When inpatient rehab ends, that is when the real work begins. While in treatment, they are under constant control, receive round-the-clock care and operate within a safe environment. Everything of that is gone for a recovering addict when they enter back into the society, and that is when relapse usually occurs
Photo by Adrian Swancar on Unsplash
Why the first 90 days function differently than “getting back to normal” outside
As long as the odds are not on your side within the first months, it is essential to plan ahead for anything less than total success
Too often relapses are permanent, re-teaching the body to tolerate higher doses of toxins or erasing valuable rehab progress. A doctor might continue to prescribe the failed dose regimen if there is no certainty that the relapse did not re-tune the patient’s endogenous opioid system. More people die from an overdose in the first weeks following a relapse than at any other time after return to drug use. Nothing is foolproof, but fewer opportunities for slips reduce risks, and case managers and doctors already factor in that one out of every five patients will return for a second round within six months of leaving. That is a built-in caution, and these same odds should be factored into the first 90 days.
The best early schedules look like military briefings – as many decisions as possible made ahead of time
That same rigidity is necessary for the first month, because it is the schedule that will allow you to retain a job, reconnect with relationships, and begin therapy without overwhelming yourself
Think of it as a framing device, something that holds everything else in place. Your first structure will flex if you are faced with even a low level of stress – a car accident, plans falling apart at work, a sudden breakup – and that first impression of a failing backbone will be difficult to shake. You must also accept beforehand that these things will happen.
Your home environment should be evaluated with a surgeon’s scalpel
Returning to a home environment rife with enablers, other addicts, or people who have done nothing to improve their own toxic behaviours during your rehab is a bad idea
That is why sober living homes return a recovering addict to a familiar setting but with greater regimentation, restrictions, and drug tests than they would find in their own residence. This is not a postponement, but a more realistic halfway point for people whose home life was in any way involved with the development of their addiction. The decision about where to live after discharge from inpatient treatment should be made with equal care as the decision to enter it – ideally before the last day of treatment.
Continuing care must be scheduled, not assumed, beginning before discharge date
Aftercare should always be viewed as another stage of treatment, where everything that comes after rehab is part of the overall picture. This being the case, that next stage should never be up for debate or assumed to be something that will happen “when the time comes.” People have far too many expectations for themselves when they leave rehab, believing that this crisis will teach them everything they need to know or that they will eventually get around to doing something like outpatient therapy.
Just as a house cannot be built before its foundation is laid, neither can the next stage of treatment be delayed until some nebulous “rehab readiness” begins. It must be a scheduled and specific step, ideally no later than the first week following discharge. Many people use an Intensive Outpatient Program as a continuation of their inpatient rehab, in that it keeps them within a similar clinical setting without removing them from their day-to-day life as much. This is a good way to extend the structure of your early recovery without losing what you built up until that point, and it is something to consider when choosing a continuing care provider like Legacy Healing NJ. This same consideration should be made when choosing a medication-assisted treatment provider if that is the route that has been decided upon.
Have a sponsor or accountability partner identified within the first week
You cannot hold yourself accountable to yourself during the first days and weeks of rehab, for the same reason that addicts cannot stop themselves from using when their cravings begin
This is why you need a sponsor or accountability partner who can help you through this vulnerable time.
You should be checking in with them on a daily basis, ideally via phone or text message, where you answer to them directly and they hold you to your standards. This daily check-in will provide you with the external source of accountability you will lack during these first few weeks. As well, having that contact who is available every day will serve as a crisis intervention measure, in that they will be able to identify changes in your voicemail and conversation tone before you realize yourself that there is a problem. Many people will hesitate to identify a sponsor or accountability partner at this stage, but the wrong one who is available every day is far better than the “perfect” one who will never be available until next year.
Replace your old social rhythms with meetings
Active addiction follows a pattern of commitments and obligations dictated by the addiction. Once that is over, these same compulsions must be channeled elsewhere, or they will quickly move to fill the hole left by the substance or behaviour of choice
That is why a recommendation of “90 meetings in 90 days” resonates so well within twelve-step fellowships, although the exact number is unimportant. What is important is finding a meeting that can occupy that daily social time slot and replacing whatever it is that previously took up that slot. Twelve-step is not for everyone, but for most people, attending meetings and/or therapy several times per week will be helpful in creating structure, connection, and support. SMART Recovery is an alternative that takes a more science-based approach to the same general set of goals. Either one of these, along with regular attendance, provides the same sort of life structuring and check-in functions that inpatient rehab does.
Provide concrete coping mechanisms for cravings
Structure does wonders for preventing cravings, but cravings tend to occur anyway, often without warning
Having a few practical coping mechanisms in place – beyond simply telling yourself to “stay strong” – can make all the difference in turning the corner away from a slip
First and foremost should be a HALT check – are you Hungry, Angry, Lonely, or Tired? Most cravings are rooted in one or more of these, and simply acknowledging it might be enough to move on. Another essential tool is urge surfing – the recognition that cravings are waves that crest and then dissipate, with a normal period of fifteen to thirty minutes if the person does not act upon it. Knowing that number in advance can turn the tide on a craving, taking the strength out of it simply by knowing how long it will last. As well, a written emergency response plan – people to call, a place to go, something to do – should always be in writing or saved on your phone, rather than thought up in the middle of a crisis. Nobody should be designing a response plan when they are in crisis.
Sleep must be considered clinically important
An inpatient rehab setting often serves to reestablish healthy sleeping patterns. For example, going to bed and waking up at the same time every day helps to reinforce circadian rhythms. As well, cutting out substances that suppress or interrupt sleep is usually enough to restore healthy sleep structure. Limiting screen time before bed and having downtime in the hour or two before bed helps to prepare the brain and body for rest.
This is important for the same reason that sleep is essential for everyone else – it is difficult to overstate the importance of it. A consistent sleep schedule, limited caffeine intake in the afternoon, and limiting screen time before bed to reduce blue light are all essential components of relapse prevention. Sleep deprivation leads to immediate decreases in impulse control and mood stability, and it is one reason why cognitive behavioural therapy is recommended for many addicts – because it often begins with improving sleep hygiene. It serves as a cornerstone for many other aspects of early recovery.
Re-entry into obligations should be gradual, not immediate.
There is the desire to return to one’s obligations as if nothing happened outside – going back to work full-time, assuming all previous responsibilities, etc. This is a mistake because re-entry should be gradual, with fewer hours at work if possible and less responsibility in general
You may even have to have difficult conversations with your family regarding what should and should not happen during your early recovery. This is where family therapy may be indicated, as the family unit may well have to restructure itself around your new requirements. The same goes for people who have dual diagnosis, an untreated mental health disorder, who require this slower pace of re-entry due to increased risks and stress levels during early recovery
Mark predictable days on the calendar for extra precautions
Certain days are always high-risk, such as paydays and weekends, birthdays and holidays, and anniversaries of deaths or other tragic events. These are all days when you should have extra precautions in place in advance, as waiting until the day itself to think about them is too late.
These days should not be surprises but rather holidays where you have a standing appointment. This is especially important if you have any kind of twelve-step program, as there will be days you know ahead of time when you will need extra help or support. You cannot build a dike when you are already in the middle of a flood – likewise, you cannot identify something as a dangerous day when you are already in it. That has to be done beforehand, when you are calm and can plan a specific appointment for a group or even a counselor visit the day itself.