Relapse definition

Psychosocial and environmental factors play a major role in the development and recovery from opioid dependence however, a detailed discussion is beyond the scope of this chapter. In general, the use of such drugs as marijuana and alcohol precedes the use of opioids (Clayton and Voss 1981 Kandel and Faust 1975). Although one cannot predict definitively which users will proceed to opioid use, those who do generally have low self-esteem, disrupted families, and/or difficult relationships with their parents. The increased availability of opioids in inner cities of major urban centers contributes to initiation of use and relapse. It is particularly difficult to avoid use and relapse in areas with high unemployment, poor school systems, and high crime rates, because living in such an area may contribute to the very affects opioid use temporarily reheves. 

Historically, osteomyelitis has been classified as acute or chronic based on duration of disease (Fig. 78-2).2,4 However, there are no established definitions for acute and chronic infections.2-4 Acute infection has been defined as first episode or recent onset of symptoms (less than 1 week).2,3 Chronic osteomyelitis is generally defined as relapse of the disease or symptoms persisting beyond 4 weeks.2,3 Others describe chronic osteomyelitis as the presence of necrotic bone.3 ... 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

As new projects are launched, it will be important to use operationalized definitions of remission, recurrence, and relapses (Frank et al. 1991) to consider and record chronobiological milestones, especially puberty, menstruation, menopause, and season to employ life charting by the patient so that brief recurrences can be identified to emphasize severity rather than dichotomous DSM-IV criteria and to consider well-known confounds such as mood subtype, age, comorbid conditions, and associated medication or substance use. 

If an antidepressant is discontinued too early, rapid and serious relapse may result. This indicates that, whereas antidepressants may shorten or curb a depressive episode, they cannot definitely end and hence cure it. The attenuation of depressive symptoms is thus not a sufficient criterion for withdrawing drug therapy (Chapter 8). The decision as to when an antidepressant may be discontinued is often difficult and also dependent on the chronicitv of the patient s depression and the number of episodes of depression experienced. 

The risk of relapse in discontinuation trials depends on many non-pharmacological, often poorly controllable factors, notably the expectations of the patients, doctors and nurses, other environmental factors, the duration of hospitalization and prior treatment, and the time interval since the last acute psychotic episode. On the basis of an analysis of 14 discontinuation trials, Kane and Lieberman (1987) found that the relapse rate varied greatly from study to study depending on the trial, relapse rates of 30 86% with clustering around 60 70% have been reported in the first 12 months after placebo substitution. According to Kane and Lieberman, this scatter is a result of the different inclusion criteria applied and the different definitions of relapse . 

E Role in therapy Betaseron is useful for reducing symptomatic exacerbation in multiple sclerosis (MS) patients with relapsing-remitting disease. The drug should be considered in patients with ch-nically deflnite or laboratory-supported definite disease. It is not indicated in those patients with primary progressive MS. Interferon beta-la (Avonex) has also demonstrated activity in MS patients. 

An important issue in maintenance treatment is the rate of relapse upon discontinuation of therapy. This differs markedly from study to study, perhaps due to their varying durations. In addition, the definition of relapse varied, so that the rate was higher when defined as a modest reemergence of psychotic symptoms rather than an exacerbation sufficient to cause rehospitalization. Using the former criteria, the relapse rate may be as high as 5% to 20% per month, whereas the more conservative criteria might yield a 1% to 10% rate. 

In another serendipitous finding, Cade noted that the first patient treated with lithium relapsed when medication was withdrawn ( 5). From this, he inferred that lithium may also be effective for maintenance treatment. Baastrup, Schou s coworker, carried out the first definitive study of its prophylactic properties ( 4, 6, 7 and 8). The ability of lithium to decrease the rate of recurrence in both unipolar and bipolar disorders was then confirmed in a series of studies by Hartigan and Baastrup ( 7, 8 and 9). 

Maintenance of remission may require addition of azathioprine or another immunosuppressive drug (see below). Tobacco smoking definitely contributes to relapse and should be strongly discouraged. 

Azithromycin is efficacious in animal models of toxoplasmic encephalitis. In a Phase I/II dose-escalation stndy of pyrimethamine (50 mg/day) plus azithromycin (900,1200, or 1500 mg/day) for induction and maintenance treatment in 30 patients with AIDS and definite or snspected Toxoplasma encephalitis, the overall response rate was 67% after 6 weeks of induction therapy (1). However, maintenance therapy for 24 weeks with this combination was associated with a high relapse rate (47%) only six patients snccessfully completed induction and maintenance therapy. Adverse events were common (particn-larly in those taking azithromycin 1500 mg) and inclnded hepatotoxicity, bone marrow suppression, ototoxicity, and gastrointestinal disturbances, which led 20% of patients to withdraw. All adverse events resolved on withdrawal. 

You have seen that arriving at a definition of alcohol and drug problems that has general consensus is no easy matter, however. This difficulty carries through to defining relapse, as reflected by the different operational definitions that have been used in research on this topic. 

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