People, Places, and Things: There’s Way More to Relapsing than Drugs Alone

Research shows that triggers related to substance use can pose a greater threat to recovery than substances themselves

By Dr. Adi Jaffe

Cognitive behavioral therapists call them the “Five W’s.” 12-Steppers call them “People, Places, and Things.” No matter how they’re labeled, “triggers” are a huge part of addictive behavior. Triggers are associations, such as the neighborhood of a bar you used to frequent or a food you used to eat while stoned, that are formed through habitual substance use. They are a product of what’s known as classical conditioning, a learning process best known for the Pavlov’s Dogs phenomenon, in which a stimulus (a ringing bell) associated with a reward (dog food) over time became pleasurable in and of itself, so much so that Pavlov’s dogs salivated when hearing a ringing bell even when there was no dog food to be found. Triggers work in the same way and play a huge role in reminding people in recovery of their drug-using past. For example, an old friend of mine said that early in his recovery from heroin addiction, he couldn’t look at the sight of his bare forearms without wanting to shoot up—meaning parts of his own body had become a powerful trigger—so he made a habit of wearing long sleeves as much as possible. Sometimes triggers are enough to set an old behavior in motion, even among people who have been abstinent for a while, and especially when they are unprepared for their effect.

So what kinds of things can trigger a desire to use again? Research on relapse has shown that there are a number of things that can summon a person back to drug-seeking long into abstinence. Stress, small drug doses, and seeing other people, places, or things that were associated with drug use are all potential triggers even after months—or years!—of abstinence. It’s probably not surprising that giving drugs to someone who’s abstinent can make them want the drug again. But, surprisingly, recent research suggests that triggers alone can be more powerful than drugs themselves in inducing a relapse! Or, put another way: substances pose less of a relapse risk than the people, places, and things associated with them.

Lights, levers, and holes

The research that we’re referring to was performed in Japan on mice (Yan et al., 2007). Simply put, mice were placed in a cage and trained to poke their noses into specific holes while pressing a lever to get a rather uplifting reward: a shot of meth to the nose. When they did so, a light also flashed above their heads. The mice did this over and over again, after which strong associations between not only the drug of meth and the drug-seeking behavior of lever-pushing and hole-poking but also the drug and the trigger of the flashing light.

Rats and levers

After the mice figured things out, they went through a period of time where their drug-seeking behaviors didn’t get them any meth. This was essentially an “abstinence” phase for the mice—they didn’t get any drugs for an extended period of time, and they eventually stopped hole-poking and lever-pushing. The next part of the experiment is where it gets interesting and demonstrates how powerful triggers can truly be.

 Researchers took the mice again and gave them a shot of meth before putting them back in the cage. The first time they did this, the mice went crazy and returned to lever-pressing and nose-poking to try to get even more meth. However, the second time around, the scientists took the mice, gave them a shot of meth to the nose, and put them back in the cage, but they didn’t do any drug-seeking behaviors.

What about the trigger? The researchers took the mice again and put them in the cage without any meth. However, this time around, the little light associated with getting meth would light up whenever the lever was pressed and the hole was poked. Under these circumstances, the mice engaged in the drug-seeking behavior over and over again to try to get meth, unlike when they first got a dose of meth and gave up after one round of the behavior.

Seeing this, the researchers went for broke and tried another run of this with the same mice, now following up five months after the last time they received meth for pushing the lever and poking the hole. After the mice were put in the cage without a shot of meth first or a reward of meth to be found, the sight of the flashing light—the trigger—was enough to get the mice engaging in their drug-seeking behavior again—a full five months after the last time doing so got them meth!

The Alternatives approach 

Everyone knows that triggers are a challenging part of addiction recovery, but the idea that they can be more influential than drugs alone in causing a return to drug-seeking behavior is a novel one. Still, this isn’t very surprising given the very long-lasting impact that drugs of abuse (especially stimulants like meth) have on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. If a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.

At Alternatives we recognize that everyone struggles with a unique set of triggers. We teach skills like Urge Surfing and Trigger Restructuring through our Bio-Affective Management system to help people process triggers better. Also, we help people form strategies to avoid the more dangerous triggers altogether wherever possible. Finally, since we let some clients choose moderation as their goal, meaning they’ll continue using at some point in their recovery, we pay extra special attention to the triggers they come in contact with—knowing full well they’ll jeopardize their recovery more than substances do.

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Yijin Yan, Kiyofumi Yamada, Atsumi Nitta  and Toshitaka Nabeshima (2007). Transient drug-primed but persistent cue-induced reinstatement of extinguished methamphetamine-seeking behavior in mice. Behavioral Brain Research, 177, 261-268.


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