John F. Kelly, PhD, of the Recovery Research Institute and Department of Psychiatry at Mass General Brigham, is lead author of a paper published in Frontiers in Public Health“Long-term relapse: markers, mechanisms, and implications for disease management in alcohol use disorder.”
Q: What challenges or unmet needs make this study important?
Alcohol use disorder (AUD) is one of the leading preventable causes of death in the United States and worldwide, and leads to significant morbidity and medical complications. While there are treatments available that can help patients with this disorder achieve stability and initial remission, relapses are common as people face the demands of recovery.
While relapses that occur early in the AUD recovery process are often associated with cue reactivity (trigger-driven) and neurophysiological instability (temporary brain-body imbalance after stopping alcohol use), little is known about what causes long-term relapses (LTRs): relapses that occur after one or more years of complete remission. These relapses are common and can have devastating consequences, yet there is a notable lack of systematic research into what causes them. Our study fills this knowledge gap.
By investigating the precursors of LTR among individuals who have had at least one year of full, sustained remission, we aim to guide long-term disease management efforts in clinical settings for AUD.
Q: What central questions were you researching?
First, we wanted to know what changes had occurred in four domains—biological, psychological, social, and treatment/recovery support services—during the year before participants’ long-term relapses to determine how common those changes were.
Next, we hoped to find out how “strong” each of these changes was in terms of relapse risk. In other words, which changes were most or least likely to contribute? We asked too when These risk factor changes occurred during the year preceding LTRs for time-based knowledge disclosure.
Q: What methods or approach did you use?
We recruited adults who met criteria for AUD and then experienced at least one year of complete remission before relapse. We restricted the sample to subjects whose long-term relapses had occurred during the previous five years, but who relapsed in prolonged remission (at least three months without AUD symptoms). Our study used a variety of methods, both quantitative and qualitative, to record details of participants’ clinical history, timing of symptom onset/change, and date and experience of relapse.
Q: What did you find?
Among all identified LTR risk factors, a reduction in recovery focus, or vigilance, emerged as both the most prevalent and the strongest factor in relapse. Participants consistently described a decline in recovery-related activities and behaviors as a central precursor, often accompanied by disengagement from mutual aid organizations and other supportive recovery services.
Psychological and social factors—including worsening mental health symptoms, loneliness, social isolation, and increased exposure to alcohol-related environments—were more strongly associated with relapse than most biological changes, which were common but generally less robust. The most notable exceptions were physical pain and recreational drug use, which, although less common, carries a significant risk of relapse. Importantly, relapse risk factors tended to accumulate and intensify during the year before relapse, particularly factors related to psychological support and recovery support service, suggesting that long-term relapse is often preceded by a detectable trajectory of escalating vulnerability.
Looking at the big picture, our findings suggest that long-term relapse in AUD is rarely attributable to a single precipitating factor or sudden event. Instead, it can be understood as the result of multiple, cumulative factors that can change over time.
Q: What are the real-world implications, particularly for patients?
First, patients who have achieved sustained remission are not necessarily “out of the woods” for relapse risk. For this reason, ongoing, proactive monitoring that extends well beyond the early stabilization phase of recovery is warranted. For clinicians, this means regularly assessing patients for changes in recovery vigilance, emerging mental health symptoms, social isolation, and disengagement from recovery aids, as these factors appear to be stronger predictors of long-term relapse.
Structured checklists (such as this one), brief clinical interviews, or “recovery vital signs” assessments incorporated into primary care or behavioral health follow-up visits can help identify early warning signs and prompt, proactive intervention.
Second, the complex nature of relapse risk underscores the importance of comprehensive, biopsychosocial models of disease management, rather than episodic or crisis-driven care. Our findings reinforce the value of reframing long-term relapse prevention as a matter of proactive guidance and risk mitigation, rather than reactive treatment after alcohol use has already resumed.
Q: What part of this job is most important to you personally?
Most importantly to me, we’ve shed light on sobriety-based warning signs that can be assessed before the potential disaster of a long-term relapse (and all the associated consequences). The preliminary, but specific, list of risks we identified through this study will ultimately empower frontline clinicians to better care for patients with AUD by monitoring and acting on these warning signs during remission to prevent relapse of the disorder. This can also increase patient awareness, leading them to pursue alternative courses of action.
