube.

Here is a link to a free workbook on managing stress to help stop drinking.

Bibliography of Sources used in this research:

1. Heilig M. Stress-related neuropeptide systems as targets for treatment of alcohol addiction: A clinical perspective. J Intern Med. 2023 May;293(5):559-573. doi: 10.1111/joim.13636. PMID: 37052145.

2. Sinha R. Alcohol’s Negative Emotional Side: The Role of Stress Neurobiology in Alcohol Use Disorder. Alcohol Res. 2022 Oct 27;42(1):12. doi: 10.35946/arcr.v42.1.12. PMID: 36338609; PMCID: PMC9621746.

3. Fronk GE, Sant’Ana SJ, Kaye JT, Curtin JJ. Stress Allostasis in Substance Use Disorders: Promise, Progress, and Emerging Priorities in Clinical Research. Annu Rev Clin Psychol. 2020 May 7;16:401-430. doi: 10.1146/annurev-clinpsy-102419-125016. Epub 2020 Feb 10. PMID: 32040338; PMCID: PMC7259491.

4. Bowen MT, George O, Muskiewicz DE, Hall FS. FACTORS CONTRIBUTING TO THE ESCALATION OF ALCOHOL CONSUMPTION. Neurosci Biobehav Rev. 2022 Jan;132:730-756. doi: 10.1016/j.neubiorev.2021.11.017. Epub 2021 Nov 25. PMID: 34839930; PMCID: PMC8892842.

5. Tunstall BJ, Carmack SA, Koob GF, Vendruscolo LF. Dysregulation of Brain Stress Systems Mediates Compulsive Alcohol Drinking. Curr Opin Behav Sci. 2017 Feb;13:85-90. doi: 10.1016/j.cobeha.2016.10.006. Epub 2016 Nov 19. PMID: 28603755; PMCID: PMC5461929.

6. Sinha R. Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci. 2008 Oct;1141:105-30. doi: 10.1196/annals.1441.030. PMID: 18991954; PMCID: PMC2732004.

7. Grant S, Colaiaco B, Motala A, Shanman R, Booth M, Sorbero M, Hempel S. Mindfulness-based Relapse Prevention for Substance Use Disorders: A Systematic Review and Meta-analysis. J Addict Med. 2017 Sep/Oct;11(5):386-396. doi: 10.1097/ADM.0000000000000338. PMID: 28727663; PMCID: PMC5636047.

**Person-centered language note: As a leading clinician in substance use disorder assessment, treatment, and recovery, I am committed to elevating the language around mental health and substance use disorder. This means I will use “alcohol use disorder” rather than “alcoholic.” It means I will use “person with a substance use disorder” rather than “addict.” I minimize my use of the term addiction because it carries stigma, often people have their own relationship with the word accompanied with misinformation. I use the term recurrence or return to use rather than relapse. However, it’s important that people searching for help get connected with services that benefit them. In this regard, people are not searching “am I a person with a substance use disorder?” They are searching “am I an addict?” They do not search, “can a high functioning person have an alcohol use disorder?” They search “am I a high functioning alcoholic.” They don’t search “treatment for people who have a recurrence” but do search “how do I stop being a chronic relapser?” As such, I want to affirm people with substance use disorders with my care, which includes language but I also need to structure my business in a way that google searches find my material.