Relapse Prevention, Part 2

In my last post I wrote about triggers for relapse and the importance of having a relapse prevention plan, if you’re trying to establish and maintain a clean-and-sober lifestyle. The relapse prevention curriculum I developed in at the University Hospital of the West Indies in Jamaica included modules on stress  management, anger management, and rational thinking – all topics I’ve covered in previous posts. In this post I’ll be writing about other aspects of recovery from addiction.

I’ve met people with serious substance abuse problems who were too  proud to admit that they needed help in their recovery. (“I’m man enough to do it on my own!”) I’ve also known drug abusers who couldn’t imagine talking to other people – especially strangers – about addiction-related things they’d done and were ashamed of. But I’ve never met a recovering addict who got and stayed clean-and-sober without help from others, either in the form of professional help, or peer support groups such as AA. The road to recovery isn’t a road to walk alone.

Although I never saw him staggering drunk, my own father was an alcoholic. A military man who prided himself on his self-control, he once went for a year without drinking, to “prove” his ability to control his drinking. He went for exactly 365 days without a drink, but he hated every day of his self-imposed sobriety. It’s a condition known in the recovery community as “dry drunk.” As planned, on Day 366 he resumed drinking, moderately at first. But within weeks he was back to hiding bottles and drinking at the level he’d been drinking before his year of “white knuckle” sobriety.

There are individuals, I’m told, who’ve regained control of their excessive drinking and become moderate “social drinkers” – but I’ve never met one. “Someday I’ll be able to drink again” is a dangerous thought for people in recovery. Addicts are notorious for irrational thinking and self-deception. Many a relapse starts with thoughts like “I’ll allow myself one beer on my birthday” or “I can still shoot pool with my drinking buddies at the bar, and just drink sodas.” One of the arguments for attending Twelve Step meetings is that in time you’ll come to recognize your own rationalizations, by listening to other addicts who’ve come to recognize their own bullshit. Twelve Step meetings are all about getting real with other addicts who they know won’t judge them, because they’ve been there, done that, themselves.

Some friends and family of addicts don’t want to support their recovery, for a variety of reasons. Other well-meaning people who care about an addicted friend of family member become enablers. With the best of intentions, they try to shield their friends or  loved ones from the natural consequences of their addictions. They think they’re being helpful, but they’re simply enabling the person to continue drinking or using. In order to truly help, enablers need to learn to practice tough love – to stop attempting to rescue the person, and to let them suffer the natural consequences of their substance abuse. A mother practicing tough love won’t bail her son out of jail, because she knows from experience that if she does, he’ll be shooting up again within hours of his release.

Most recovering addicts come to the realization at some point in their recovery that they not only have to stop their drug-of-choice, but all intoxicating substances. I’ve known a number of crack and opioid addicts who initially believed that they could substitute alcohol and/or cannabis for their drug-of-choice, only to find that it was just a bridge back to their preferred drug. Cravings are one of the most common triggers for relapse, and getting high or intoxicated doesn’t improve anyone’s judgment or ability to resist cravings.

In my last post I mentioned euphoric recall (addicts dwelling on memories of the good times they’d had drinking and drugging, before getting addicted) as a trigger. This is one form of rumination, but addicts can also ruminate about how much they’d like to get high right now. This kind of thinking activates cravings that lead to relapses.

I’ve had some personal experience with this, as a recovering nicotine addict. What I found was that when I ruminated on how good it would feel to light up a cigarette, I relapsed time and again. Eventually I was able to identify my ruminations as a predictable relapse trigger, and to stop dwelling on thoughts about how I’d like to have a smoke. I still have occasional situation-specific cravings for tobacco, but I no longer feed the initial thought with more thoughts, and the cravings only last for a few seconds. After years of being  nicotine-free, the long-term rewards of being a non-smoker outweigh any momentary cravings I might have to light up again.

Who is an addict?

Who is an addict? It depends on who you ask.  To some people it’s an ugly word with negative connotations relative to, say, substance abuser. To others it’s a term with an important meaning, and recovering addict is a badge of honor, one day at a time. Addict is just a word for something real; it’s not a specific thing like a tiger or the Pope. It has no absolute meaning, but is associated with the medical model, in that it classifies addiction as a disease – specifically a chronic, progressive, relapsing disease.  Some add “fatal” to the list of adjectives, believing that if you can’t maintain recovery, your addiction will eventually kill you. To admit you’re an addict is to admit that you’ve lost control.

I’ve attended open Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings, and believe that regular attendance of 12 Step meetings is the only path to recovery for some addicts. I’ve recommended checking out 12 Step programs to many substance abusers during my career, but I disagree with anyone who claims there’s only one way – whether 12 Step programs, or Rational Recovery, or the Bible – to stay clean and sober.

My prescription for long-term recovery from substance abuse is “whatever works for you.” If believing you have a treatable life-long disease works to keep you in recovery, or believing you have an addictive personality, or believing that you have to “get right with God” to stay clean and sober, go with it. Your path to recovery is yours, but might not be what others need. It takes most people with substance abuse problems many relapses to learn what does and doesn’t work for them, as was the case with my recovery from nicotine addiction.

Not everyone has to “hit rock bottom” before getting it right. I’ve known a few people with many years in recovery who didn’t relapse once after resolving to quit. I’ve also known people in long-term recovery who initially needed to attend 12 Step meetings, but said that at some point they internalized the principals of the program and no longer had to attend meetings. Nobody has the authority to tell you that you’ll have to go to meetings for the rest of your life, in order to stay in recovery. But if you do, that’s not  a sign of weakness. It’s just part of your personal recovery plan.

Substance abuse occurs along a spectrum, and people’s definitions of abuse may differ; but being addicted generally means not being able to control your drug use once you start using mind altering chemicals. Within the recovery community it’s generally believed that if you’re addicted to whatever “drug of choice,” you also have to abstain from all other chemical highs in order to keep from relapsing on your favorite drug. I’ve known a number of chronic substance abusers who believed that substituting alcohol and/or marijuana would help them to keep from relapsing on “hard drugs” like meth or heroin or crack. (Alcohol is a hard drug, but it’s legal.) I’ve never seen it work and have concluded that you can’t solve a chemical dependency problem with chemicals.

The concept of addiction has broadened, and now a lot of people believe that sex and gambling and other non-drug-related behaviors can be addictive. The “old school” definition of addiction was characterized by three clinical phenomena: tolerance, withdrawal and physiological cravings. Tolerance means that you have to increase your dose over time to get the high you used to get from a lower dose. Withdrawal means that when you abruptly stop using an addictive drug, your body goes through distinct physiological changes – ranging from unpleasant or painful to potentially fatal – for a period of time. Physiological cravings are like hunger. Your body is telling you it needs something, and a strung-out heroin addict craves a fix the same way a starving man craves food.

Chronic marijuana use can lead to psychological dependence, but cannabis doesn’t meet the old school definition of addictive. Similarly, sex and gambling aren’t characterized by tolerance, withdrawal and physiological cravings. However, in many respects compulsive sexual activity and compulsive gambling resemble addiction, because they involve loss of control over certain activities, and some of the same neurotransmitters are involved. Like drugs, sex and gambling can predictably stimulate the brain’s “pleasure centers.” Psychological learning theory provides a good framework for understanding such compulsive activities, and I’ll elaborate in a future post.

Denial has killed millions of addicts. If drug abuse or compulsive behavior is hurting you or others, or you’re losing control of some important aspect of your life, find someone reliable and get real with them. Explore options and work on developing your personal recovery plan. Even if your plan doesn’t include active participation in a 12 Step program, it may borrow from the 12 Steps or Rational Recovery or other models. And you can’t stay in recovery without help from supportive people who understand you and don’t judge you. You need someone to share your thoughts and feelings with in recovery. We come to know ourselves better by letting others know us better, warts and all.