Key risk factors identified for long-term relapse in alcohol use disorder

John F. Kelly, PhD, of the Recovery Research Institute and Department of Psychiatry at Mass General Brigham, is the 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 leading causes of preventable death in the United States and worldwide, and leads to substantial disease and medical complication. While treatments are available that can help patients with this disorder achieve stability and initial remission, relapses are common as people grapple with the demands of recovery.

While relapses that occur early in the AUD recovery process are often tied to cue reactivity (trigger-driven urges) and neurophysiological instability (temporary brain and body imbalance after alcohol use stops), little is known about what drives long-term relapses (LTR): setbacks that happen after one or more years of complete remission. These relapses are common and can have devastating consequences, yet there's a notable lack of systematic investigations into what precipitates them. Our study fills this knowledge gap.

By exploring the precursors to LTR among individuals who 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 question(s) were you investigating?

First, we wanted to know what changes had occurred across four domains-biological, psychological, social and treatment/recovery support services-during the year prior to participants' long-term relapses to determine how common these changes were.

Next, we hoped to learn how "potent" each of these changes were in terms of relapse risk. In other words, which changes were most or least likely to contribute? We also asked when these risk factor changes occurred during the year preceding LTRs to uncover time-based insights.

Q: What methods or approach did you use?

We recruited adults who met the criteria for AUD and subsequently experienced at least one year of complete remission prior to a relapse. We restricted the sample to individuals whose long-term relapses had occurred during the five years prior, but who were back in sustained remission again (at least three months without any AUD symptoms). Our study used a variety of methods, both quantitative and qualitative, to capture details of participants' clinical histories, timelines of symptom onset/offset and relapse date and experience.

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 most potent contributor to relapse. Participants consistently described the deprioritization of recovery-related activities and attitudes as a central precursor, often accompanied by disengagement from mutual-help organizations and other recovery supports.

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 potent. The most notable exceptions were physical pain and recreational drug use, which, although less frequent, carried substantial relapse risk potency. Importantly, relapse risk factors tended to accumulate and intensify over the year prior to the relapse, particularly factors related to psychological 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 justified. For clinicians, this means routinely assessing patients for changes in recovery vigilance, emerging mental health symptoms, social isolation and disengagement from recovery supports, as these factors appear to be more potent predictors of long-term relapse.

Structured checklists (such as this), brief clinical interviews or "recovery vital signs" assessments embedded within primary care or behavioral health follow-up visits may help identify early warning signs and prompt timely, preventive intervention.

Second, the complex nature of relapse risk highlights the importance of integrated, biopsychosocial disease-management models, rather than episodic or crisis-driven care. Our findings reinforce the value in reframing long-term relapse prevention as a matter of anticipatory guidance and risk mitigation, rather than reactive treatment after alcohol use has already resumed.

Q: What part of this work feels most meaningful to you personally?

Most meaningful to me is that we've shed light on sobriety-based warning signs that can be assessed prior to the potential disaster of a long-term relapse (and all of the associated consequences). The preliminary, but concrete, list of risks we've identified through this study will ultimately empower frontline clinicians to better care for AUD patients by screening for and acting on these warning signs during remission to prevent disorder recurrence. This may also raise awareness in patients, leading them to take alternative courses of action.