RELAPSE

Relapse is common in chemical depency populations.

Relapse is common in chemical dependency populations. Nonetheless, it is a critical re-activation of the disease that can be life threatening. One of the goals of HIMS is to effectively treat this illness. Effective treatment includes minimizing relapse occurrences. The treatment, continuing care, and monitoring aspects of the HIMS program are structured with this goal in mind.

Although the definition of relapse focuses on the actual physical consumption of an addictive chemical, “relapse” can also be viewed as a process rather than an event. While we will shortly define the characteristics of a relapse event, it is vitally important to recognize relapse as a process. The drink or drug use that marks a relapse is typically preceded by “relapse thinking.” Relapse thinking is usually apparent in “high risk” behavior before consumption occurs.

Relapse for an alcoholic or addict is a conscious process. A relapse occurrence is generally not surprising to the individual or a result of some accidental circumstance. People in good recovery NEVER forget their illness, and constantly guard against circumstances that may lead to a relapse.

Defining Relapse

A relapse is the use of a mood altering substance (over-the-counter, prescription, legal, or illicit) for euphoric effect after receiving a chemical dependency or abuse diagnosis and without the knowledge and approval of the treating physician or IMS. This definition of relapse is specific and has some limitations related to time and circumstance. It does not require recurring reuse of the drug. We do not view a one-time event as a “slip,” thereby minimizing its severity or importance. A one-time reuse is a relapse.

This is not to say that relapses don’t have different levels of severity and quality, but that one should not minimize the seriousness of a relapse event, even if occurring on only one occasion. In the HIMS world, the term “slip” is sometimes used to refer to a relapse following initial treatment, but prior to a pilot regaining medical certificate. The HIMS database maintained on relapse rates characterizes a “relapse” as an event occurring after an initial special issuance for chemical dependency. Medically speaking, a Slip” is a relapse.

Warning Signs

As previously stated, relapse is not an unconscious or subconscious event. Individuals in good recovery continually take action to reinforce their awareness of their illness. This action may be regular participation in a local peer recovery group, service work accomplished through their union organization or simply daily habits like reading the Big Book of Alcoholics Anonymous or daily meditations. Regardless of the method or methods employed, recovering alcoholics and addicts who identify themselves as having the illness will undertake regular practices to guard against relapse.

Those who do relapse either reject having the disease on some level, or do not believe the illness is as unpredictable, powerful, progressive and chronic as it is characterized. In other words, there exists a belief that one can “successfully” drink or use and control that use despite past evidence to the contrary.

Abstinence from a substance is not the same as sobriety.

Abstinence is consciously not physically exposing the body to the chemical causing past dependency. It is a physical phenomenon. Sobriety is a mental state of awareness of the disease, active participation in continuous steps to prevent relapse and serenity with the decision to live life in that way.

The psychological and neurobiological mechanisms employed to rationalize and justify this belief structure are probably more important for some to study than others. What is important for everyone to recognize is that these beliefs will usually manifest in behavior prior to the individual actually taking a drink. The consequences of unauthorized use of a drink or drug for a pilot in HIMS are usually severe, resulting in loss of medical certification, probable retreatment and possible job loss. Thus, a relapse is not approached lightly. One may begin to see evidence of “relapse thinking” as a result of a failure to commit to the daily steps required to prevent relapse. Relapse thinking is manifest in high-risk behavior, i.e. behavior that often precedes an actual relapse event. In the recovery community, this is often termed “stinking thinking.”

High-risk behavior that may indicate an impending relapse is not difficult to see in the informed person. But, as it occurs prior to actual drinking or drug use, problems occur when trying to “intervene” based solely on its presence. However, one can take steps to increase the level of support provided to that high-risk individual, and to increase the level of monitoring of their sobriety. 

Examples of behavior often found in individuals contemplating a relapse:

Some individuals may show these behaviors, yet never pick up another drink or drug. Some may also relapse without showing any external signs, although most will admit post-discovery they were experiencing high-risk thinking prior to drinking or using. Most individuals who relapse, will give some external indication prior to the event. Good HIMS monitoring programs watch for these signs and then take steps to support the pilot’s continuous recovery and sobriety.

Frequently, relapses also tend to cluster around particular events. The individual may see these events as reductions in the threat associated with getting caught. Alternatively, these events are viewed as symbolic of being “cured and in control” and therefore complete abstinence is no longer necessary. These events may be viewed as merely points of celebration and it is “normal” for alcoholics and addicts to celebrate by drinking or using drugs. For whatever reason, relapses do occur at particular “risk points,” although they are certainly not limited to those points in time. Some common risk points are:

• Release from residential treatment
• First “sober” FAA physical exam
• Arrival of the FAA Special Issuance Authorization letter
• First “sober” airline trip as a crew member
• Anniversaries of all kinds – last drink, release from treatment, etc.
• Last “sober” FAA physical exam.
• Relaxation of FAA monitoring requirements and lower risk of detection
• Various life stress points – divorce, birth of a child, weddings, etc.

Just as a good support program will be cognizant of high-risk behavior, it will also be aware of high-risk times or events. Every circumstance that leads to an increased probability of relapse should be of concern. Whenever those circumstances are present, steps should be taken to reinforce the recovering person’s sobriety. This is an important role of the HIMS Monitoring Team.

It is important to note that experiencing a relapse is not a requirement for good recovery. Many individuals are able to establish and maintain continuous sobriety following their initial treatment experience. Those individuals usually indicate that the event leading to their treatment, or the treatment experience itself, was effective in breaking through their denial. They also cite the quality of the compliance-testing program, participation in groups like Birds of a Feather, and being involved in their local recovering communities as important factors in maintaining their sobriety. For these individuals and others, long-term sobriety begins with “owning” the illness. For those whose ego won’t allow them to admit they are sick and need help, the success of their sobriety is very uncertain.

Prevention Steps

The first step to take in minimizing relapse events is to design a monitoring program that proactively addresses relapse risks. In fact, the entire monitoring process can be viewed from a risk management perspective. Early in sobriety when the risk of relapse is generally higher, the program should be designed to provide higher levels of support. These higher levels of support usually involve more contact with the HIMS AME/IMS, the aftercare group counselor, the HIMS Monitoring Team, the AA sponsor and the peer support group. Since the HIMS pilot are not flying early during their sobriety, they should expect to participate in recovery related activities frequently.

In addition to a high level of early participation, the monitoring program should involve a discussion of various risks to sobriety and help the pilot develop a plan to prepare for them. Since certain events create “trigger points” for relapse, these events should provide a focus for additional sobriety support. Support can be accomplished through group therapy discussions, company and peer monitor meetings, discussions at peer recovery meetings like AA and NA, and through additional testing. It is very important to establish good sobriety testing protocols during early sobriety, including accomplishing “base-line” testing and random, off-duty sobriety testing using a variety of methods.

Participating in these events is not prohibited, but participation should be proceeded by the development of an “escape plan.” The escape plan should be developed with 12 Step sponsors, peers, counselors and the AME/IMS, the pilots should not use a plan they have developed themselves. Examples include having a means of transportation away from the event and calling a sponsor if the urge to drink/use arises, abstinence testing immediately following the event, what to drink and how to respond when offered an addictive substance.

Create an Escape Plan

In all cases, it is important for the support team to maintain a healthy skepticism when working with those who are new to recovery. As a group, pilots are particularly adept at adapting to circumstances involving monitoring. They are evaluated on a regular basis and learn to “play the game.” Early in sobriety, many of those new to recovery are genuinely happy to be sober, but life without alcohol or drugs can also be very challenging. When those challenges arise, and they will, the newly sober pilot should express some concern about meeting these difficulties.

People who are newly sober often begin to gain a sense of hope and wellbeing that has been absent for many years. These positive feelings give rise to an optimistic outlook. This emotional state is so common in early sobriety that people in that stage of recovery are often said to be living on a “pink cloud.” For example, if a pilot in the HIMS program is 60 days sober and describes a universally optimistic experience, that would not be unusual or a cause for concern. However, the same attitude expressed 12 months into recovery would be a danger sign. Individuals working hard at their recovery will often be struggling with changes in their family relationships or with the rigors of step work at a year sober. So, an attitude of “some days are difficult” is both healthy and expected at that point.

If a HIMS pilot consistently describes sobriety as wonderful and claims to be free of problems and concerns, a monitor should presume the individual’s sobriety is at risk. This “Pollyanna” attitude is either an example of self-delusion or the recovering person is minimizing the problems they have and the risks to their sobriety. Either situation requires close attention to the individual and increased support.

In addition to the steps associated with program design to address relapse risk, one must also address specific circumstances of relapse behavior. Initially, one must determine if a particular behavior represents a relapse risk or not. As sobriety progresses, so too will the process of personality change that accompanies it. It is important to be cognizant of these changes over time, as a behavior present early on in sobriety may not be a problem, while the same behavior a year or two later would be troublesome. The “everything’s wonderful” attitude mentioned above is a good example of such behavior.

Similar situations occur throughout the recovery process, with stable recovery usually being achieved somewhere between two and five years of sobriety. For those in recovery, this process is somewhat transparent having been through it themselves. For others, it may not be apparent at all. As members of the pilot’s monitoring team, if doubt exists as to the appropriateness of any particular attitude or behavior, it is important to discuss the situation among the team members. Generally, a consensus will be reached on whether or not additional support should be provided.

Relapse Behavior Actions

When behavior arises that may indicate a pilot’s sobriety is at risk, the person observing the behavior should communicate their concerns to other members of the monitoring team. It often occurs that more than one team member will have similar concerns or experiences. If a number of different people are seeing problem behavior, increased support and monitoring is needed.

Generally, besides addressing the issue directly with the pilot involved, it is also important to provide graduated disincentives if the pilot is non-compliant. These disincentives may involve removal from the flight schedule, increasing the frequency of testing, medical grounding, or extension of the Step Down monitoring phase the pilot is in.

The HIMS AME/IMS has considerable authority to take action as the pilot’s medical qualification is contingent on the IMS’ continued sponsorship. For company actions, authority should be established either through a return to work letter or contract given to the pilot when they return to flying.

Occasionally, pre-relapse behavior may be repeatedly occurring without any evidence of a physical relapse. The pilot may be maintaining abstinence but have lost sobriety. Relapse is probably imminent. Although the pilot has not violated the Special Issuance, it may be appropriate to remove the pilot from flying status and offer a “tune-up” through an Intensive Outpatient Program to help avoid the physical relapse. The pilot’s acceptance or not of such an offer gives a strong indication of the recovery status and willingness to get help.

If the HIMS Team suspects or has identified a relapse, the following steps should be taken:

In all cases of addressing a relapse or other problem behaviors, it is important to be consistent with the actions that are taken. Similar situations should be handled in a similar manner. Wide deviations in the relapse consequences or disincentives used can lead to legal problems and litigation in the future. It is also important to follow through with compliance actions. It does no good to increase monitoring requirements on a pilot if the pilot is then not held to that new standard.

The pilot who relapses will be filled with shame, guilt and fear. The pilot will need emotional support and reassurances that relapse is part of the power of the disease. Ask about suicidal thoughts as the despondency and hopelessness of going back to treatment, facing the family, job insecurity may be overwhelming. The HIMS Team can be a tremendous help. Peers can facilitate connections with other pilots that have relapsed and returned to flying as source of comfort and hope.

Finally, no recovery from this illness is perfect. It is an ongoing effort characterized by good days and bad, progress and, sometimes, regression. However, those who eventually succeed at recovery consistently show a good attitude about their situation. The prime characteristics of this attitude are rigorous honesty, open mindedness, willingness, and humility. If recovering pilots exhibit these qualities, it is likely they will remain sober.

If they don’t, they may be at risk for relapse. In every case, one must remember that compliance is about behavior, not attitude. Although we hope every recovering pilot has a good attitude, no one can force a pattern of thinking on someone else. One could make a case, though, that a person with a poor recovery attitude should continue to be monitored as they represent a relapse risk.

Re-treatment

Most relapse events will result in some form of re-treatment for the pilot. The type of disclosure, type of drug used, and length of use all impact the type of re-treatment. While there is no FAA imposed limit on the number of treatments a HIMS pilot may undergo, generally, the treatment experience tends to become longer and more intense each time. And, most company programs will shift the cost of treatment increasingly to the pilot with each event. Initial and relapse treatment may be conducted at the same facility, but some airlines choose to use different treatment programs for each group. Since the pilot was not able to maintain sobriety following the first treatment, it’s thought that a “fresh” approach at a different facility might be beneficial.

Occasionally, a pilot may be forthcoming in revealing a relapse and report it to the HIMS Team. An example might be reporting having a sip of champagne at a child’s wedding and then calling the sponsor to discuss. In a recovery program of rigorous honesty, the pilot would then come forward voluntarily. Assuming an investigation is consistent with the pilot’s self-report, a lower intensity of treatment may be appropriate. Because this represents a violation of the conditions of the Special Issuance, the same recertification process is required as for a pilot that concealed drinking for months and was discovered by testing or direct observation. The period of observation before submitting a request for a new special issuance would be shorter in the first case than it would be in the second situation.

Of course, there are a number of factors that tend to influence the re-treatment decision. Many times the actual nature of the relapse is unknown when the re-treatment decision is made, and the pilot will usually claim it either didn’t occur or only admit to a one-time relapse event. If one were to base the length of treatment on this available data, one would typically underestimate the severity of the relapse.

There are also cost issues for the grounding and re-treatment of the pilot. There may be limitations on available sick benefits. Also, the pilot will not be enthusiastic about navigating the re-certification process once again. All of these factors tend to encourage taking a limited response to the event in order not to “punish” the pilot for a minor “slip.” HIMS strongly cautions against taking this attitude. Those who relapse are prone to relapse again. Furthermore, each relapse event can be life threatening. For those who relapse more than twice, one airline has a historic mortality rate of 40%. Consider a relapse as a warning, and every reasonable step must be taken to minimize the chance of another relapse in the future. Those steps include a full treatment experience.

Re-certification

The re-certification process does not vary significantly for the relapsed pilot from what was experienced in the initial medical certification process. FAA will require that the previous neuropsychological testing be repeated to ensure there is no cognitive damage. Additionally, FAA views relapsed pilots as a higher risk group and therefore, will normally take a bit longer to recertify the individual and place them in a longer period of formal monitoring. FAA will also look for evidence the pilot has undergone a change from their previous post-treatment condition. In other words, it is helpful if FAA can perceive the pilot is doing something differently than the behaviors that led to the relapse.