drug

Substance Abuse 101

BACKGROUND

I decided to begin the year with the topic that holds the greatest degree of passion for me–alcoholism and alcoholics; actually addiction from all types of substances. There are millions of addicts in North America and depending on the study you read, the ranges begin with a low of 5% and can go up to as high as 12%. I think part of this discrepancy is definitional in nature; researchers and those working within the field of addiction use differing terms to define alcoholism or drug addiction.

There are three differing classes of substance user; those that are non-dependent users—people who use substances but are not yet dependent upon them…substance abusers—people who use substances in a manner that they were either not intended for or the use of said substances is causing problems in at least one major life area (MLA)…and those that are substance dependent which is defined by those individuals that are using substances in a manner that causes problems in MLA’s and where they often experience tolerance, withdrawal, and significant loss of control.

Given these definitions, we have approximately 8% of the population that is substance dependent. John Bradshaw (Bradshaw on the Family) believes that for every one addict there are three to four other individuals impacted by their disorder; so when we do the math on these types of numbers it is easy to see how addiction and addiction issues are so prevalent in our society. North America consists of approximately 350,000,000 people—if 8% are addicted, we have 28,000,000 people suffering from addiction. In addition, if we add in those directly affected from the addiction we are now at approximately 84,000,000 either addicted or impacted by an addiction. This is a HUGE societal issue both in terms of financial cost and in terms of the cost in human suffering. We spend billions of dollars every year in health care, occupational productivity losses and accidents, and corrections/policing to deal with the consequences of addiction. It has always surprised me why we do not spend more on both prevention initiatives and relapse prevention skills development.

AM I AN ADDICT?

There are a number of questionnaires that exist that provide an answer to this question; the Michigan Alcohol Screening Test, the Drug Abuse Screening Test, the Addiction Severity Index, the Alcohol Use Disorders Identification Test, and many others.

The easiest test is the Cage Questionnaire– Have you ever felt or tried to cut down on usage? Have people annoyed you by being critical of your use? Do you feel bad or guilty about your usage? Do you use first thing in the morning (eye-opener)? If you answer yes to any one of these questions you would benefit from seeking a qualified assessment from someone who specializes in addictive disorders.

WHAT TO DO IF YOU’RE ADDICTED

If you know you are suffering from an addictive disorder, the first thing to do is seek help from someone who is trained and certified in this area. Many people (professionals included) are well intentioned but not effectively trained to treat addiction and may end up further enabling this problem or recommending unsuccessful strategies at resolution. Given the sheer prevalence of addiction, it continues to amaze me that you can receive a PhD education in psychology without ever taking a course in addictive disorders! Successful treatment for addiction involves many and sometimes all of the following recommendations–abstinence from all mood-altering substances, detoxification, medical examination, inpatient or outpatient intensive therapy, regular and ongoing attendance at the appropriate 12-step meetings, and relapse prevention post treatment for up to two years.

It is important to highlight that addiction is a relapsing disease; more people will relapse in their first year of recovery than remain abstinent. The largest contributors to relapse include– not attending 12-step meetings, isolation, undiagnosed and untreated concurrent disorders (other psychological disorders like depression, bi-polar disorder, etc), and no access to relapse prevention counseling.

RESOURCES & LINKS

http://www.samhsa.gov/
http://www.ccsa.ca/
http://www.alcoholics-anonymous.org
http://www.na.org/
http://www.al-anon.alateen.org/

TODAY HAS STARTED–HAVE A GREAT ONE!!

Case Example – Substance Disorders

Having been privileged to work with thousands of addicts over the course of my career, I have seen my share of successes and devastation. In presenting these cases, all identifying information has been removed and all names of people and places altered to assure anonymity. I present these cases not as a means to sensationalize this disorder but to show the extremes of impact that addiction can have and the joys that are experienced through recovery.

John came to see me post inpatient treatment for a problem with Percocet. When we first met, he was very angry with the medical profession and he was holding them, more specifically his family physician, solely accountable for his disorder. Upon meeting John he presented very positively from a physical aspect, was well spoken, and cooperative. John entered treatment after he was discharged from a local hospital for severe withdrawal treatment. Apparently, John had experienced a back trauma in his work and sought medical attention from his family MD. His MD placed him on a short-term disability immediately and prescribed a dose of Percocet (oxycodone and acetaminophen) to address his pain issues. Through diagnostic testing, it was determined that the back trauma was muscular and not structural. It was suggested that he seek a course of physiotherapy to remediate the problem. John attended the physiotherapy but continued to complain of back pain to his MD. He later admitted that he continued these complaints as a means to obtaining more Percocet as John discovered that taking Percocet also allowed him to ignore other issues within his life. Over time, John’s MD had increased his intake levels to 70 Percocet per day or 350mg of oxycodone—this is a significant amount of narcotic but clearly shows the bodies ability for the development of tolerance levels. Of additional concern was the amount of acetaminophen being ingested and thus processed by the liver. Percocet is a highly addictive narcotic with an elevated tolerance cycle. It is a medication to be used with caution and constant monitoring…in John’s case neither of these conditions existed. John might have continued this addictive cycle had it not been for a business trip. Somehow, John did not fully think through the amount of prescription he would require while away and as a consequence ended up running out of his Percocet! Percocet is not a medication you want to run out of especially at the levels that John was taking. This drug has a short life within the body, which means withdrawal effects will begin soon after the last dose. Within six hours of not having his Percocet John began to experience higher levels of pain, was sweating profusely, and was very agitated. Within the first 24 hours after his last dose, John experienced a cardiac event as a result of his withdrawal–it was this event that placed him in the hospital and later into inpatient treatment.

As I stated, by the time John came to me he was very angry with his doctor and blamed him for the addiction. Not that the doctor wasn’t at fault for part of this occurrence, however it needed to become clear to John that it was his lying and deceit that led to the elevated prescribing. His doctor was simply responding to someone with pain management issues…however, upon further exploration the doctor might not have taken this route with John. As therapy evolved John was able to see his part in developing and maintaining this disorder, had accepted the need to remain abstinent, and was active in Narcotics Anonymous. Nevertheless, I jump ahead…how did he get here in the first place?

John came from a dysfunctional family system (like all of us) that was scattered with alcoholics. Because of this, he had sworn to himself that this would never happen to him; albeit that he would drink now and then, his use was not in a dependent class when we met. He was abusing alcohol now and then and also found that it became a precursor to his elevated Percocet usage. Upon taking Percocet for the first time, he felt an overwhelming sense of relaxation and release from his stresses, which he enjoyed. Over time and due to tolerance rationales he had to continue to increase the dosage to chase that same effect. On a few occasions, he feared of overdose but was afraid to seek medical attention because he knew he would lose his prescription. He began to lie to his physician about his pain levels and make claims that the physiotherapy was causing more pain to justify the increased prescription amounts. As his Percocet intake increased, he also began to isolate from others for fear they would discover what he was doing. John began to discover what every addict finds out—you can chase that original high forever but you‘d never find it again. It was only by “mistake” that John ended up stopping, had he not had a cardiac event he might still be using today or worse…he may have eventually overdosed. In a strange way, he remains forever grateful for that trip that sent him into withdrawals.

TODAY HAS STARTED…HAVE A GREAT ONE!

Relapse Prevention

We received a request to talk about Relapse Prevention, so that is what we will focus upon this week. This is such a large area to cover off; as such, I will do my best to provide information, meaning, and some exercises that will provide a good beginning in the area. Relapsing back into substance use means differing things to different researchers and treatment providers; some see short-term use or initiation of substance use (a couple of days) as a “lapse” and would suggest that a “relapse” does not occur until the use pattern “gets out of control”…I am of the mindset that once a person begins the re-initiation of substance use, they have relapsed. AA often uses the term “slip”; I however am not a supporter of this term as it carries a connotation of being a mistake of sorts versus a stance of accountability. When it comes to substance use for an individual that has a dependency disorder, accountability is a key feature for recovery to take place.

Relapse Prevention (RP) is an active approach towards the retention of abstinence and recovery development. It should begin at the conclusion of either an Inpatient or Outpatient treatment program and run concurrent to 12-Step recovery involvement. Many RP programs will run a minimum of six-month post-treatment upwards to two years. The highest risk for relapse is contained within the first year of recovery; it is escalated dramatically if an individual does not access RP activities. RP work carries more significance in the ability to maintain a recovery focus then initial treatment.

When it comes to dependency disorders much of the research suggests the following truths; abstinence is a requirement (controlled use is not an option), 12-Step programs significantly influence the ability to maintain abstinence, intensive initial treatment services can assist in setting a healthy foundational component to recovery (these can either be of an inpatient or outpatient setting), RP is essential to ongoing recovery, and spiritually based programming reduces relapse rates.

The beginning basic to RP focus upon concepts related to coping with cravings and urges to use. The areas involved in dealing with cravings & urges include Avoid, Confront, Distract, and Remind.

With respect to Avoidance, the following suggestions can be implemented.
• Avoid getting in the situation where you are tempted in the first place.
• Avoid making substances easy to attain. Get rid of it.
• Avoid your using friends, at least until you have some stability.
• Avoid passive activities that have naturally accompanied using, like watching television or lounging at home. Stay busy, make plans, and get out of the house and into a non-using situation.
• Avoid your triggers. You know what will trigger your using. Avoid these situations. Be proactive and plan for when they might occur so that you can handle them in a healthy way, without turning to substances.
• Avoid letting yourself be run down. If you are Hungry, Anger, Lonely or Tied (HALT), your inner strength, and awareness will be compromised. You need to nourish yourself and your spirit with healthy living and healthy choices.

With respect to Confronting, the following suggestions can be implemented.
• You cannot always control whether or not you will have an urge to use. However, you can control how you respond to that urge. Rather than worry about the urge, take a step back and let it happen. See it for what it is…a temporary feeling of desire or need. It will not last long and it cannot control you unless you allow it to.
• Confront your self-talk. Urges often come in the form of self-talk that gives you permission to use. For example, “I’ll just have a short one, that’s not really drinking”.
• When you encounter your urges as self-talk, you have to confront this self-talk immediately and forcefully. Say to yourself “I will not stray from my plan” or “I know better so I can do better.”
• Confront your urge with your long-term goals. Think about how you will feel tomorrow if you give in and how you will feel you if you do not. Consider the list of reasons you have created for why you want to stop using.

The next blog will continue with the other items that can be implemented to control cravings & urges. Controlling these areas is a very small, but important, part to RP. By week’s end, we will look at the more difficult work in this critical area to ongoing Recovery.

TODAY HAS STARTED–HAVE A GREAT ONE!

Relapse Prevention Part 2

The last two skill sets in addressing cravings and urges in the Relapse Prevention area include Distract and Remind. Similar to Avoidance and Confronting, implementing these two skill sets will go a long way in keeping you sober and on the path of recovery.

The third skill for coping with urges is Distraction. Distractions are things that you do to take your mind off the urge and point it in a healthier direction.

Here are a few examples of some Distractions:

take a walk, take a drive, do exercises at home or go to the gym, go jogging, listen to favorite music, telephone a friend, clean out the garage, cook something interesting, go to the library or bookstore, work in the yard, clean and polish the car, take a shower or bath, read the newspaper, a magazine, or book, drink something nonalcoholic, rent a video or DVD, write a letter or email, plan your next vacation, make a shopping list, clean out the refrigerator, plan future finances, surf the internet…The list of potential distractions is endless.

The fourth and final skill presented here for coping with cravings and urges is to Remind.

• Remind yourself of the reasons why you want to stop using and what you specifically hope to gain from this new pattern
• Remind yourself that you want better relations with friends
• Remind yourself that you want better health
• Remind yourself that you want to treat your family with the love and respect that they deserve
• Remind yourself that you want to work to your full potential at your job
• Remind yourself that you want to sleep better
• Remind yourself that you want to look better and age beautifully or handsomely

Your attentiveness to all four of these critical components as options to fend off a relapse will provide you with renewed strength and courage in moving forward. RP is an ongoing exercise of knowing where your weaknesses exist and having a pre-planned set of behavioural activities to counter these events if or when they occur. For those of you in early recovery that do not experience cravings or urges be thankful for that blessing and then do the exercises anyway, complacency, over-confidence, and attitudes of superiority have knocked down many an addict.

Approach your recovery with humility and a thankful heart–For this is a GIFT not a GIVEN!

TODAY HAS STARTED–HAVE A GREAT ONE!

Relapse Preventions – Final Thoughts

Our exploration related to Relapse Prevention simply touched the surface of a very complex area. I may come back to it as we move along or if there continues to be requests to learn more about this area–I always look forward to your emails (thanks Inny for requesting RP). All we had time for in a week was to cover the basics in addressing any cravings or urges. These tools of Avoid, Confront, Distract and Remind may become your life preservers if you have been attentive to the tasks.

It is imperative to remember that substance disorders are a relapsing reality; it is only the blessed few that will walk this path and never know the hideousness called Relapse. More people will relapse then remain abstinent. The vast majority of those relapses will occur within the first two-years of recovery. The primary reasons for relapse include…
• Complacency
• Attitudes of superiority
• Lack of humility
• Lack of commitment
• Keeping secrets
• Limited or no attendance at appropriate 12-step programs
• Difficulties with the spiritual aspects to recovery
• No access to relapse prevention treatment

If you do relapse, know that this is not the end of the world and it is critical that you stop again ASAP. Some people that relapse begin to think that they might as well “do it right” now that “everything” is ruined. Let me begin by telling you “Everything is not Ruined”!However, it could become that way if you keep going versus stopping soon into the relapse. Another strange message that AA and other 12-step programs send around relapse is that a person has to start over if they relapse. Don’t get me wrong here though, I think the world of the 12-step programs and believe they have contributed to the recovery of more addicts than any other treatment modality; so even if I question a few of the messages I still believe these programs are an addicts best chance at recovery. For some people this discounting of their previous experience or work can be counter-productive as they are more likely to be the ones’ that believe they “might as well do it up right given that it’s all gone”. Let me be the first to tell you, it is not all gone…if you stop soon into a relapse you can do some immediate damage control and you can simply pick up where you left off and learn from the experience.

As I stated before…Recovery is a Gift not a Given! Be grateful for everyday you have substance free and do the work needed to keep your gift…try and remember that people die because they did not get access to the help you have already received. Good luck and Good Recovery.

TODAY HAS STARTED–HAVE A GREAT ONE!

Interventions

This week’s blog will explore Interventions; the structures, the steps, the limitations, and the goals. There are times when a family member, a friend, or an employer has exhausted all efforts to refer someone they are concerned about to enter treatment for a substance disorder. In these circumstances, an Intervention Program may be the route to pursue.

Interventions are intense measures intended to place the full scope of someone’s addiction in front of them with an accompanying request that they choose treatment or be prepared to live with the consequences of continued addiction patterns. Not everyone is suited for an Intervention Program; all qualified Interventionist’s, will conduct a preliminary interview to determine a family/individual’s suitability for the process.

There a number of goals to an Intervention that are equally important; however, one key to a good Intervention is having the addicts’ supports well educated and supported regardless of the choices made by the addict at the Intervention. Primary goals include…

  • Education
  • Support Development
  • Psychological/ Emotional Healing
  • Treatment Acceptance
  • Consequence Enforcement

All Interventions begin with a preliminary consultation with the family and/or concerned persons’ requesting the Intervention. At this stage what is explored is the suitability for the Intervention to occur. An Intervention will only occur if…

  • All members are invested and willing to accept direction
  • All other means to offer assistance have been exhausted or the severity of the addicts condition warrants this type of action
  • There can still be an impact in circumstances where an Intervention has already been conducted without treatment success
  • All members are prepared to enforce meaningful consequences should the addict choose not to alter their behaviors
  • All members are prepared to address their own addictions should these exist
  • All members are prepared to stop any enabling behaviors with the addict

An Intervention is not a democratic process; the Interventionist will take complete control over the process and directions. This is a psychotherapeutic exercise whereby input on what to do or how to do things will not be acceptable. Interventionists will often excuse people from being part of the process if they do not see them as helpful to the addict.

Next time we will go through the steps to an actual Intervention and explore why these are used and what outcome is being sought.

TODAY HAS STARTED—HAVE A GREAT ONE!

Intervention Phases – Phase 2

Upon conclusion of the Psycho-Ed session on addictive disorders, any participant who holds dramatically differing views on the perspective, approaches, and recommendations for the treatment of addiction will be excluded from moving on with the intervention process. Addictions are treated through a few approaches; the vast majority of those working in the field approach addictions with a focus upon abstinence. There are some individuals that are proponents of harm-reduction models, which allow for reductions in use versus total abstinence—these individuals are not well suited for an intervention style approach and as such would be no longer involved in most interventions, as they would likely continue some form of enabling behaviors.

For those that do move on, the next Phase explores the development of Impact Statements and the beginning of seeking help for themselves. Those closest to an addict cannot exist in this environment without having been affected by the conditions. Close family members and friends typically develop some forms of enabling patterns and/or their own co-dependency concerns (see past blogs on co-dependency) from living with an addict—it is essential that they begin a recovery process too. This is where a key point exists; no matter what the addict chooses to do, an intervention is successful if family and friends receive their own recovery process and the addict is held accountable for their behaviorsfrom this point forward. One rationale for this accountability factor is that addicts will only change if the negative consequences for not changing are greater than the consequences for changing. People that have lived with addicts know that this accountability stance is a difficult step to take; for these people there are helpful programs from Alanon Family Groups, which will provide a clearer insight into living with addiction and minimizing personal impact. Alanon provides a program of psychological, emotional, behavioral, and spiritual recovery. There are additionally groups for teens (Alateen) and co-dependents (CODA) that are also built upon the principles of Alcoholics Anonymous. Most Interventionists will require that those moving forward in an intervention process begin accessing an appropriate personal program of recovery.

The second piece to this Phase is the development of Impact Statements; all participants are sent away with the task of writing out how the addict’s behaviors have specifically affected their lives. This is a highly charged and emotional activity for most as they will need to bring forward memories that at times may have been horrific events…this is not an easy task. There are differing ways at approaching this task with many taking either a chronological approach or an intensity focus.

Next time we will explore the events of a Preliminary Intervention.

TODAY HAS STARTED—HAVE A GREAT ONE!

Intervention Phases – Final Phases

Now that all of the prep work is in place for an intervention to occur, it is essential to perform a “test run” of this process so that all participants get a feel for what this will look like.

During the Preliminary Intervention Phase, all participants will get the chance to…

  • Read their already prepared scripts and make appropriate wording adjustments
  • Experience the emotional ranges that will likely be heightened during the actual intervention
  • See the global impact that this addiction has brought about
  • Ask any questions they have about accessing supports for themselves

The Interventionist will…

  • Assist in wording corrections for accuracy and impact
  • Reduce major redundancies
  • Explore for potentialities of continued enabling
  • Field and answer questions about process and support seeking
  • Finalize the members’ for participation, place an ordering to impact statements, discuss treatment options and finalize selection, and deal with any current emotional affects

The Intervention Phase will put everything to date into action. Interventions will occur at a neutral site selected by the Interventionist; participants will arrive at least an hour before the event is to occur in order to get comfortable with the surroundings and to address any last minute questions—if the Interventionist has any concerns at this point around participation it is the last opportunity for removal if necessary. One of the participating members will bring the addict to the intervention where a specifically selected seat will be open for them to occupy. The intervention begins with an opening statement form the Interventionist regarding the reason for meeting and an overview of the process. From here, participating members will read their impact statements in a pre-designed order. The addict will be given the opportunity to select the treatment options or face the consequences of continuing their behavior. If they select treatment they will be off to the facility immediately following the intervention…if they select going their own direction, they will be free to depart knowing that at least this group of individuals will no longer enable their problems or provide support. Often times they will be provided with the Interventionists phone number should they eventually choose to follow ALL of the recommendations made at the intervention; this still allows for assistance without separating members of the participating intervention out from each other.

Finally, a Post Intervention Follow-Up session occurs (typically within two-weeks) to discuss progress being made with both the members and the addict. If the no-treatment option was selected the focus will be upon strengthening the resolve to enforce the intervention consequences and to discuss the potential outcomes if any member of the intervention returns to enabling patterns.

TODAY HAS STARTED—HAVE A GREAT ONE!