Predictions of more political, economic and social turmoil and volatility in South Africa, coupled with a crippling drought which is bound to see food prices and consumer inflation soaring, set the scene for a particularly challenging 2016.

Many South Africans, already mentally fragile because of personal or external circumstances, may therefore find it increasingly difficult to remain mentally healthy, fit and focused. Chances are that the above bleak scenario may also prompt former substance abusers who, through sheer perseverance, managed to rehabilitate themselves, only to revert to ‘old habits’.

Tough as it may seem, rising to the challenge to remain mentally strong and healthy or avoid relapse, is not impossible, stresses psychiatrist Dr Mike West from Akeso Clinic Milnerton, who provides the following advice to guide us to mental health and wellness on the road ahead:

  1. Connect with others. “Getting to know your neighbours, work colleagues, friends, family, even your car guards, will allow you to develop and maintain strong, healthy relationships which can have a positive effect, not only on your own well-being, but also on that of others. In this day and age where we are increasingly concerned with ourselves and tend to neglect reaching out to, and connecting with others. Pay it forward!
  2. Be mindful. “Often we are so consumed either by revisiting the past or contemplating the future, that we lose sight of the present and the possibilities and opportunities it may bring,” stresses Mike. “Mindfulness and meditation are able to suppress activity in a region of the brain called the default mode network, a region commonly overactive in depression and anxiety,” he explains.
  3. Learn to say no. “Burn-out is one of the leading causes of loss of workplace productivity worldwide and is becoming increasingly common in South Africa as workplace demands intensify. Pay attention to yourself and take heed of the warning signs your body gives you – it is your own best informant.
  4. Ask for help. “The most difficult step in seeking help is most often the first step: admitting that there is a problem and asking for help. Avoiding that first step can lead to more challenges accumulating, with a risk that things become overwhelming and impossible to carry.
  5. Diet and exercise. “The importance of a balanced diet and regular exercise cannot be overstated – the positive physical and mental health-related outcomes are innumerable. Avoid fad-diets or diets that promise quick results. The only way to truly lose weight and keep it off is through hard work and perseverance, with a double-serving of calorie-burning exercise.”

 

Reasons for relapse

For victims of substance abuse who have seemingly successfully completed a rehabilitation course, the challenge in 2016 to avoid relapse is huge, Mike agrees.

Relapses occur for a number of reasons, he explains. “First, chronic use of some substances can result in changes in the anatomy and functional connectivity of brain circuits. The good news, however, is that the brain has a remarkable ability to recover, although this takes place over a period of months to years, as opposed to days and weeks. It is difficult to outpace our innate neurobiology, meaning that continuation of care after completing rehabilitation is vitally important.”

“Second, a rehabilitation programme may in some instances be quite disconnected from the stressors that participants experience outside of the clinic, area where a patient resides or faces ongoing stressors; logically it becomes far more difficult to abstain when there are ongoing stressors and environmental challenges.

“Third, there is also still a marked pejorative stigma around being a substance user or being in recovery. Many people still incorrectly view addiction as a moral failing, or a weakness in character, including addicts themselves.  Meaning that some patients are less likely (and sometimes less able) to reach appropriate help before things spiral out of control.”

Dangers of relapse

According to Mike, one of the biggest dangers from a medical point of view, of going back to ‘old ways’, is that patients often overestimate their tolerance to particular drugs after a period of abstinence. “This is especially true in the case of drugs such as heroin – most reports of fatal overdoses occur after periods of abstinence. Many substances, when used over a long period of time, result in a degree of tolerance, i.e. a need to take more of the drug to achieve the same effect. This tolerance, however, rapidly decreases when an individual is no longer using the substance. A seemingly small ‘dose’ therefore may potentially be toxic in these situations.”

Other dangers include fracturing of relationships, loss of employment and income, and the destabilisation of concurrent psychiatric or physical health conditions, Mike adds. “Individuals who relapse, often (wrongly) feel an inordinate amount of guilt and shame – feelings that, in themselves, carry their own risks”.

Relapse rate

It is estimated that 40-60% of patients with substance-use disorders will relapse within the first 12 months of treatment, says Mike. “While this number seems high, it is comparable to relapse rates (i.e. a recurrence of symptoms) for other chronic medical conditions such as diabetes, hypertension or asthma. These rates of relapse steadily decline the longer an individual is on treatment.

“Having said this, it’s important to stress that a relapse should never be seen as a ‘failure’. There are so many determinants affecting one’s likelihood of relapse that a relapse should rather be used as an informative learning experience, both for the patient and the health care provider. Careful thinking and analysis around relapses can provide useful strategies to implement in the future to reduce the chance of future relapses”

Risk factors

Risk factors for relapse in patients with substance-use disorders are often multifactorial. “One of the biggest risk factors is the presence of an untreated co-occurring psychiatric disorder, such as depression or anxiety.  Mental illness and substance use disorders have an intimate relationship, with fuzzy boundaries at best between cause and effect.

“Other risk factors include sustained sleep difficulties, low motivation for recovery, poor social support for recovery, high levels of personal stress and expressed emotion in families, and a previous history of multiple prior treatments punctuated by relapse,” Mike explains.

Negative coping strategies such as comfort eating or social withdrawal, should be avoided at all costs. At the same time, trigger situations where one is likely to encounter alcohol, drugs or triggers for their use, should also be avoided. “Plan safe social activities with sober people you feel comfortable with.  In addition, regular and frequent contact with counsellors and therapists should be a priority. “

Recovery

“Have a realistic view of recovery – relapse rates are high in the first 12 months and a relapse is never reason to terminate treatment. Rather, it becomes an indication to increase the intensity and frequency of contact with addiction services,” says Mike.

“Knowledge is power. Both the patient and family must understand the effects of drugs on the individual, as well as understand the nature of the recovery process and any anticipated challenges. Recovery is like a major highway, complete with good parts, bad parts, bumps and potholes – to have a realistic view of what is to come may help individuals and families navigate those rough patches.

Prevention

“One cannot overstate the importance of maintenance pharmacotherapy – there now exists good quality evidence that support the use of medication in the treatment of alcohol, opioid and tobacco use disorders, says Mike.

“Often medication is used in the short-term to facilitate detoxification, but arguably the strength and maximum benefit of these medications exists in the recovery period as effective tools at helping patients achieve and maintain their recovery.

“Medication, however, is not everything and there are a number of non-pharmacological strategies that may be useful. These include making use of available social support groups in the community and maximizing social support from friends and family – these can provide a useful outlet for difficult thoughts, feelings and emotions and are oftentimes more readily accessible than professional help. “Booster sessions in the recovery period are a useful strategy too. These follow-up sessions following initial treatment can give an added layer of resilience, especially at high-risk times (such as this time of year).

“Keeping a journal can be therapeutic in itself.  Capturing thoughts in writing can make them appear more manageable. Exercise, meditation and mindfulness may be used to help deal with cravings and unwanted thoughts, and at the same time have their own independent beneficial effects on physical and mental health. Lastly, a functional analysis of previous or recent relapses may provide very useful insights into the chain of events that led to it, and highlight specific areas for future interventions.”

Aftercare

“Recognition that addiction is a chronic relapsing condition, has led to a gradual change in the delivery of services, emphasising the importance of aftercare or continuing care. It is a flexible approach with changing intensity, depending on the current needs of the patient,” Mike explains.

“Aftercare allows for the continuation of long-term care between patients and healthcare providers as opposed to short-term interventions during crisis periods. Aftercare also allows for patients to develop self-efficacy and self-management techniques over time in a safe, comfortable space with a clinician they feel comfortable with. Comprehensive aftercare allows for linkages to be made between patient orientated community resources, such as social services, support groups and so on. Lastly, it is easier to measure patient’s clinical status and progress over time with more regular contact.”

Concludes Mike: “Thanks to improved medications, together with an enhanced understanding of neurobiology and a less pejorative view of substance users, addiction is now a readily treatable disease. With time, naturalistic studies suggest that, with the requisite interventions and support, most substance users will eventually refrain from substance using or abuse. Whether this translates into evidence of a “cure” is less clear, but most certainly addiction can be treated, and successfully.”

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