When one begins to use a mind-altering substance, the notion is that it will be used only on social occasions, with certain friends, or for specific purposes. I think it is safe to say no one intends to become addicted; however, the history of excessive use and abuse of alcohol and other drugs indicates that many do get trapped and experience severe life-altering problems as they progress through the use stages and ultimately reach the addicted stage. Interestingly, once an individual has reached the addiction stage, there is little chance of turning back.
From a broader perspective, not everyone that drinks alcohol or uses other drugs becomes addicted. Tempered use or abstinence from alcohol and other drugs is typical for most people, most of the time. The occasional use of psychoactive substances may begin because of curiosity or influence of family or friends. The early experimental stage of the use of a mood-altering substance usually occurs during the adolescent years, generally between 10 and 14 years of age. The typical progression of use is from tobacco and/or alcohol, followed by marijuana. As use continues, other illicit drugs that are either inhaled or ingested orally 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 (drink/use a few times per month, typically on weekends when at a party or other social event, use is generally with friends; however, individual may drink/use alone).
- Person experiments with 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.
Regular Use/Abuse Stage (Drugs are used on a regular basis (several times per week); individuals may drink/use to intoxication/impairment; drug use is situational; may commence binge drinking; may use alone rather than with friends).
- Experience the pleasure the drugs produce; 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 at least maintain normal feelings;
- May begin to encounter legal problems (public intoxication; driving under the influence; spouse/child abuse).
Compulsive/Dependent Use Stage (Drug use on a daily or almost daily basis; individual is consumed with an uncontrollable and compulsive urge to seek and use, even in the face of negative health and social consequences). Note: Characteristics noted above are generally more applicable to the later phase of the Compulsive/Dependent Use stage. Characteristics may vary considerably during the early part of this stage.
- 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 functioning is impaired
- Tolerance is noted (more of a drug is needed to reach the desired effect)
- Relationships with others may become strained and stressful
- Responsibilities such as family and job are neglected
- Continue using to avoid withdrawal symptoms
- Individuals major focus in life is when and where will I get my next fix
- Drugs/alcohol are needed to avoid pain and depression
- Individuals use to escape the realities of daily living
- An individual may experience severe health, social and financial problem
- Legal problems are a way of life
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) describes criteria for the diagnosis of disorders related to the taking of drugs of abuse (including alcohol). The DSM-IV divides the Substance-Related disorders into two groups: the Substance Use Disorders (Substance Dependence and Substance Abuse) and substance-Induced disorders (substance Intoxication, substance withdrawal, and others). The criteria to be used for a diagnosis of Substance Abuse will be presented first, followed by the criteria for Substance Dependence; the criteria for Substance Intoxication and Substance Withdrawal will follow.
A drug abuser is one who continues to use despite recurrent social, interpersonal, and legal difficulties as a result of his or her use. Harmful use implies use that results in physical, legal, or mental damage. The essential feature of Substance Abuse is a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of the substance. In order of an abuse criterion to be met, the substance-related problem must have occurred repeatedly during the same 12-month period or been persistent. There may be repeated failure to fulfill major role obligations, repeated use in situations in which it is physically hazardous, multiple legal problems, and recurrent social and interpersonal problems. Unlike the criteria for Substance Dependence, the criteria for Substance Abuse do not include tolerance, withdrawal, or a pattern of compulsive use and instead include only the harmful consequences that result from repeated use. The criteria for Substance Abuse is:
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
(1) Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household);
(2) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use);
(3) Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct);
(4) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights);
B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
The essential feature of Substance Dependence is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues the use of the substance despite significant substance-related problems. In essence, it is a pattern of repeated self-administration that can result in tolerance, withdrawal, and compulsive drug-taking behavior. Those who are substance dependent meet all of the criteria of alcohol abuse, and they will also exhibit some or all of the criteria for dependence. The criteria for substance dependence is a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
(1) Tolerance, as defined by either of the following:
(a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect;
(b) A markedly diminished effect with continued use of the same amount of the substance;
(2) Withdrawal as manifested by either of the following:
(a) The characteristics of withdrawal syndrome for the substance (b) the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms;
(3) The substance is often taken in larger amounts or over a longer period than was intended;
(4) There is a persistent desire or unsuccessful efforts to cut down or control substance use;
(5) A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
(6) Important social, occupational, or recreational activities are given up or reduced because of substance use;
(7) The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance use (e.g., current use despite recognition of substance-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption).
The essential characteristic of substance intoxication is the development of a reversible substance-specific syndrome due to the recent ingestion of (or exposure to) a substance. The clinically significant maladaptive behavioral or psychological changes associated with intoxication (e.g., belligerence, mood lability, cognitive impairment, impaired judgment, impaired social or occupational functioning) are due to the direct physiological effects of the substance on the Central Nervous System and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
The essential feature of substance withdrawal is the development of a substance-specific maladaptive behavioral change, with physiological and cognitive concomitants, that is due to the cessation of, or reduction in, heavy and prolonged substance use. Substance-specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.
The signs and symptoms of withdrawal vary according to the substance used, with most symptoms being the opposite of those observed in intoxication with the same substance. The dose and duration of use and other factors such as the presence or absence of additional illnesses also affect withdrawal symptoms. Withdrawal develops when doses are reduced or stopped, whereas signs and symptoms of intoxication improve (gradually in some cases) after dosing stops.
Progression/Time Line Through the Stages
When describing the stages of substance use, a factor that is often overlooked or under-evaluated is the timeline for each stage and the cumulative time it typically takes for an individual to progress through the stages and to become addicted to or dependent upon his or her drug of choice. The timeline depicted below is for alcohol; the stages and times for other types of drugs would vary considerably (time-wise), but the overall concept is valid for most psychoactive drugs. It should be noted that the stages are not absolute and do not have a precise timeline 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 (spouse may require them to choose between alcohol and his or her family); however, in the middle and later stages, there is little chance of the individual being able to control their use without professional help.
Figure 1 depicts the approximate time frame for each stage (phase is used in lieu of a stage in figure 1). 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.
Increased situational use (seeking out drinking functions), as well as psychological factors (need a 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 all stressful situations and to enhance joy associated with celebratory occasions. Also, 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 in 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 is 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 use stage, an individual can stop drinking. 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 will I get my next drink. I have met individuals in the compulsive/dependency stage that would lie, steal, cheat, 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 alcoholics have the physiological and psychological underpinning to get into recovery themselves.
The Compulsive/Dependency stage typically extends for several years. The early sub-stage typically does not extend beyond five 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 emersion into a drug-related lifestyle and will generally last until either recovery starts or death.
THE ESSENCE OF ADDICTION
Dr. Alan I Leshner, PhD., Director, National Institute of Drug Abuse, 2001, provided the following insight into drug addiction. He states: The word Addiction calls up many different images and strong emotions. But what are we reacting to? Too often, we focus on the wrong aspects of Addiction, so our efforts to deal with this difficult issue can be badly misguided. Any discussion about psychoactive drugs, particularly drugs like nicotine and marijuana, inevitably moves to the question, but is it really addicting? The conversation then shifts to the so-called types of Addiction, whether the drug is physically or psychologically addicting. The issue revolves around whether or not dramatic physical withdrawal symptoms occur when an individual stops taking the drug, what we in the field call physical dependence.
The assumption that follows then is that the more dramatic the physical symptoms, the more serious or dangerous the drug must be. Indeed, people always seem relieved to hear that a substance just produces psychological Addiction, or has only minimal physical withdrawal symptoms. Then they discount the dangers. They are wrong.
Defining Addiction Twenty years of scientific research, coupled with even longer clinical experience, has taught us that focusing on this physical vs. psychological distinction is off the mark and a distraction from the real issue. From both clinical and policy perspectives, it does not matter much what physical withdrawal symptoms occur. Other aspects of Addiction are far more important. Physical dependence is not that important 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 tremendously is whether or not a drug causes what we now know to be the essence of Addiction: 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.
The 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 the principal target symptoms for most drug treatment programs. For an addict, there is no motivation more powerful than a drug craving.
Rethinking Addiction focusing on Addiction as compulsive, uncontrollable drug use should help clarify everyone’s perception of the 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, the concept of uncontrollable drug seeking and use. The task of treatment is to regain control over drug craving.
Rethinking addiction also affects which drugs we worry about, as well as the nature of our concerns. The message from modern science is that in deciding which drugs are addicting and those that require societal attention, we should focus primarily on whether taking them 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 requirements 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 on 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 others during his or her early life) it leads to that individual having a distorted cognitive ability. That, in turn, enables the individual to continue to use and will ultimately result in unmanageability of his or her life (if the cycle is not disrupted). The following paragraphs describe each block and how it impacts the user’s life.
An individual’s value/belief system reflects his/her perception of self and represents values, judgments, and myths that he/she believes to be true. A person’s value/belief system is fairly well established by an early age and is refined and honed as life experiences make us into the person we are at any given time in our lives. It is a major control and decision-making guide and helps us to choose 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 lives. Most individuals have a value/belief system about:
- Alcohol and other drugs use
- Peer pressure/fitting in
- Time management
- Social involvement
- Community involvement
- Family Roles
A clinician should explore a client’s 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, I want to determine if their parents or caregivers had a permissive attitude toward drugs. I also want to know what type of neighborhood they lived in and what was the norm regarding the 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 a specific activity (such as the use of alcohol and/or other drugs). To give an example of how our belief/values work in the life of a drug user, let’s suppose a person forms a concept of a problem using as one who dropped out of school and is unemployed. Now, let’s 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 for drug use. It should also be noted that an individual’s belief system about drug use might change in response to his or her own experiences and influences from clinicians and treatment programs. The cycle may also be disrupted by other factors (generally a crisis) in the user’s life.
Distorted Cognitive Ability
A flawed or permissive value/belief system results in a distorted cognitive ability that, in turn, results in illogical and impaired thinking. The affected individual continues to make high-risk decisions for themselves. With respect to the 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. Examples include, 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 to break through denial and accept the reality of their situation. 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 adopt new coping strategies and new ways to channel himself or herself away from his or her former lifestyle. Learning new concepts is frequently met with resistance, as many individuals don’t want to change and will only change in response to pain or another 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 is open and honest and willing to accept that change is needed. If they have a good attitude, it is easier for them to see 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.
Cycle of Use
The cycle of use is an outcome of an individual continuing to live with distorted cognitive functioning. This ongoing activity results in Addiction (again, compulsive, uncontrolled drug craving, seeking, and use). This lifestyle is problematic and typically follows a well-established pattern (Reference Individual Addiction Cycle). At this stage of use, his or her drug-related choices begin to disrupt normal activities with family, work, school, and social and community. His or her use is increasing in importance to where it is masking most other activity/relationships. It generally results in behavioral problems or unmanageability 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 only then may we stop to look at the cause. 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 decisions.
INDIVIDUAL ADDICTION CYCLE
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).
Figure 2. Individual Addiction Cycle
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 mental 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 timeframe, or the mind will increase the desire to satisfy the impulse. An approach to understanding this phase of use is for clients to explore the answers to questions such as:
- What thoughts did you focus on when you initially began the use of drugs?
- Was your intent to be accepted by your peers?
- Was your objective to prove your manhood or womanhood?
- Did you use it as an act of rebellion?
- What role did peers play in your decision to experiment?
- How did the focus items change as the compulsion to use increased?
- What are your thoughts at present?
- What do you think about using it again?
- How often do you think about using it?
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 again, 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. Consequently, a big shopping spree or hanging out with the former using buddies are positive events in our minds, and we want to repeat them. There is a strong drive to set aside or dismiss concepts that would limit us from 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 events 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 (Figure 1) discusses preoccupation, which is thought without action (it may lead to action), whereas this cycle addresses a set of habits (rituals) that are typically completed without thought.
A using ritual is a 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 another catastrophic event, 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 use. This is another view of compulsivity. Its 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 keys 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.
The third block of Figure 2 is compulsivity. 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. Consequently, compulsivity is characterized by 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, fear, hopelessness, and helplessness, shame, guilt, depression, and despair are often encountered. One must remember that our minds retain positive memories and have a tendency to set aside the negative ones. The individual thinks he/she will experience a high when, in fact, he/she has been deceived by his/her own mind. Depression can result from an individual expecting an unrealistic outcome and finally realizing 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 neutralizing thoughts. So, instead of facing the Addiction, the individuals’ mind has found another way to deny the Addiction. Thereby, the cycle continues.
People begin to use drugs 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 of experimenting with other drugs. Research suggests that the use of alcohol and/or other drugs by other family members is a risk factor as to whether children start using drugs. Parents, grandparents, older siblings, other relatives, and caregivers are all role models for children to copy and follow. I personally like to expand the model concept to everyone who is an authority figure or in a position to influence a child’s life. 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 present trend is that only a few high school students use cocaine; however, the risk of doing so is much greater for youths who have tried marijuana than for those who have never tried it.
The following trends have been observed for heavy users versus their non-using counterparts:
Lower educational achievement levels: This difference is more pronounced in math and science than in social studies and courses such as music and art. It appears that some students lack the drive or desire to remain focused on solving 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.
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 users 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 one week following cessation of use, but returned to normal by four 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 alcohol 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 a 14-session cognitive-behavioral group and 2-sessions of individual counseling (this amount of counseling is similar to the American Society of Addictive Medicine, Level 1) are effective for some patients. 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. Marlott and Gordon in 1995 provided a comprehensive relapse prevention technique for alcohol and other drug addicts. They suggested an approach where high-risk situations were assessed, and then coping strategies were developed for each situation. The following factors were analyzed for each situation:
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, Marlatt and Gordon suggest the following intervention strategies:
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. According to Ricky George (1990), 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 individuals to decide to enter treatment).
- Stop 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)
Phase 1: Recovery (Getting Started)
- Helps individual 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 skill.
- Accept personal responsibility for self (choices, decisions, behaviors, and consequences);
- Express feelings.
Phase 2: Recovery (Early)
- Accepts the need for recovery
- 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 the 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 the success of recovery.
- Incorporates problem-solving skills into a new lifestyle.
- Comfortable with lifestyle changes.
- 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 the scope of life; it starts to fulfill potential.
- It develops balance and takes control of life.
- Develops independence from the treatment program develops self-initiative.
- Accepts identity as a recovering individual.
- Positive experiences fuel personal growth.
- Focus on the total person (activities, spiritual growth, and independence).
Keys To Avoid A Return To Problematic Use For Clients:
- High Activity Level: An idle mind often wanders in the wrong direction.
- Generate To-Do lists to guide daily activities.
- Goal setting 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.
–Avoidance of high-risk situations and activities
-Events that previously led to use
-Avoid people/functions whose focus is on drug use
–Avoid things 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 positive 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 overly confident feelings, such as discourage clients from thinking, “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.
They are 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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