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Addiction Back to Course Index

 


 

 

They intend  to use on social occasions, with certain friends or for specific purposes.  Few, if any, set out to  cause harm to themselves or others; however, the history of problematic or excessive use and abuse of alcohol and other drugs indicates that many do get trapped and experience severe life altering problems as they increase their use and continue to make high-risk decisions.  Ultimately, if the using process continues it may result in addiction.  Interestingly, once an individual reaches the addiction stage there is little chance of him or her returning to a non-drug lifestyle without professional help. 

From a broader perspective, everyone that drinks or uses other drugs will not become a problem user or addict.  Tempered use is typical for many people most of the time, but addiction is a widespread problem for many.

Occasional use of psychoactive substances may begin because of curiosity or influence of family or friends.  The early experimental stage of use of a mood-altering substance usually occurs during the adolescent years, generally between 10 and 17 years of age.  The typical progression is from tobacco and/or alcohol followed by marijuana.  As use continues, other illicit drugs that are inhaled, injected, or ingested are added to the menu.  Generally, the use of more potent drugs, particularly those requiring hypodermic administration, begins somewhat later.

 

 

The commonly accepted stages of alcohol and other drug use along with some of the characteristics associated with each stage are as follows:

Experimental/Recreational Use Stage:  An individual may drink or use a few times per month, typically on weekends when at a party or other social event.  Use is generally with friends; however, individuals may drink/use alone.  This may result in minor health problems and/or misdemeanor legal problems.  The more common reasons people choose to use:

  • Experiment with alcohol and other drugs to satisfy curiosity
  • To acquiesce to peer pressure
  • To obtain social acceptance
  • To defy parental and other authority
  • To take risks or seek a thrill
  • To relieve boredom; appear grown up
  • To produce pleasurable feelings and to diminish inhibitions in social/personal settings
  • Alter mood in social settings
  • To mask social ineptness
  • Because they like how it tastes and how it makes them feel (less inhibited/increased risk taking)
  • Feeling that its their right due to passage to adulthood
  • Influence of co-workers

 

Regular Use Stage: An individual typically uses alcohol and/or other drugs on a regular basis; generally several times per week.  Individuals typically drink/use to intoxication/impairment.  Use is situational and an individual may commence binge drinking; may use alone rather than with friends.  Binge drinking is especially risky as people generally drink to excess and lose their ability to think rationally and to control their actions; also, their emotions are seriously flawed. Individuals begin to encounter the consequences of their use.  For example, financial problems are generally more pronounced and they begin to experience increased social, work, and family problems. Use during this phase is driven by or result in:

  • Experience the pleasure the drugs produces; alter emotions/moods
  • Cope with stress and uncomfortable feeling such as pain, guilt, anxiety and sadness
  • Overcome feelings of inadequacy
  • Avoid depression or other uncomfortable feelings when not using; substances are used to stay high or to mask uncomfortable feelings
  • Increased legal problems (public intoxication; driving under the influence; spouse/child abuse)
  • Increased financial problems
  • Increased social, work and family problems.  Family involvement is disrupted due to use; poor performance at work/loss of employment.

 

Compulsive/Dependent Use Stage: An individual typically uses on a daily basis or almost daily; individual is consumed with an uncontrollable and compulsive urge to seek and use, even in the face of negative health and social consequences.  Characteristics of this phase are:

  • Use is out-of-control
  • Time, energy, and money are focused on seeking and using drugs
  • Total preoccupation with drugs and drug related activities
  • Most family, social and work functions are impaired
  • Tolerance is noted (more of a drug is needed to reach desired affect)
  • Relationships with others may become strained and stressful
  • Responsibilities such as family and job are neglected
  • Continue using to avoid withdrawal symptoms
  • Major focus in life is when and where will I get my next fix
  • Alcohol and other drugs are needed to avoid pain and depression
  • Individuals use to escape the realities of daily living
  • Individual may experience severe health, social and financial problems
  • Legal problems are a way of life


Stage/phase progression (time wise)

When describing the stages of substance use a factor that is often overlooked is the timeline for each stage and the cumulative time it takes for an individual to progress through the stages and to become addicted to his or her drug of choice.  The time line depicted below is for alcohol.  The stages and times for other types of drugs would vary considerably but the overall concept is valid for most psychoactive drugs.  It should be noted that the stages are not absolute and may vary significantly from person-to-person.  Also, the dependency stage is best characterized as three sub-stages: early dependency stage where individuals may very well have the ability to control their use if they are sufficiently motivated to do so (spouse may require them to choose between alcohol and his or her family); however, in the middle and latter stages, there is little chance of the individual being able to control their use without professional help.

Figure 1 depicts the approximate time frames.  As can be seen, an individual may remain in the experimental/recreational use stage for 10 to 15 years prior to progressing to the regular use/abuse stage.  Typically, the regular use/abuse stage is shorter than either of the other stages.

 

ADDprocess fig1

Figure 1


Increased situational use (seeking out drinking functions), as well as psychological factors (need drug to feel normal) helps to accelerate individuals through the Use/Abuse stage rather quickly.  Also, during this stage, alcohol is often used as a crutch to help cope with stressful situations and to enhance joy associated with celebratory occasions.  Alcohol becomes the primary self-administered medication for all ills.  It can become progressively more important to the individual and can become a dominant factor in all decisions and actions.  As can be seen on Figure 1, the time frame for stage 2 is from three to five years.

The final stage is the Compulsive/Dependency stage.  It is helpful to divide this stage into three sub-stages and look at the characteristics of each sub-stage independently.  In each case, the point of focus is that alcohol and other drugs are becoming more important to the individual and he/she is making more concessions to it in terms of withdrawing from family, work and community responsibilities.  Typically, early in the compulsive/dependency stage an individual can stop drinking and/or using.  It typically takes a catastrophic life incident (serious illness, accident, loss of family/family member) for the individual to revert to abstinence on his/her own.  Through my years of counseling I have seen approximately 5 to 10% of early compulsive/dependency alcoholics undergo a successful recovery program motivated internally (self initiated).  The middle and late sub-stages are a different story.  The most significant characteristic of an individual in this stage is that the most important thing on their mind is when I will get my next fix.  I have met individuals in the compulsive/dependency stage that would lie, steal, imagescheat or do almost anything to obtain alcohol or other drugs. They demonstrate the uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences lifestyle every day of their life.   Unfortunately, few stage 2/3 abusers have the physiological and psychological under pinning to get into recovery themselves.

The Compulsive/Dependency stage typically extends for several years.  The early sub-stage typically does not extend beyond 5 years.  The middle sub-stage is characterized by a worsening of the early sub-stage and can last up to five additional years.  The final stage is characterized by total immersion into a drug related lifestyle and will generally last until either recovery or death.

 

Twenty years of scientific research, coupled with even longer clinical experience, has taught us that primary focus on the physical withdrawal issues leaves the addict short of the necessary work that needs to be done from a psychological standpoint.  From both clinical and policy perspectives, it does not matter what physical withdrawal symptoms occur beyond the medical issues.  Other aspects of addiction are far more important.  Physical dependence is not that important to the long term success of recovery because, first, even the florid withdrawal symptoms of heroin and alcohol addiction can be managed with appropriate medications.  Therefore, physical withdrawal symptoms should not be at the core of our concern about these substances.  Second (and more important), many of the most addicting and dangerous drugs do not even produce very severe physical symptoms upon withdrawal. Crack cocaine and methamphetamine are clear examples.  Both are highly addicting, but stopping their use produces very few physical withdrawal symptoms, certainly nothing liked the physical symptoms of alcohol or heroin withdrawal.

What does matter is whether or not a drug causes what we now know to be the essence of addiction which is the uncontrollable, compulsive drug seeking and use, even in the face of negative health and social consequences.  This is the crux of how many professional organizations all define addiction, and how we all should use the term.  It is really only this expression of addiction uncontrollable, compulsive craving, seeking and use of drugs that matters to the addict and to his or her family, and that should matter to society as a whole.  These are the elements responsible for the massive health and social problems caused by drug addiction.

Essence of Addiction Drug craving and the other compulsive behaviors are the essence of addiction.  They are extremely difficult to control, much more difficult than any physical dependence.  They are principal target symptoms for most drug treatment programs.  For an addict, there is no motivation more powerful than drug craving.

Rethinking Addiction focusing on addiction as compulsive, uncontrollable drug use should help clarify everyones perception of nature of addiction and of potentially addicting drugs.  For the addict and the clinician, this more accurate definition forces the focus of treatment away from simply managing physical withdrawal symptoms and toward dealing with the more meaningful and powerful concept of uncontrollable drug seeking and use.  The task of treatment is to regain control over drug craving, seeking and use.

Rethinking addiction also affects which drugs we worry about and the nature of our concerns.  The message from modern science is that in deciding which drugs are addicting and require what kind of societal attention, we should focus primarily on whether taking those causes uncontrollable drug seeking and use.  One important example is the use of opiates, like morphine to treat cancer pain.  In most circumstances, opiates are addicting.  However, when administered for pain, although morphine treatment can produce physical dependence which now can be easily managed after stopping use it typically does not cause compulsive, uncontrollable morphine seeking and use, addiction as defined here.  This is why so many cancer physicians find it acceptable to prescribe opiates for cancer pain.

Treating Addiction:  Follow the science.  It is important to emphasize that addiction, as defined here, can be treated, both behaviorally and, in some cases, with medications, but it is not simple.  We have a range of effective addiction treatments in our clinical toolbox although admittedly not enough.  This is why we continue to invest in research, to improve existing treatments and to develop new approaches to help people deal with their compulsive drug use.

Our national attitudes and the ways we deal with addiction and addicting drugs should follow the science and reflect the new, modern understanding of what matters in addiction.  We certainly will do a better job of serving everyone affected by addiction – addicts, their families and their communities if we focus on what really matters to them.  As a society, the success of our efforts to deal with the drug problem depends on an accurate understanding of the problem.

 

 

The addiction process is presented to help the clinician and the drug user to better understand the why behind their use and abuse of drugs.  Our hope is that the better this process is understood, the more effective counseling and other treatment modalities can be toward helping the user to achieve a drug-free life.  It is imperative that clinicians in the field of addictions understand the cognitive, behavioral and physical aspects of drug use.  The objectives are for the clinician involved with treatment to recognize the special needs of this sub-population and design treatment modalities aimed at their specific needs.  For example, as it is beneficial for an insulin dependent diabetic to be educated on all aspects of diabetes, it is equally important for the problematic drug user to be educated in all aspects of his or her drug of choice including impulse control, distorted cognitive ability and the consequences of poor decision-making.

Figure 1 depicts a typical addiction process and identifies the major functional blocks of the process.  The essence of this process is that if an individual has a flawed or permissive value/belief system (based upon his or her perceptions of events, teachings and influences of his family, friends, peers and other during his or her early life) it leads to that individual having a distorted cognitive ability.  That, in turn, enables an individual to continue to use and will ultimately result in the inability to manage his or her life (if the cycle is not disrupted).  The following paragraphs describe each block and how it impacts the users life.

1

 

An individuals value/belief system reflects his/her perception of self and represents values, judgments and myths that he/she believes to be true.  A persons value/belief system is fairly well established during the pre-teen years and is refined and honed by our experiences to make us into the person we are at any given time in our live.   It is the major control and decision-making guide and helps us to chose between right and wrong and things we do versus things we don’t do.  Our value/belief system influences our thinking and decision making throughout our life.  Most individuals have a value/belief system about:               

  • Religion
  • Alcohol and other drugs use
  • Sexuality
  • Race
  • Careers
  • Age
  • Peer pressure/fitting in
  • Time management
  • Social involvement
  • Community involvement
  • Family role
  • Social norms

 

A clinician should explore a clients value/belief system to better understand what they believe about various topics including topics related to drug use.  An area I like to explore with clients is the environment they were exposed to during their early life.  For example, one area to explore is if their parents or caregivers had a permissive attitude toward drugs.  What type of friends did they have was their neighborhood safe and what was the norm regarding use of alcohol and other drugs?  Other questions might include:


Were you exposed to limits or restrictions as a youth?

Did your parents use alcohol or other drugs?

Were you allowed to drink or use other drugs with your parents?

At what age did you start to drink or smoke?

Was there a permissive attitude toward alcohol and other drugs in your home/neighborhood?

Did you have a detailed schedule as a youth?

Did your parents involve themselves with your friends?

Did your parents monitor your activities?

 

Obviously, exposure to a permissive attitude/environment will enable a young person to form a positive image of most activities and/or to establish a distorted mental picture of specific activity (such as use of alcohol and/or other drugs). To give an example of how our belief/values works in the life of a drug user, lets suppose a person forms a concept of a problem user as one who dropped out of school and is unemployed.  Now, lets suppose this individual is a compulsive user but does not meet his or her pre-programmed characteristics of how they perceive an addict to be or act.In this case, the individual would test his situation against his value/belief system and would conclude he or she does not have a drug problem.The cycle is repeated until there is a match between his/her behavior and his/her pre-programmed belief/value system about drug use.It should also be noted that an individuals belief system about drug use might change in response to his or her own experiences and influences from clinicians and other treatment modalities.  The cycle may also be disrupted by other factors (generally a crisis) in the users life.

 

 

A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking; consequently, the affected individual continues to make high-risk decisions.With respect to use of drugs, it results in compulsive, uncontrolled drug craving, seeking and use.It follows that an individual is unable to comprehend the reality, consequences or truth about events/actions/activities.

When an individual cannot see the reality or truth about things, the distorted cognitive activity is generally referred to as denial.  The most common forms of denial are:

Rationalizing: Making excuses for drug use. 
Example, I’m restless and it helps me sleep; all of my friends use more than me.

Minimizing: Indicating his/her use is less serious than it really is.
Example: Sure I drink occasionally, but not that much; I only drink on weekends, real alcoholics drink every day.

Blaming: I drink because; everyone else does. The user admits involvement but the responsibility for it lies with some else.

An important challenge facing most compulsive users it to break though denial and accept the reality of their situation; consequently, the greatest challenge in counseling situations is to help the individual through this process.This generally takes patience, professionalism, research, and a willingness to face adversity. The client must adjust to a changing lifestyle and adapt new coping strategies and new ways to channel himself or herself away from his or her former lifestyle.Learning new concepts is usually met with resistance, as most individuals don’t want to change and will only change in response to pain or other strong motivator.Distorted cognitive activity or impaired thoughts mask the reality of most situations, and truth (in many cases) ceases to exist.A drug user in a quagmire may gain insight as to their preconception (thinking) regarding excessive use by answering and analyzing the following questions:

 

Most frequently used form of denial (with respect to drug use) is: __________ (rationalizing, minimizing, blaming or others.)

Most frequently processed impaired thought:_____________________________.

I’m not a problem user because: ______________________________________.


If an individual becomes emotionally stressed when asked these types of questions, it is a strong indication that the individual is in denial regarding their involvement with drugs and they are in need of professional help. The key to any cognitive change is that the individual be open and honest and willing to accept that change is needed.If they have a good attitude, it is easier for them to accept the perils associated with compulsive use.The net is that people can change but in most cases the change must be initiated at the cognitive level.If one is in denial regarding a problem there is very little that anyone else can do to help that individual.

 

 

The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This on-going activity results in addiction (again, compulsive, uncontrolled drug craving, seeking and use). This lifestyle is problematic and typically follows a well-established pattern.  At this stage of use, his or her drug related choices begins to disrupt normal activities with family, work, school, social, and community.  Also, it may cause personal health problems as well as financial problems that are difficult to deal with.His or her use is increasing in importance to where it is masking most other activity/relationships.It generally results in behavioral problems or the inability to manage of one’s life.

As use continues, the individual begins to encounter the negative consequences of his/her behavior.In general, the consequences cause pain (psychological or physiological) that, when severe enough, may increase his or her willingness to accept help.The hypothesis is that deeply embedded in human nature is the tendency to resist all change until we finally experience pain and then we may stop to look at the cause of the pain.This process may manifest itself in any of the following:

  • Physical (health problems, increased risk taking)
  • Social problems (family, work, school, community)
  • Emotional (feelings of guilt, shame or depression)
  • Spiritual (low self esteem, feeling empty, isolated)
  • Financial (heavy debt load; inability to manage)

Another self-analysis assignment is for an individual to identify the negative consequences as a result of his/her drug use.This exercise is generally done over several counseling sessions and ultimately will lead the individual to accept responsibility for their decision

 

Figure 2 depicts an individual addiction cycle for a drug user and identifies the major blocks associated with the cycle. Most clinicians believe that all addictions fit into a cycle and that it starts with a cognitive process related to the event (thinking about or preoccupation with the activity).

 

3

 

Preoccupy is defined as to absorb wholly the mind or attention of or occupy beforehand or before another. It can be viewed as a locked in mind state, where the main focus is on obtaining his or her drug of choice. Some individuals are so focused they appear to be in a somnolent state (as of deep hypnosis) where the individual may have limited sensory and motor contact with his or her surroundings and subsequent lack of recall. Most somnolent states vary in intensity, duration and frequency. The initial onset may be mild but generally get more intense as time passes without satisfying the impulse. The intensity of the state also varies depending on how long the individual has been a drug user as all individuals are creatures of habit and we program ourselves to expect resolution within a predetermined time frame or the mind will increase the desire to satisfy the impulse.  An approach to understanding this phase of use is to ask the user a series of questions such as:

  • What thoughts did you focus on when you initially began use drugs?
  • Was your intent (to be accepted by your peers)?
  • Was your objective to prove your manhood or womanhood?
  • Did you use as an act of rebellion?
  • What role did peers play in your decision to use?
  • How did the focus items change as the compulsion to use increased?
  • What are your thoughts like at present?
  • What do you think regarding using again?
  • How often do you think about using?

Remember that it takes time to break old habits and to re-program our minds to desire different things.  Also, remember the urge to continue to use will be very strong when an individual initially stops.  Its also safe to say that everyone thinks about resuming use, and individuals must be resilient in their efforts to break the cycle. This exercise is intended as a tool that will help the individual to become familiar with how his/her mind works and the thought processes prior to previous relapses.  Again, the mind wants to continue to do those things that bring pleasure.  A big shopping spree or hanging out with former using buddies are positive events in our minds and we want to repeat them.  Therefore there is a strong drive to set aside or dismiss concepts that would limit us doing what we want to do.  I have often stated in-group sessions that using is an extremely selfish action.  It basically says I will do what I want to do without any consideration for my health, family or other considerations.  Unfortunately, we all know there is the negative side to compulsive use, but our mind is quick to “set aside” those thoughts when the other (positive) thoughts are being processed. As healthy, normal humans, it is always a good idea to keep the rewards versus consequences balanced in our minds.  I often use the phrase, when one makes the decision (for example, to get high on drugs) they also accept the consequences.  Sometimes good happens, but most of the time bad and sometimes catastrophic event occur.


The second part of the individualized addiction cycle is a set of habits that typically lead to use.  Some counselors may refer to this as ritualistic or as a person being on autopilot where the behavior is almost fully automatic and, once initiated, the activities are generally done without thinking. The preceding cycle discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (ritual) that are typically completed without thought.

A using ritual is the behavior that leads to use.  For example, it may be as simple as an urge to get together with old friends (former using buddies) or thinking about an event that previously included drug use (concert).  It may also be triggered by an argument with a spouse; loss of a job or other catastrophic events or it could be as insignificant as driving through a neighborhood where his or her former supplier lived.In any event, it is something that triggers a thought in our minds that initiates a chain of events that leads to using.This is another view of compulsivity.  It’s also important to note that when a ritual is initiated, it is very difficult to stop the process.For a compulsive user, it is virtually impossible without professional help.

Another assignment for the addicted individual is to describe what triggers their use. List and analyze the activities and behaviors leading to use.The objective is that the better we understand what motivates an individual; the easier it is to interrupt the cycle. The second part of the exercise is to identify what could be done to disrupt the process. This may be as simple as planning an evening of entertainment at home with the family.Whatever the case may be, the better one understands themselves, the easier it is to manage their lives and to make better decisions.

Compulsive actions are related to an irresistible impulse to perform an irrational act.In essence, the user has an impulse control problem and/or is susceptible to relapse. Compulsivity is characterized as continued use of the substance despite significant substance-related problems.Some clinicians refer to this phase as when the user begins to experience the consequences of his use.  Also, most users are aware of their need to stop using and have made several unsuccessful attempts to stop.This tendency leads to a look at relapse where the clinician and user attempt to identify what triggered the action (resumption of use) and how he or she may avoid that activity in the future.  The clinician must always be mindful that when the user resumes use, he or she expects to experience euphoria.  Unfortunately, the opposite emotions, of fear, hopelessness and helplessness, shame, guilt, depression and despair are often encountered. One must remember that our minds retain the positive memorizes and have a tendency to set aside the negative ones.  Consequently, the individual thinks he/she will experience a high, when, in fact, he/she has been deceived by his/her own mind.  I think one of the root causes of severe depression is when the individual is expecting an unrealistic outcome and finally realizes he/she has to deal with a set of negative consequences.

Despair is the end result of addiction and is where feelings of hopelessness abound. This block represents the consequences of compulsive use (negative impact on family, work, society, health) and the user generally has feelings of shame and guilt following episodes of use.However, the addicted individuals mind attempts to soften his/her despair by processing thoughts such as I will never use again; things will be different in the future. The effect of this mental defense mechanism is to alleviate the bad feeling as quickly as possible by processing the neutralizing thoughts.  So, instead of facing the addiction, the individuals mind has found another way to deny the addiction.  Consequently, the cycle continues.

 

 

People begin to use due to curiosity and a desire to fit into a social group (peer pressure).  Certainly, a youth who has already begun to smoke cigarettes and/or to use alcohol is at a higher risk to experiment with other drugs.  Research suggests that the use of alcohol and/or other drugs by other family members increases the risk of early experimentation as well as early problematic use.  Parents, grandparents, older siblings, other relatives and caregivers are all role models for children to copy and follow.  At times, parents blindly trust teachers, youth camps, sports figures and others with their children without being aware of the negative influences that could surround these individuals. Studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol or tobacco. 


 

The following trends have been observed for heavy users versus their non-using counterparts:

Users as a whole have a lower educational achievement level.  This difference is more pronounced in math and science than in social studies and courses such as music and art and the finding is dependent on the age of first use. Some students lack the drive or desire to remain focused to solve difficult problems, whereas it may very well increase their interest in non-technical studies.It should be noted that this is a generalized trend and specific individuals may be able to excel in math and science and use drugs.

Many experience increased personality disorders such as depression, anxiety, fear, impaired judgment, distorted sensory perceptions, difficulty in carrying out complex mental processes, and impaired motor performance,  Some user experience unusual anti-social behaviors and a rebellious attitude.

Research has indicated an adverse impact on memory and retention that can last for days or weeks after the acute effects of the drug subside.For example a study of over 100 college students found that among heavy users (of marijuana) their critical skills related to attention, memory, and learning were significantly impaired even after they had not used the drug for at least 24 hours.A follow-up to the initial study showed that a group of long-term heavy users ability to recall words from a list was impaired 1 week following cessation of use, but returned to normal by 4 weeks.The implication is that even after long-term heavy use, if an individual quits, some if not most of his or her cognitive abilities may be recovered.

 

 

The American Society of Addictive Medicines (ASAM) has taken the lead in the standardization of concepts and approaches for alcohol and other drug treatment programs.

The levels of care established by ASAM are:

 

Level 0.5  Early Intervention

Level I  Outpatient services

Level II  Intensive Outpatient/Partial Hospitalization Services

Level III  Residential/Inpatient services

Level IV  Medically-Managed Intensive Inpatient services

 

A referral for a specific level of care must be based on a careful assessment of the patient with an alcohol and/or other drug problem. The overall objective is to place the patient in the most appropriate level of care (described as the least intensive level that could accomplish the treatment objectives while providing safety and security for the patients). The levels of care represent a continuum of care that can be used in a variety of ways depending on the patient’s needs and responses.  For example, a patient could begin at a more intensive level and move to less intensive levels either in consecutive order or by skipping levels.  A patient could also move to more intensive levels depending on need.

A study of adult drug users found that 18-sessions of cognitive-behavioral-therapy (CBT) group counseling followed by 2-sessions of individual counseling (this amount of counseling is similar to the American Society of Addictive Medicine, Level 1) is effective for most patients who have not advanced to the addicted stage. This counseling includes motivational interviewing and advice on ways to reduce use. The study also indicated that focusing on what triggers their use and then help them to devise appropriate avoidance strategies could help patients. Outcome studies revealed the following results:

(1) use and related problems (school, work, family), as well as psychological problems, decreased for at least one year after treatment;

(2) approximately 30 percent of former users were drug-free after three months.


 

A significant challenge facing recovering addicts is to avoid relapse.  Treatment needs to find an approach where high-risk situations are assessed, and then coping strategies are developed for each situation.


Consider the following:

 
Self-Efficacy:  The individual’s perception of his/her ability to cope with situations.
Expectations:  What is the consequence to the user of a specific behavior?
Attribute:  Why an individual exhibits a specific behavior.
Decision-Making:  Methodology used when the individual chooses a specific action.
 
Once this analysis is complete, the following intervention strategies can be employed:
 
Self-monitoring:  Maintaining a log of urges/needs to use drugs. Additional information, such as the intensity of urge and coping strategy employed may also be documented. 
Direct observation:  The individual rates the degree of temptation due to various situations. The individual may respond to an imaginary past episode or a fantasy about a past episode and then describe what he/she may have done differently to avoid future encounters. 
Coping Skills:  This analytical tool is used to document the client’s ability to cope once a high-risk behavior is encountered. This helps the individual to identify strengths and weaknesses and helps the client focus on areas that need improvement. 
Decision Matrix:  The matrix is used to document the consequences of a specific decision or action. It may be used to gather immediate, as well as delayed consequences, and can document both positive and negative outcomes.  Behavioral
Commitment: This tool is intended to establish limits on drug use (if any).It is also a commitment to seek help at the first episode of use, to prevent a full-scale return to using. 
Reminder Questions: They are used to key specific avoidance actions in the event of a strong urge.

 

It follows that a primary goal of any prevention program is to enable the individual to cope with the future, inevitable urges to use.  The initial step is to identify the coping strategies that can be used in high-risk situations.  It is also important to discuss an implementation plan for how these skills will be used.  Some have referred to this process as setting up a self-management program.  The goals of self-management programs are to teach the individual to anticipate and cope with the problem of relapse. This approach generally combines behavioral skills training, cognitive interventions, and lifestyle changes to help the individual modify their behavior.

The most frequently applied prevention method is the cognitive-behavioral approach. The primary feature of this approach is that it acknowledges the individual may have had little or no control over becoming a compulsive user but has total responsibility for the management of his/her recovery.

 

 

This model is based on the concept that recovery is a process that requires the mastery of emotional, psychological, social, and recovery-related tasks.  These tasks, which become increasingly more challenging, are the foundation for recovery.  Recovery is defined as the ongoing process of improving one’s level of functioning while striving to remain drug-free.  A brief overview of a recovery process follows:

Pre-treatment phase:  The individual experiences or becomes aware of unpleasant consequences associated with drug use (family problems, loss of friends, loss of a job, loss of freedom); Loss of control of their life, and emotional pain (may motivate an individual to enter treatment).

Initial stabilization:  Stop the use of all drugs; avoid former using buddies; professionally managed coping and emotional strategies (to ease the discontent associated with urges to resume using);  Help with controlling impulsive behavior (counseling). The following phases are followed:

Phase 1:  Recovery (Getting Started): Helps individuals to accept and comprehend the addiction process: Identify use triggers: Develop a plan to avoid and control impulses. Learn problem-solving, stress management, and anger management skills. Accept personal responsibility for self (choices, decisions, behaviors, and consequences) Express feelings.

Phase 2:  Recovery (Early); Accepts need for recover; Accepts responsibility for the management of drug use; Begins to develop a drug-free self-image; Acknowledges the need for lifestyle changes; new friends; Adjusts to non-use behavior applies new problem-solving skills as needed; May struggle with peer and family issues as a drug-free lifestyle is demonstrated; Improved self-image.

Phase 3:  (Middle) Changed behavior and cognitive awareness aligned with new self-concept; Accepts responsibility for own recovery; Recognizes and embraces success of recovery; Incorporates problem-solving skills into new lifestyle; Comfortable with lifestyle change; Continues to struggle with peer and family issues; Learns to balance and control life.

Phase 4: (Advanced) Focuses on learning coping skills to help deal with peers and family; Increases scope of life; starts to fulfill potential; Develops balance and takes control of life; Develops independence from the treatment program develops self-initiative; Accepts identity as a recovering individual.

After Care: Positive experiences fuel personal growth; Focus on the total person (activities, spiritual growth, and independence).


Keys To Avoid Relapse:

  • High Activity Level: An idle mind often wanders in the wrong direction;
  • Generate To-Do lists to guide daily activities;
  • Set goals to acknowledge and reward success;
  • Individual reward system: work toward a specific individualized reward. For example, a new car, trip, clothes;
  • Plan pleasurable activities; Hobbies, travel, reading, etc.;
  • Plan self-improvement activities; Items that will help the individual feel good about themselves;
  • Exercise/active lifestyle;
  • Nutrition program;
  • Plan rest/relaxation time;
  • Eliminate or minimize stress where possible;
  • Think positive; Avoid high-risk situations here possible;
  • Avoid events that previously led to relapse;
  • Avoid people/functions whose focus is on drug use;
  • Avoid events and peoples that have triggered previous relapses;
  • Develop mind-management techniques: Block negative thought processes. The mind always leads the physical act (i.e., an individual thinks positively regarding an activity before they do the activity). Consequently, if we could train our minds to detect wrong thinking (about drug use), then we could alter or disrupt those thoughts and focus on different things or thought processes to avoid actually using;
  • Avoid overconfident feelings, such as, I am in control, and I have this problem licked. Generally, overconfidence leads to high-risk behavior and poor decision-making;
  • Avoid out-of-balance emotional states. Either feeling too good (overconfident) or too bad (depression) can lead to the resumption of use.

Forgetting or rationalizing away the pain and anguish of the former lifestyle. Our minds will sometimes focus only on the pleasurable aspects of a former activity and completely mask (or forget) the negative consequences. At times, individuals are convinced that returning to a former lifestyle would be wonderful (feeling, emotions, etc.)  Also, when they actually return to that lifestyle, they become deeply depressed as the reality of their actual use is realized.  The mind is a wonderful thing, but it too must be monitored and trained, and one must realize that the mind can be misleading in some cases.

 

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