‘Frequent Flyer’ Is a Systemic Failure, Not a Patient Trait

Over the past 6 months of my psychiatry residency, I have seen the same patients admitted 3, 4, sometimes more times to the hospital. The admissions follow a familiar pattern. Patients present seeking alcohol detoxification, opioid treatment, or acute psychiatric stabilization for suicidal ideation. The diagnoses vary, but the trajectory does not. These patients return again and again, often labeled—quietly or explicitly—as “frequent flyers.”

What these patients consistently share is not diagnostic complexity, but structural vulnerability. Many are unhoused, most lack stable family support. Many do not have insurance, reliable transportation, or consistent access to outpatient care. During hospitalization, we do what we are trained to do: we stabilize withdrawal, adjust medications, provide crisis intervention, and, when possible, arrange temporary housing or referrals. Yet upon discharge, the conditions that precipitated the admission remain unchanged.

In addiction psychiatry, relapse is an expected feature of illness, not a moral failure.^1,2 The course of recovery is deeply individualized, shaped by neurobiology, psychosocial stressors, environmental context, and access to care. No clinician can reliably predict how many relapses a patient will experience before achieving sustained sobriety, particularly in the treatment of substance use disorders.

A similar pattern is observed in severe mental illness. Patients with bipolar disorder or schizophrenia frequently experience relapse, even when engaged in treatment. These episodes often reflect the chronic and relapsing nature of brain-based illness rather than conscious choice. In addiction, neuroplastic changes within reward and stress circuits generate persistent cravings that can impair executive functioning and emotional regulation long after detoxification.² Over time, patients may develop coping strategies that allow these cravings to attenuate—but before these skills can take hold, patients require consistency, safety, and predictability.

This reality exposes a fundamental contradiction within our treatment systems: we expect abstinence without first providing stability. Housing instability and food insecurity are well-established barriers to psychiatric and addiction recovery.^3,4 Without stable housing, it becomes nearly impossible to maintain medication adherence, attend outpatient appointments, or participate meaningfully in recovery programs. Stability is not the reward of abstinence—it is the prerequisite. Only when individuals are no longer preoccupied with survival can they fully engage in treatment.

Yet, while relapse is theoretically accepted as part of addiction, our systems are paradoxically structured as though stability must already exist before treatment can succeed.^3,4 This disconnect transforms chronic illness into a revolving door of crisis intervention, where acute symptoms are addressed while underlying vulnerabilities persist.

Language further reinforces this cycle. The term “frequent flyer,” when used in clinical settings, subtly signals that a presentation is not urgent or deserving of the same level of attention as a first encounter. It shifts clinicians from curiosity to routine, from vigilance to resignation. The admission becomes procedural rather than clinical.

Embedded within this language is an unspoken narrative: when will you learn? When will you get yourself together? The term reframes relapse as personal failure rather than predictable consequence. Clinical language has been consistently shown to shape clinician attitudes and stigma toward patients with substance use disorders.⁶ Over time, repeated exposure to this framing risks normalizing crisis and dulling urgency—even when patients present with recurrent suicidal ideation, repeated detox admissions, or cyclical psychotic decompensation.

As residents, we may not consciously endorse these beliefs, yet we absorb them through repetition. We learn which patients prompt urgency and which prompt endurance. Predictability is mistaken for safety, and familiarity for stability.

As a psychiatry resident, I have come to understand—often painfully—what medicine cannot fix alone. I have learned the distress of stabilizing patients whom I know are likely to return.

The resident role occupies a paradoxical space: it is both powerful and profoundly limited. Patients trust us. Families seek our guidance and view us as experts. For a brief period within the hospital walls, patients believe we can fix what feels unfixable. Yet our influence is confined to a specific place and time. Once patients are discharged, and much of what we have arranged exists only on paper: appointments they may not be able to attend, medications they may not be able to afford, and temporary housing that does not resolve long-term instability.

What leaves the hospital with the patient is not the safety we created, but a plan that assumes resources they may not have. Repeated hospitalizations, then, are not evidence of failed motivation, but markers of unmet systemic needs.

So how do we stop “frequent flyers”? The question itself may be misplaced. A more honest and clinically useful question is: how do we provide stability?

The answer begins with a return to the basics—food, shelter, clothing, access to healthcare, and dignity. Stability must come first. Only then can patients reliably attend appointments, take medications, and engage in recovery. As substances become increasingly accessible and societal attitudes toward drug use continue to evolve, the challenges facing addiction psychiatry will only intensify. Without meaningful structural solutions, the cycle of crisis, stabilization, and discharge will persist.

If we are serious about reducing relapses, recidivism, and human suffering, stability cannot remain an afterthought. It must be recognized as a clinical intervention in its own right—one that precedes abstinence, supports recovery, and restores dignity to patients too often reduced to a label.

Dr Jean is a psychiatry resident at Centerstone, Bradenton, Florida.

References

1. National Institute on Drug Abuse. Drugs, Brains, and Behavior: The Science of Addiction. National Institutes of Health; 2020.

2. Volkow ND, Koob GF, McLellan AT. Neurobiologic advances from the brain disease model of addiction. N Engl J Med. 2016;374(4):363–371.

3. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care. Am J Public Health. 2006;96(4):616–621.

4. Tsai J, Rosenheck RA. Housing stability and recovery among chronically homeless adults with serious mental illness. Am J Psychiatry. 2015;172(5):455–462.

5. Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? Int J Drug Policy. 2010;21(3):202–207.