Monday, December 24, 2012

Do relapse rates rise around the holidays?

Many people assume that the time between Thansksgiving and the winter solstice holidays are the most difficult time of the year for people in  recovery. Temptations are harder to avoid, what with office and holiday parties, family gatherings, and so forth. Many people with alcohol dependence come from families with many heavy drinkers, so alcohol may be flowing freely, and there may be others who are intoxicated. (Ever notice how boring and obnoxious intoxicated people can be if you're not intoxicated yourself?) So cue-induced craving is certainly an issue, whether your cues are visual, smells, other being surrounded by others who are drinking. How can someone protect themselves, what are the best strategies?

Another major trigger for many are negative or painful feelings. The constant drumbeat and ceaseless streaming of happy families enjoying their time together is very different from what most of us experience. Especially in early recovery, loneliness is common, and made so much more painful as we imagine all the other people surrounded by relatives and friends, all enjoying themselves and each, celebrating their good fortune. And that's how families usually are right? (Wrong!) Interactions with family members are often their most difficult and painful during the holidays. Young adults home for the holidays fall into acting like 15 year-olds, and parents play along. Having to endure another holiday with your obnoxious brother in law from the other political party or religious group seems like it will make you explode.

Finally, we all get knocked out of our normal rhythms of self-care and self-regulation during the holidays. We get swept off our feet, we lose our ground. Our work-out routine gets disrupted. If we travel our time clock gets out of whack. If we're working a 12-Step program, our home group and sponsor may be back home while we're visiting relatives in Seattle. If we're in therapy or seeing a psychiatrist, those appointments are harder to find. And then there's Seasonal Affective Disorder (SAD,) so in temperate climes, we may become more depressed. Most people with Major Depression or Dysthymic disorder have seasonal sensitivity, making depression worse in the winter. We eat too much, sleep too much (or too little), get lazy. It's a wonder any of us make it through sometimes.

One basic strategy for managing the holiday season comes from cognitive behavior therapy (CBT.) The principles are: Recognize, Avoid and Cope. Recognize a high risk situation before you're in it. Anticipate it. Ruminate about it. How might you be affected? What are your triggers? How solid are you feeling in your recovery right now? Main principle: don't test yourself. If you're feeling shaky, pay attention. Second principle: take care of yourself. No one else will. Then, if you can, Avoid the high-risk situation completely. Don't let guilt or a sense of obligation push you into a high risk situation. Your recovery is more important than anything or anyone else. Finally, if you cannot avoid the situation, Cope with it. Devise strategies for managing it. Talk to your therapist, support friends and family members, psychiatrist, or sponsor. Consider using an anti-relapse medication over the holidays, even if you usually don't. Antabuse, which makes you ill if you drink, is a particularly useful one, but naltrexone is also good. Topiramate is less so because it takes a long time to ramp up on the dose. If you are in a 12-Step program, schedule your meetings, being specific about when and where. Decide what your emergency strategy is is you are in a situation and don't trust yourself to drink. For example, get out of there, go for a walk, excuse yourself and go to a meeting or meet up with a friend, or call a supporter. Can you identify supportive people at the gathering? Or, better yet, bring your own! Make sure you pay attention to sleep and exercise and alone time. Meditate or have a relaxation training session. Get a massage. Well, you get the idea.

So, do relapse rates go up during the holiday season? Here's a graph from a fascinating study by Mark Goldman and colleagues, who tracked drinking for 365 days in young adults. (Goldman M, et al., Psychol Addict Behav. 2011 March; 25(1): 16–27.)

As you can see, the major peaks for young adults are Spring Break, New Years, Halloween and July 4th. Thanksgiving ranks about the same as the Super Bowl. Christmas is, like, nada. On the other hand, a study in Finland found that alcohol poisoning fatalities were greatest there during Mayday, Midsummer and Christmas celebrations. A 1989 study by the CDC found increased rates of alcohol-related traffic crashes and fatalities during the holiday season, but with the changes in DUI laws, it is hard to extrapolate. But I couldn't find one study in PubMed examining relapse rates among recovering alcohol dependent persons over the holidays.

So what's the answer? Well, we don't have good scientific evidence one way or another. In my clinical experience, alcohol dependence, like other serious chronic illnesses, often have a pattern of their own. Serious depression and suicide don't go up over the holidays. (Suicides peak in the spring.) My own impression is that there is no big jump in relapses in general, although specific people may struggle more during this time. But it always helps to be prepared. Recognize, Avoid, Cope, and have a great solstice celebration!


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