Relapse Prevention Plans
Addiction is a chronic disease often marked by cycles of relapse and remission. But for people who have an addiction who are leaving jail or prison, relapse—a normal, but preventable, part of addiction—can not only jeopardize recovery, it can also undermine their reentry into the community and increase their risk for recidivism. Further, rates of overdose and overdose deaths among people reentering the community from jail or prison are alarmingly high, due to relapse to substance use.
While correctional agencies, probation and parole agencies, and community-based behavioral health treatment providers are working collaboratively to support people returning to the community from prison or jail, they often struggle to account for relapse prevention among people who have an addiction. The development and implementation of relapse prevention plans (a best practice in addiction treatment) as part of a Collaborative Comprehensive Case Plan (CC Case Plan) for reentry, can help to reduce the chances of recidivism and relapse for people who have an addiction, and ensure coordination and linkages among all of the entities involved in their care.
What are relapse prevention plans?
While relapse is a normal part of addiction, it is preventable with the right planning structure in place as someone is nearing their release from jail or prison. A relapse prevention plan is a therapeutic tool used to identify and list a person’s triggers for using substances again and strategies for how a person can manage their triggers throughout the recovery process. When used to support a person reentering the community from prison or jail, these plans help to minimize the risk of relapse and, subsequently, reduce a person’s likelihood of recidivating since substance addiction is a significant risk factor for criminal activity—both by their direct relationship to crime and risk, and indirectly by the negative effect of addiction on responsivity to interventions.
How to identify who needs a relapse prevention plan?
Screening is the first step to identifying who needs a relapse prevention plan. Because people who have an addiction often use multiple substances, correctional agencies should have universal screening for use of multiple substances at booking or intake. Screening should be administered by correctional facility staff early on to identify people who have addiction and those who use substances in ways that threaten their health and safety.
- There are validated, brief screening tools that are available to the public and should be used to identify people who have signs of addiction.
- If someone screens positive, they should receive a full assessment to confirm diagnosis and determine the severity of their addiction, be referred to the most appropriate treatment both within the facility and as they reenter the community, and receive an individualized relapse prevention plan as part of overall reentry planning to support their successful return to the community.
- Furthermore, written protocols should guide decision making for referring people for assessment, managing people in withdrawal, and determining when someone needs a higher level of care.
How are relapse prevention plans developed?
Once correctional agency staff have determined that a person requires a relapse prevention plan, a group should be assembled to develop the plan. Following the CC Case Plan model, the development process should include the following participants:
- The person in recovery who is reentering the community
The person should guide the development of the plan based on their own experience with addiction. This information can be gleaned from the person either individually or from group therapy sessions. They should also understand the purpose of the plan and the plan’s contents before they agree to follow it.
- The lead case planner
Relapse prevention plans can be developed by any of the lead case planners (the agency or organization that takes the lead in case planning and case management)–whether behavioral treatment provider, community supervision agency, or correctional agency—as part of the person’s CC Case Plan. Depending on the lead case planner, there are different action steps that lead case planners can take so that relapse prevention plans are developed and made part of the CC Case Plan:
- Behavioral health treatment provider: (1) conduct in-reach into the jail or prison to coordinate with entities involved in planning for the person’s reentry and (2) develop the relapse prevention plan before the person is released from jail or prison.
- Correctional agency or probation or parole agency: coordinate with behavioral health treatment providers, including both the health care provider in the facility and the community-based behavioral health treatment providers, to obtain the relapse prevention plan and ensure that it is included as part of the CC Case Plan.
- Members of the person’s support network
Participants who have a substance addiction should identify people who are in their support networks, who are positive, prosocial influences in their life. Once identified, lead case planners can include these people in the development and implementation of the person’s relapse prevention plan and ensure that they are provided with information to help the participant succeed in recovery.
How are relapse prevention plans implemented?
When possible, relapse prevention plan development should begin weeks or months prior to release so people can familiarize themselves with the content in their individualized plan and begin practicing the coping skills they identified. Ideally, this time would also provide the individual’s support network and treatment team with a chance to better acquaint themselves with the plan. Once developed, lead case planners should incorporate the below components to efficiently implement the relapse prevention plan. The final version of the relapse prevention plan should be shared with all of the people involved so they understand and can help the person achieve their goals. This can also help them better understand how they can help if the person has a relapse.
- Case conferences
Case conferences are regularly scheduled meetings where the various entities involved in a person’s diversion or reentry planning review participants’ cases prior to their release from jail or prison or before they enter a diversion program. These conferences are a great opportunity for members of the person’s support network to share and review the participant’s relapse prevention plan.
- Continuing care
If the lead case planner is not a community-based behavioral health treatment provider, that lead case planner should ensure that participants are directly connected to a behavioral health treatment provider immediately upon the person’s release. Additionally, during this “warm handoff,” the lead case planner should ensure that the behavioral health treatment provider receives a copy of the person’s relapse prevention plan so they can continue their treatment and care post-release.
- Information sharing
If the lead case planner is a correctional staff member, they should also make sure that a person’s community behavioral health provider and parole/probation officer and support network are aware of the action steps to be taken if a person relapses and needs medical attention.
- Regular check ins
Lead case planners should periodically check in with the person and their support system to adjust the plan as necessary. This could include developing new goals or adding new coping skills.
What should relapse prevention plans include?
Relapse prevention plans should include and identify:
- Individualized recovery goals
Each person’s recovery goals will be unique and include both short-term and long-term goals. Goals can change over time, especially between the time a person is still in jail or prison and after the person reenters the community, so the goals should be flexible and allow for periodic adjustments. A person’s individual recovery goals can be aligned with some of the risk factors determined from their criminogenic risk and needs assessment such as substance use and anti-social associates. To address those risk factors, for recidivating and relapse, in a comprehensive manner the lead case planner should coordinate with the person’s support network prior to release from a jail or prison and post-release. Theses coordination efforts will help to address risk of relapse and often risk of recidivating.
- Potential triggers for relapse
Triggers will vary from person to person and may be physical (such as the places where people obtained or used drugs in the past) or may be associated with family or the peers with whom they previously used drugs. Other triggers may be internal and can include feelings such as stress and anxiety. These triggers can lead people to experience cravings, which are strong and persistent desires to use substances, which left unaddressed, can result in relapse. In some cases, lead case planners can provide or link the person to a provider who prescribes medication-assisted treatment (MAT)such as naltrexone, methadone, or buprenorphine to help reduce cravings as they reenter the community.
- Early warning signs of relapse
Early warning signs are the small changes in a person’s thinking and their behavior that signal a relapse may be starting. These warning signs can include behaviors such as going to treatment appointments less frequently or not at all, beginning to socialize with the same peers who were previously associated with the reason for their incarceration, and expressing desire to use substances again. People are not always cognizant when they are experiencing early warning signs of relapse. Since friends, family members, and practitioners often notice when someone seems different or acts out of character, it’s important for lead case planners to educate members of the person’s support network on potential early warning signs of relapse to help them be mindful and prepared to act swiftly if they see the signs appear.
- Coping skills
When someone can identify and execute effective coping strategies (e.g., a behavioral strategy such as leaving the situation, or a cognitive strategy such as remembering their reasons for wanting to quit), they are less likely to relapse compared to a person lacking those skills.
- Action steps
The relapse prevention plan should include clear action steps for what to do if the person feels they are coming close to relapsing or they have relapsed, as well as contact information for any specific individuals or providers they may need to consult quickly. These steps should include:
- Calling or visiting a medical or mental health professional immediately
- Activating in-case-of-emergency procedures
- Meeting with their behavioral health treatment provider to reinforce recovery goals
- Connecting with their lead case planner or support network to engage in activities they enjoy while in recovery
What should lead case planners do if someone relapses after leaving jail or prison?
While relapse prevention plans are a useful tool for ensuring recovery and successful reentry for many people, lead case planners and members of the person’s support network should still be prepared to respond if someone relapses or overdoses upon their release from jail or prison. Lead case planners should:
- Understand that people in the criminal justice system who have substance addictions are at higher risk for relapse, overdose, and overdose death upon release from prison or jail.
- Know each participant’s individual triggers for substance use relapse upon release.
- Obtain information about previously prescribed medications and the names and contact information for the person’s health care providers, when permissible. Note: behavioral health treatment providers are familiar with privacy protections such as the Health Insurance Portability and Accountability Act (HIPAA) and Title 42 of the Code of Federal Regulations (CFR) Part 2 and can facilitate appropriate sharing of information.
- Identify the signs and symptoms of overdose and contact medical assistance immediately if this is suspected. Lead case planners and other members of the person’s support network should also be able to recognize the signs of overdose and know to contact emergency medical assistance if overdose is suspected. In some instances, lead case planners or family may also be able to administer naloxone if they have been trained in naloxone administration and someone overdoses from opioids.
- Reengage the person in treatment. In cases where the lead case planner is not the behavioral health treatment provider, the person who has relapsed should be connected directly to the most appropriate treatment provider. If there is a peer specialist working with the person or there are peer specialists working in a treatment program, it can be helpful for them to connect with the individual following an overdose, to help them reengage with treatment. A person’s support network can also help people reengage with treatment.
- Provide positive messaging to the person, and encourage them to make additional efforts to restart their recovery, drawing upon what they’ve learned from their most recent relapse.