Stress and Treatment Initiation

by National Institute of Health

(Page 5 of 6)

Discrete stressful events often provide impetus to an alcoholic person to seek treatment, especially when other resources and responses have failed to alleviate the stressful situation. This correlation between stress and treatment initiation was highlighted in several studies comparing alcoholics who had initiated treatment with alcoholics who received no treatment. In those comparisons, alcoholics entering treatment were more likely to perceive their drinking problems as severe, had more symptoms of alcohol dependence, and experienced more stressors and negative events in various life domains. Of prime importance, these stressors included both chronic hardships (strains in employment or marriage) and acute stressful events (accidents, criminal charges, or divorce) that often are associated with drinking.

Alcoholics with greater resources in multiple domains (those who are employed and have an intact marriage) are likely to seek treatment for alcoholrelated problems more quickly than are alcoholics with fewer resources. For example, social resources, such as an extended network of family members and friends, may increase the probability that a drinker's alcohol-related problems are pointed out to him or her by other people, thereby leading to early treatment seeking. This hypothesis contradicts the notion that an alcoholic must lose all his or her resources ("hit bottom") before seeking treatment; rather, it suggests that resources should be increased ("the bottom should be raised") so that the person seeks treatment before experiencing multiple devastating consequences of alcoholism.

In summary, stress in many cases may play a causal role in the initiation of treatment. This role, however, probably is moderated and mediated by numerous factors, including a drinker's resources, social pressure, problem-solving skills, and coping strategies.

Stress and Relapse

Both discrete, stressful life events and chronic stressors may play a role not only in the development of alcoholism and AOD treatment initiation, but also in the relapse of people recovering from AOD abuse. To explain the association between stress and relapse, as well as the fact that not all AOD abusers relapse when encountering stress, Brown and colleagues have proposed the stress-vulnerability hypothesis. This hypothesis posits that AOD use in the face of severe stressors is mediated by the presence or absence of both protective factors (good social support) and risk factors (homelessness and unemployment). The hypothesis is supported by findings that severe stress (defined as life adversity posing either a high personal threat or chronic coping demands) which occurred prior to and independent of alcohol use was related to relapse after treatment. Thus, during a 3-month followup period after treatment, patients who relapsed had experienced twice as much severe stress before entering treatment compared with patients who remained abstinent. The study also calculated a composite "psychosocial vulnerability score" based on the patient's coping skills, social resources, confidence that he or she would be able to resist an urge to drink, and level of depression. According to that analysis, people whose scores in these areas improved during treatment had better outcomes (a lower risk of relapse). These findings emphasize the connection between stress and relapse and suggest that resilience to stress-induced relapse can be improved during treatment.

Another study followed a large group of alcoholics, opiate users, and cigarette smokers in early abstinence to investigate the effects of acute stress and commitment to abstinence on relapse. The commitment to abstinence was measured using a scale that allowed the participants to choose between six different treatment goals, ranging from abstinence to no change in use. The researchers found that commitment to abstinence was the strongest predictor of abstinence during the followup period. Furthermore, an association between elevated stress levels and relapse existed only when the subjects were interviewed after their relapse (retrospectively) about the factors contributing to their relapse, but not when stress levels were assessed before a relapse occurred (prospectively). This observation suggests that stress may not actually lead to relapse; instead, the relapse may have resulted in increased stress and the subjects may have used the attribution of stress as causing the relapse as a way to make sense of the relapse. The actual relationship between stress and relapse in this study is difficult to assess, however, because the followup period was rather brief and the study did not assess the effects of chronic stress. Nevertheless, the study results emphasize the need for more careful, prospective studies of the relationship between stress and relapse.

Stress Management in AOD Abuse Treatment

As the studies reviewed in the previous section indicate, stress may play a crucial role in the relapse to AOD abuse after treatment. Accordingly, the incorporation of treatment strategies to help patients cope with stressful events could reduce relapse risk. Such strategies may include pharmacotherapeutic as well as psychosocial approaches, as discussed in the following sections.

Pharmacotherapy

Besides contributing to relapse to alcohol, stress also may play a role in relapse to other psychiatric disorders, such as depression and anxiety. As with the treatment of such disorders, it therefore makes sense that pharmacological management for recovering AOD users should be maximized during times of stress to help reduce risk of relapse. Accordingly, treatment of anxiety may be a useful component of alcoholism treatment.

As mentioned earlier in this article, at a neurochemical level the connection between stress (and/or anxiety) and resumption of alcohol use appears to involve several neurotransmitter systems in the brain, including serotonin pathways and reward pathways, which use dopamine and opioid peptides. Accordingly, medications affecting those systems (SSRIs and opioid antagonists) may play a significant role in minimizing the risk of relapse after stressful events. Other anxiety-reducing therapeutic agents that act on the same systems, such as benzodiazepines, have abuse potential themselves, making their use in people with AOD use disorders risky.

About the Author

NIH is the nation's medical research agency - making important medical discoveries that improve health and save lives. The National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services, is the primary Federal agency for conducting and supporting medical research.