substance use

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!

Spirituality in Recovery

This week it has been requested that I write on a topic that I have researched but by no means feel like an expert on; this area is so large that commentary upon a piece does not make one an expert. That topic is spirituality; my research in the area covered Judeo Christian perspectives in recovering alcoholics. I have read plenty in the area and spoken too many about their experiences; and from this I have come to understand that I know only a little. From the concepts and experiences that I have taken away I will share some here over the following week, including spiritual development.

Firstly, let us define the difference between religious and spiritual and explore how these fit into recovery processes.

Religious: A religion is a set of tenets and practices, often centered upon specific supernatural and moral claims about reality, the cosmos, and human nature, and often codified as prayer, ritual, or religious law. Religion also encompasses ancestral or cultural traditions, writings, history, and mythology, as well as personal faith and religious experience. The term “religion” refers to both the personal practices related to communal faith and to group rituals and communication stemming from shared conviction. Religions include Christian, Muslim, Buddhist, Islamic, Jewish, etc.

Spiritual: Spirituality, in a narrow sense, concerns itself with matters of the spirit, a concept often closely tied to religious belief and faith, a transcendent reality, or one or more deities. Spiritual matters are thus those matters regarding humankind’s ultimate nature and purpose, not only as material biological organisms, but also as beings with a unique relationship to that which is perceived to be beyond both time and the material world. Spirituality also implies the mind-body dichotomy, which indicates a separation between the body and soul.

Research in both of these areas is showing that individuals that are religious and/or spiritual are showing better recovery outcomes from a wide variety of physiological and psychological aliments. This is something that the founders of AA either knew or stumbled upon back in 1935. Many 12-Step programs are built around spiritual principles—not religious doctrine.

From a perspective of recovery from substance disorders, the 12-Step programs were all founded upon Judeo Christian concepts and principles couched softly to be inclusive of every possible religion or spiritual focus. Original AA documents included language like “Jesus”, “Lord”, and “Saviour” only to be altered into one term—God. The founders of AA altered what could have been determined to be a “religious” program into one that became “spiritually” focused. Then in the late 90’s there was research showing meaningful splits between “spiritually focused” groups versus “secularly focused” groups and the potentiality of outcome to this pattern. In other words, AA and other 12-Step groups were beginning to split upon meaningful dimensions of a spiritual program versus a non-spiritually focused program. Some meetings were still inclusive of discussing the concepts of God, Spirituality, and the Principles while others began to focus upon more life focused structures like Relationships, Communication, and Balance. It was also the first time ever AA was not in a growth position compared to every decade that preceded it since its inception in 1935. I personally do not see this as a coincidence; many AA groups were now beginning to mirror pop psychology and new age principles that would have drawn many away from the more traditional aspects of recovery to something you could now get without attending AA—just look in the self-help section of any bookstore. The problem becomes that bookstores cannot convey experience, strength, and hope that only comes from two alcoholics talking to each other. In those discussions, couched in those concepts, AA was the most successful recovery modality of any approach at treating addictions. It still is; with one caveat—groups that are spiritually focused produce better, longer-lasting and more meaningful recovery experiences than secularly focused recovery.

I have been privileged to meet thousands of alcoholics over the course of my career and the one thing I can clearly state is that those with a “spiritually” focused recovery have a better chance at long-term success in their recovery. I will provide examples as we go through the week. For today, those in recovery may want to explore those groups that are spiritual versus secular. For those suffering from other ailments, you may want to seek additional spiritual cures in addition to all of your other treatments…you may find additions to your recovery there.

TODAY HAS STARTED—HAVE A GREAT ONE!

12-Steps Programs: Steps 1 – 3

The 12-Step Programs have saved and altered millions of lives across the globe. Today we will begin looking at these steps and the meanings/ interpretations behind them.

Before AA began, the Oxford Groups existed as a program of recovery from alcoholism. The Oxford groups were based upon the principles of absolute honesty, absolute purity, absolute unselfishness, and absolute love. What they discovered were that these four principles were difficult for anyone to maintain, let alone a recovering addict—thus AA was born as a program that was built upon the principle of “progress not perfection”; people were suggested that they made progress in their recovery not attain a perfect recovery. Absolutes were left behind and a “suggested program” was introduced.

Part of this program was the 12 suggested steps towards a life of recovery. The key to that statement is the “suggested” part, individuals could decide to do the steps or not do the steps, —and the only requirement to attending a 12-Step Program is the desire to change.

Today we will look at the first few steps of the AA program—other programs basically mirror the AA program by altering the word alcohol to suit the issue.

1–We admitted we were powerless over alcohol— that our lives had become unmanageable.

This step gets at the heart of accountability. Many have interpreted this as defeat. This is not intended as a statement of defeat, but rather a statement of becoming accountable for one’s actions and bringing a link between alcohol use and unmanageability. It is quite simple—over-use of alcohol causes problems in people’s lives and excessive over-use of alcohol destroys people’s lives. Alcoholics are infamous for seeking every other rationale besides alcohol for why their lives are in chaos; this step puts the accountability where it belongs.

2–Came to believe that a Power greater then ourselves could restore us to sanity.

As stated earlier, AA was built upon Judeo Christian principles and AA incorporated the need for spiritual recovery from alcoholism. Years of research had defined alcoholism as a bio-psycho-social disorder…today that has been extended to include spiritual. There have been vast amounts of research done in the area of spirituality over the past 15 years as it relates to alcoholism with many researchers drawing clear linkages between these two areas. AA was well ahead of its time in the development of this piece. The founders of AA understood the need for individuals to have a program of recovery that extended outside of the individual to something or someone more powerful and thus helpful. The simplistic definition of “insanity” is performing the same activity over and over and expecting different results; restoration of sanity here is the understandings that change were needed for change to occur.

3–Made a decision to turn our will and our lives over to the care of God, as we understood Him.

Having performed research in the area of spiritual belief systems and alcoholism, I am keenly aware of the differences between those that accept and rely upon God as part of their recovery versus those that choose a different path. What this step requests is that a person is willing to rely upon God for good direction in their life (some members of AA even define God as Good Orderly Direction)—most addicts have not done an outstanding job in directing their own lives and thus a spiritual outside support can be essential. It additionally moves one away from ego based direction to understanding and appreciating external direction. How God is defined is reliant upon each individual member of AA—there is no stated religion or spiritual belief system in this step.

These steps build the initial foundations for recovery. When we come back to this, we will begin to explore the action steps within the 12-Steps.

12-Step Programs: Steps 4 – 9

Once a foundation is set within a 12-Step Program, it is time to begin the work. Steps 4-9 are Action Steps within AA and the other 12-Step Programs. These steps are not to be taken lightly, require a significant amount of work, and will be life changing if approached and worked at properly. It is often within these steps that a person will discover if recovery is going to work for someone; those committed to the process will struggle, will experience a range of emotions likely never seen before, and will want to quit over and over but they will not allow themselves to be defeated by a process of internal change and resolution.

Step 4: Made a searching and fearless moral inventory of ourselves.

It is difficult to change what we do not know; this step is designed to explore the inner workings and character of the alcoholic. One is asked to identify resentments, fears, sex problems, and begin the process of knowing where amends will have to be conducted. The founders of AA knew that a life lived with resentments could not be lived by an addict thus it became the critical focus of step-4. Resentments are often driven by anger, ego, hurt, loss, pride, jealousies, etc….all of which are egocentric patterns; a sober alcoholic had to be more than egocentric to realize a world of recovery. Resentments would need to be driven out and replaced with “other-centeredness”, selflessness, and acts of altruism, humility, and honesty. Step-4 begins this process.

Step-5: Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Knowing what we have done wrong in our lives is one thing—seeking absolution and resolution from God, ourselves, and another is an entirely different activity. Most addicts have difficulty living within their own skin as a result of their behaviors while under the influence of substances. They need to know that what they have done is forgivable. This step provides a clean slate and also a sense of accountability. This step is a working step at reparations between oneself and God; a healing of that relationship and a deeper understanding that actions are accountable for “Recovery without Divinity holds the potential for reduced individual and societal accountability”.

Step-6: Were entirely ready to have God remove all these defects of character.

Step-4 explores a listing of one’s positive and negative traits; in step 6, an addict needs to be prepared to let those things of the past slip away for a new life to begin. Some addicts get comfortable in their patterns and thus experience anxiety in relation to letting these go. This step begins to open one up to new patterns, which lead to new character traits.

Step-7: Humbly asked Him to remove our shortcomings.

This step acknowledges two things; one is that change is needed and the second is that this is not likely to occur simply within one’s own volition. An additional key to this step is the need to become humbled—not humiliated—but humbled, a trait often void in dysfunction.

Step-8: Made a list of all persons we had harmed, and became willing to make amends to them all.

The list of those needing amends is made back in step-4. However, it is at this point in one’s recovery they are asked to become prepared to make those amends. Like the other steps, this step is well placed from a timing perspective as early recovery phases of development would not have a person exist in a position of restitution. However, once a person has been able to fully explore their own clear contributions to their dysfunction they are now better placed to seek forgiveness versus blame for their respective conduct.

Step-9: Made direct amends to such people wherever possible, except when to do so would injure them or others.

This step is simply a follow through to the preparedness sought in step-8. The focus here is not to simply feel better by clearing away the wreckage of one’s past, but truly trying to make what was once wrong… right in another’s life. This step is well placed as so many addicts try to do this in their first week of recovery, which mirrors the many promises they have made in the past. This step is not about promise but about correction. For amends to carry greater meaning there needs to be some recovery time in place so that others are seeing an earnest effort at change. Another key here is not making amends if that amend would harm another human being; this is not about conscience clearing on the part of the addict.

Next time we will cover the steps that provide ongoing maintenance in the recovery process.

12-Step Programs: Steps 10 – 12

The “Maintenance Steps” within the 12-Step Programs consists of steps 10-12. These steps are critical for ongoing development, spiritual development, and other centeredness.

Step 10—Continued to take personal inventory and when we were wrong promptly admitted it.

Albeit that step four explores one’s personal assets and dysfunctions, this step looks to carry on that activity as a means of not stockpiling issues and concerns; the purpose here is to deal and address life immediately versus delayed responses. Daily personal inventories vary for everyone however, most explore where they were wrong in the day, where they may have acted selfishly, and where they may need to take corrective actions. In step four individuals have identified both their positive and negative traits; this step can also allow for a progress gage on areas that a person might be looking to change.

Step 11—Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Spiritual development is meaningfully tied to ongoing recovery rates; this step assists in that processes by having one connect regularly with their spiritual resources. Addicts have a tendency to have had years of dysfunctional behavioural patterns and this step seeks to explore spiritual principles as their guiding directives versus self-will.

Step 12—Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

William James and C. S. Lewis have spoken extensively on the areas of spiritual awakenings/ experiences and according to James’s work there are two types of spiritual experiences…those that are of an educational variety and thus developed over time and those that are of a conversion experience which is a result of complete self-surrender. In either of these experiences, individuals have a new or renewed awareness of spiritual principles and the goal is to inject these principles into daily living. The other part to this step is reaching out to others as a means to assisting them in recovery, which in turn assists those who are helping—many addicts have lived a life of selfishness and self-centeredness, this activity moves them away from these negative patterns and allows them to experience the benefits of reaching outside of oneself.