Family Addiction – A Tough Nut to Crack

Guest author – Lisa Fredriksen from breakingthecycles.com:

I was 49 years old when one of my loved ones entered a residential alcohol treatment program and I found myself plunged into a whole other world – a world that included terms and concepts like codependency, adult children of alcoholics, 12-step programs, co-addictions, dual diagnosis and the role a family member has in the denial that protects a loved one’s drinking. The family addiction world was a world I found confusing and overwhelming as I learned just how many of my loved ones had an alcohol problem and what that had meant in my life.

True to my nature, I began my quest for deeper understanding in the same way I’d approached my six other published nonfiction books and numerous articles. I immersed myself in research, intent on learning as much as I could about the subject – in this case alcoholism and treatment programs – and then all of the other issues that emerged as I tried to understand why a loved one drinks too much and why someone like myself puts up with it for so long. I started attending Al- Anon meetings, doubled my individual therapy sessions and attended family-help group sessions at the treatment center, as well.

codependencyMy book, If You Loved Me, You’d Stop! What You Really Need To Know When A Loved One Drinks Too Much, and my blog, www.breakingthecycles.com, are the culmination and continuation of my discoveries. I hope that by sharing what I have learned, others – whether a parent, friend, sibling, spouse or child – will find the tools they need to live their lives.

I share this information because I wish I had known it, that it had been openly and freely talked about, long before I’d spent decades grappling with my various loved ones’ drinking. I try keep my shares (including my book) very short and simple. I know, myself, that when I first started looking for information, I was frustrated with the variety and depth of the books and research on what I was striving to understand – excessive drinking (alcohol abuse), alcoholism, co-addictions, adult children of alcoholics, codependency, dual diagnosis, how to help the alcoholic stop drinking, how to heal the family, how to talk to your children, family in recovery – and the list went on and on.

For now, I’d like to leave you with my top key discoveries:

1. Alcoholism is one of the diseases of addiction – a chronic relapsing disease. Check out www.hbo.com/addiction for a wealth of information. It’s produced by HBO, NIAAA, NIDA and The Robert Wood Johnson Foundation.
2. To begin treating addiction, the substance of abuse must be stopped in its entirety in order to allow the structural and chemical changes in the brain to change and recover.

These first two discoveries freed me from my continued efforts to try control my loved ones’ drinking and thus stop my nagging, raging, deal-making and shaming – the behaviors I’d been using in order to “help” them stop [hence the title of my book, If You Loved Me, You’d Stop!…]. They also allowed me to respect the person but hate the disease and know that until that person came to grips with the power of addiction, they would/will continue to drink, no matter how hard they try to control their drinking.

3. Other family members need help, too, in order to change some of the behaviors they’ve adopted in order to survive but that are actually getting in the way of their living healthy, happy, fulfilling lives, regardless of whether their loved one stops drinking or not.
4. Alcoholism is a young person’s disease. Due to brain imaging technologies of the past fifteen years or so, neuroscientists have been studying how the brain develops. According to NIAAA, half of alcoholics were addicted by age 21 and two-thirds were addicted by age 25. Click here to better understand why.
5. Having a dual diagnoses (a mental illness, such as depression, bipolar, ADHD or PTSD) and an addiction (to alcohol or drugs) is common. Click here for information.

The cost of quitting alcohol and drug addiction – treatment tips for addicts

Many users are discouraged by the cost of drug and alcohol addiction treatment programs. The treatment programs that advertise, which are normally the only ones most people hear about (you know them: Passages, Promises, Betty Ford and more) may offer services that are worthwhile, but they may not and consumers have no way to evaluate this as they’re asked to spend tens-of-thousands of dollars per month (as much as $80,000 in some cases). Unfortunately, inpatient treatment is the only form of treatment most people have ever heard of and even though research does show that individuals can get a greater benefit from inpatient treatment, it usually makes a significant difference only for the most difficult addicts to treat, and I mean difficult – injecting drug users, those with numerous previous attempts, multiple time felons, and such. Still, when families contact me, it seems that they overwhelmingly believe that residential is the only way – But they’re wrong.

Many health insurance companies will help cover certain outpatient treatment programs (Like Matrix; Kaiser Permanente has their own) that can  help put the vast majority of those who are seeking addiction treatment on the right track. Many outpatient programs offer great bang-for-your-buck, delivering intensive treatment protocols that are evidence based and can help most addicts get better at a far reduced cost of only a few thousand dollars a month. Anything is better than doing nothing, and taking the first step is always the hardest move. Fact is, many insurance companies will not pay for inpatient or residential addiction treatment until outpatient options have been tried and failed. If clients feel they need the added security of a safe, drug free, residence they can combine outpatient treatment with a good sober living facility (but DO NOT pursue this option for patients with serious mental health issues until you’ve seriously consulted with professionals).

If you’re thinking about quitting, simply making your way to a 12-step meeting in your area can end up opening a whole new world of possibilities, but if that doesn’t work know that there are many more options. If you’re wondering about specific options for yourself or someone you love, feel free to contact me and I’ll do my best to help guide you. If you’re looking for a more anonymous, automatic way of doing some of this searching, make sure to check out our Rehab-Finder, it should help guide you in the right direction. We’re currently going through a real verification process to do some of the quality-assurance legwork for you!

Calling bullshit on addiction treatment bullies

About three years ago, I was attending a national conference on public health (American Public Health Association) and presenting my posters on the relationship between drug use and violence, and sexually transmitted infections and injecting drugs. As I walked the aisles I ran into a woman who runs a Florida addiction “treatment” facility. We talked for a bit about my work, her facility, and then we shared some of our personal stories. Mine included meth addiction, jail, recovery, and now graduate school studying addictions. Everything was great until I mentioned that I now drink alcohol socially… “We’ll save a seat for you” she told me as she handed me her business card. Idiot.

Recovery bullies and addiction treatment

Dr. Adi Jaffe Lecturing in Los AngelesAs soon as my version of recovery from addiction didn’t match her expectations, it was an immediate failure. Forget the 6 years I’d spent free from crystal meth use, the excellent graduate school career that was producing real results I was there to present. Forget the fact that my family, my bosses, and my girlfriend at the time thought I was doing amazingly well – As far as this woman was concerned it was her way, or her way. Well I call bullshit on that thinking once and for all.

Unfortunately for her, the research evidence, as well as the actual human evidence that I’ve seen, shows that recovery from addiction comes in many colors and flavors, like pretty much everything else in life. We’ve covered research on all about addiction before showing that the best evidence to date actually calls into question the idea that relapse is the necessary disaster so many paint it as. The fact that the majority of those who meet criteria for drug dependence at some point in their life actually recover on their won is also there, and although this does nothing to reduce the impact of addiction on all those who have an incredibly difficult time quitting, it’s there and can’t be ignored. Drug dependence is almost certainly not a one size problem and the solution is probably far from a one-size-fits-all, no matter how much you like your own solution.

So there’s cognitive behavioral therapy, peer support solutions (like SMART Recovery, Rational Recovery, Life Ring, 12 Step groups like Alcoholics Anonymous, and more), medication-supported recovery (like Suboxone, Methadone, Vivitrol and more), Motivational interviewing and other Motivational Enhancement techniques, as well as a whole host of psychotheraputic approaches that are more eclectic. No research we have to date indicates that any of these approaches is necessarily more effective than others, which means that they are all essentially equally effective. We’ve already talked about some combinations that work very well together, like PHP programs for physicians, but there is absolutely nothing to indicate that the 12-steps (for examples) are somehow superior to CBT, or Rational Recovery, when it comes to treating addiction.

If you get better, you’re a success in my book

When it comes down to it, whether this Florida 12-stepper likes it or not, I am still a social drinker and I still don’t believe that this nullifies any of my other achievements or my successful recovery. More importantly, it doesn’t nullify the success of millions of others, no matter how poorly it fits with some people’s notions. When a life gets overrun by drug use or another addiction, a successful outcome to me means recapturing a functional life that is no longer dictated by the pursuit of that addictive behavior. Anything more or less is a personal preference sort of thing. The problem with these idiots who will absolutely ignore success because it doesn’t conform to their expectations is that they drive people out of treatment and away from success and that is not okay. I’ll continue to call them out for their narrow mindedness and hopefully eventually, their voice will be far from the dominant one.

One day at a time, but not forever!!!

If you’ve ever gone to a 12-step meeting, you’ve heard the phrase “one day at a time,” so often as to make it a mantra. Personally, it always left me wanting more.

Is “one day at a time” enough?!

I think the notion is a correct one… when it comes to early recovery. However, once the initial excitement of staying sober has worn off and life without the crutch of drugs, alcohol, or any other addiction, begins, I believe that there is great value in planning.

Thinking ahead is exactly the sort of thing that addicts don’t do well. As far as I know, there’s only one way to improve a lacking skill – practice.

If a recovering addict truly takes things “one day at a time,” never making plans that take the not-so-near-future into account, where does that leave him except for being sober for one more day? As far as I’m concerned, that’s simply not enough.

I had a lot of learning to do when it came to living a normal life after I cleaned up. I barely knew how to function in the simplest ways without the crutch I’d become so comfortable with. I’ll never forget the single sentence lesson my dad gave me over the phone regarding handling my mail.

“Most people pick up their mail, open it up on the spot, throw away what they don’t need, and handle the rest immediately” he told me.

To me, that was more than a foreign concept; it just sounded strange. You see, I would let mail pile up for weeks, eventually throwing it away when it simply seemed overwhelming. The notion of taking care of my mail, or anything else for that matter, on the spot, sounded so simple as to be impossible. But guess what – it works!!!

Fortunately for me, by the time my dad had shared those pearls of wisdom, I’d been clean for six months and ready to put the lesson into action.

Making plans the right way

Recently, my fiance introduced me to an exercise that requires you to write down your plans for next week, next month, next year, and five years from now. I liked it because it made me think concretely about where it is I’m going in life both in the very short, and relatively long, future. By writing down how I saw different aspects of my life play out in the next five years, I got to think about them more directly than I ever had before.

I’ve adapted the exercise for addicts in recovery. I think that you should try it as early as you feel comfortable with it. The trick early on is to just complete it. Once the first draft is finished, you should go back and change it every once in a while.

Given how quickly things change in early recovery, the second draft should be completed after a week. Since you’ll be getting better, and more realistic, every time, the third draft should probably be done about a month later. From that point on, further edits can be done whenever life calls for it.

I think you’ll find that simply going through the exercise will tell you a lot about where you are in your recovery.

The exercise itself

The first thing you’ll need is a piece of paper. Divide the paper (you can use one side or both depending on how much you like to write) into five sections and title them as follows: “Tomorrow”, “Next week”, “Next month”, “Next year”, and “Five years from now.”

Under each one of the headings, answer the following questions for each of the time periods. Be as specific as possible. Feel free to add, or replace, any of these questions with ones you see as more relevant to your life.

  1. Where will you be living?
  2. What will your job be?
  3. Will you be in a relationship? If so, with who?
  4. How much money will you be making?
  5. What car (or other mode of transportation) will you have?
  6. List your five most important relationships – Describe the quality of each.
  7. What special trips, events, or occasions, will you be taking part in or planning?

That’s it. You’re done. Take a deep breath and read over the list.

Though it seems simple enough, you’ll see that answering these questions can be quite difficult at first. This is especially true the more specific you try to be (answers like “I’ll be living in a 3 bedroom house in Mar Vista with hardwood floors and a home office that faces east” might take some time for some of you).

Again, the point is simply to complete the exercise that first time. I promise you that it gets easier with time. Since you’ll be repeating it relatively often initially, you’ll be able to adjust your plans according to the changing circumstances of your life. Feel free to go back and redo the list any time.

Having goals, both short and long term ones, will help focus your mind. It will also plant the seed of the direction in which you want to take your life. Without this direction, things can seem chaotic, especially when one has recently given up their best friend (cocaine, marijuana, porn, and chocolate fudge ice-cream can easily be thought of as best friends when one is in the throws of addiction or recently out of it).

One day at a time is great, but when you want more out of life, planning is the only way to go.

Replacement therapy as addiction treatment – Why it makes sense

I’m a little sick and tired of hearing discussions that continuously talk about opiate replacement therapy (think methadone, suboxone, subutex) as not being true addiction treatment because those individuals are still using a drug. While some recent advances will hopefully allow more and more people to achieve medication assisted recovery through antagonist therapies (like naltrexone and its once a month wonder Vivitrol), agonist therpy, or replacement therapy, has been working wonders with heroin addicts and other opiate addicts who have tried quitting multiple times and have failed only to succeed wonderfully using these medications.

What replacement therapy as addiction treatment looks like

A recent comment on this blog compared using suboxone to get off heroin to drinking beer while trying to quit liquor. Let’s assume for a second that this is a worthy comparison (although buprenorphine is a partial agonist for opiate receptors and not a full agonist), the one thing it’s missing is context, so let’s give it some: take Paul, a daily drinker who puts down a fifth of Vodka or more on a daily basis. He’s been doing this for years and the physical toll has been immense – His liver is failing along with his health and his pasty white skin looks good with his shuffling and  Wernicke-Korsakoff syndrome due to improper thiamin (vitamin B) intake. He hasn’t been able to hold down a job for years due to the shaking and blacking out not to mention the need to always have alcohol around for when the withdrawal starts. He’s tried to quit drinking several times but the DTs, shakes, and generally horrible feeling almost always makes him go back to drinking soon after and even the few attempts at medically supervised addiction treatment failed when he relapsed within weeks of leaving treatment. One day, someone promises Paul a solution to all his problems and gives him a magical beer that he has to drink in the morning when he wakes up. Not believeing it, but figuring “what the heck,” Paul keeps drinking all that day but then remembers to take that pill early the next morning… He still drinks that first day, though not as much because he doesn’t feel like he needs it, and day by day he begins to consume less liquor and finds himself having that one beer in the morning and sometimes another in the middle of the day. Within a few weeks he’s drinking no more liquor and all he has are those two beers every day. He feels great, has started getting some color back and is looking healthier than ever. He’s even managed to get a little job, though he’s not overcommitting yet not fully believing that this will really last. His memory returns fully and he feels like he did 20 years earlier, hardly believing he’s given so much up for that liquor he doesn’t really want anymore. A year later Pual feels like a new man and never looks back.

Keeping our options – Replacement therapy included

As far as I’m concerned that story, which we hear over and over with buprenorphine-using ex heroin addicts, is not only worth keeping patients medicated forever but makes the notion of not offering replacement therapy when it is appropriate simply crazy. I didn’t even get into the fact that reductions of this kind in heroin use bring about other great health benefits like lower injection rates that bring down HIV/AIDS and hepatitis C infections not to mention all the other complications that injecting is good for.

Like we’ve said many times here on A3, there is no single addiction treatment that will work for everyone but it is absolutely crazy to dismiss therapies that have been repeatedly shown to work (yes, including AA and other 12-step based approaches) and make lives endlessly better. We have a whole box full of addiction treatment tools, let’s not start trying to hammer with a flathead screwdriver please…

People, places, and things – How important are drug-related triggers for addiction relapse?

In cognitive behavioral therapy they’re a big part of the “Five W’s” = When, Where, Why, With, and What. In the various 12-step programs they’re simply referred to as “People, places, and things.” But no matter how you refer to them, drug-associated cues, or “triggers” as they are more commonly known, obviously play a big role in reminding addicted individuals about their drug-seeking behavior, and they are often enough to restart old behavior, even among those who have been abstinent for a while and especially when unprepared for their effect.

Different triggers to reactivate old behavior

Research on relapse (what researchers call reinstatement) has long shown that there are a number of things that can return a person, or an animal, to drug seeking after they have been abstinent for a while. Stress, small drug doses, and the presentation of triggers are all very capable of doing this, even after months of abstinence and likely even years. It’s probably not surprising that giving drugs to an abstinent person can make them want the drug again. In fact, I would venture to guess that most readers believe that this is the most powerful way to induce a relapse (assuming the initial exposure was out of a person’s control and doesn’t count).

Well, recent research suggests that in actuality, triggers, or those people, places, and things, might be more powerful or at least longer lasting relapse risks than even taking drugs!

Triggers, not drugs, are shown to be longest lasting relapse risk

Researchers in Japan trained mice to press a lever for meth, getting them to poke their nose into a hole 60 times for a total of 30 meth administration per three hour session. Every time they poked their nose in the right hole they got a shot of meth and a little light above their nose-poke hole went on (this will become the trigger in the end). Once they were doing this reliably the researchers took away the meth and the animals learned, within 10-20 days, that pressing the lever no longer got them a drug and reduced their number of presses to less than 15 presses per session.

After all this the researchers gave the mice an injection of meth 30 minutes before putting them back in the box – leading the mice to start pressing again for the drug even though in the previous session they has pretty much stopped pressing knowing that no drug was coming. Obviously, the drug injection caused the mice to relapse back into their drug seeking. But, as you can see from the figure below (on the left side, the right side shows that the mice didn’t poke their nose into a hole that did nothing as a control), this little trick only worked once, and the next time the mice were given a shot of meth before being put in the box (after once again being taken through extinction training teaching them that pressing the lever did nothing), they didn’t press the lever any more and just around not doing much.

For the following part of the study the researchers once again took the animals through extinction training (and once again the mice stopped pressing the lever for meth) and then in a following session reintroduced the little light that used to go on every time the mice originally got meth. Just like they did with the meth the animals immediately went back to pressing the lever like crazy, hoping that now that the light was back, so was their meth. Just like with the drug relapse experiment above, the researchers repeated this whole process over two months later, only this time, the little light managed to re-trigger the lever pressing again, unlike the one-trick-pony meth. Seeing this, the researchers went for broke and tried another run of this with the same animals, now following up five months after the last time the animals received meth when they pressed the lever. Again the little light got the animals to increase their pressing, only this time it was a little less impressive than the first two tries (but still significantly higher). All in all, the little light managed to restart the lever pressing by the mice three times and a full five month after the meth-relapse experiment had failed!!!

Conclusion, thoughts, and implications about triggers, relapse, and addiction

In a completely different article I’d written that researchers found a number of different patterns of relapse among alcoholics who went to rehab and that in fact, the vast majority of those who did relapse never went back to the kind of heavy drinking that characterized their earlier problem (see here for One is too many, a thousand not enough). While this research touches on a different aspect of relapse, it once again challenges our thinking about the crucial factors in relapse prevention among addicts. Everyone knows that triggers are important, but the fact that they are at least as powerful and apparently longer lasting dangers than even being re-exposed to the addictive drug is a novel one. Still, this isn’t very surprising given the very long-lasting impact of drugs of abuse (especially stimulants like crystal meth) on learning mechanisms. In my opinion, and based on my own experience, those changes are essentially permanent and the only thing that makes an ex-user less likely to run back to pressing that drug lever when being re-triggered 10 years later is the life they’ve built, the experience they have, and the training they’ve undergone in reacting to those triggers. As you can see from the graph above, if a person runs back to the drugs and actually starts using again on that first, second, or third exposure to a trigger they are likely to start the whole cycle again, possibly making it ever more difficult to escape the next time.

Obviously preventing trigger-induced relapse should be a major strategy of addiction treatment and indeed, from CBT relapse prevention strategies to groundbreaking medications that have been shown to be effective for relapse rate reduction (like Vivitrol, Buprenorphine, Bupropion, and more), there is quite a bit of effort going exactly that way.

Citation:

Yijin Yan, Kiyofumi Yamada, Atsumi Nitta  and Toshitaka Nabeshima (2007). Transient drug-primed but persistent cue-induced reinstatement of extinguished methamphetamine-seeking behavior in mice. Behavioral Brain Research, 177, 261-268.

Is anonymity the final shame frontier in addiction?

I’m a drug addict and a sex addict, and as far as I’m concerned, staying anonymous let’s me remain buried in shame, and a double life, that keeps me always one step ahead of those close to me. Did I say too much? Did I give away my secrets? None of those  questions matter when everyone knows everything there is to know about you. For a disease couched in anxiety, obsessions, and compulsive behavior, there’s very little that can be more triggering.

The difficulty of confessing addiction

Obviously I’m not naive to the consequences of confessing to others, and I’ve had a few very uncomfortable conversations that ended in people losing my number or superiors telling me they didn’t need to know. When it comes to the former, it’s their choice, and it might be a wise one, but having those who stay close to me know my truths keeps me safe by making me accountable and protects others from being hurt. And I can hurt with the best of them. Maybe that’s why when it comes to physician treated addicted physicians, there are no secrets, no anonymity, the family and employers are made part of the process. Some notable addiction providers (like Journey Healing Centers and others) have programs that explicitly involve the family in the treatment process as well. Getting the secrets out works to break away from the shame.

We’re only as sick as our secrets, even together

On an organizational level, I understand the need for anonymity to avoid having any specific member represent the group. But that logic only holds when everyone is told to remain anonymous. Otherwise, the entire group represents itself, which is, if nothing else, truthful. If one person slips, relapses, or goes into a homicidal rampage, it only makes the rest of us look bad if no one knows that millions others are “the rest of us.”

Over and over I hear people talk about the secret of their addiction and the lies they have to tell to cover up their shameful acts. Unfortunately, that only contributes to the stigma of addicts and makes it all the more difficult  to get some perspective on the actual problem: We do things we don’t want to over and over regardless of how much they hurt us or those around us

If you’ve read anything on this site, you know that I believe in many factors that contribute to addiction, including biology, environment, experience, and their interactions. Still, when it comes down to it, the misunderstanding of addiction is often our number one problem. And anonymity does nothing to reduce that misunderstanding.

How we can make a difference

Media portrayals only exacerbate the problem as they show us stories of addicted celebrities who are struggling but then leave the story behind before any recovery occurs. That way we only get to see the carnage but have to look pretty hard to see anything more.

But we can change all this with a small, courageous, action. We can let those around us know that we’re addicts, that we’re doing our best to stop our compulsive behavior and that we want them to hold us accountable. If we slip, we can get back up because we don’t compound the shame of a relapse with lies we tell, and those around us know that even a relapse can be overcome because they’ve seen those examples over and over in all the other “confessed” addicts around.

It’s time to leave the addiction “closet” and start living. We may not be able to change who we are easily, but we can change the way we go about living and make it easier on ourselves and on others. By breaking our anonymity, we can help assuage our own shame and let everyone know that addiction is everywhere and that it can be successfully overcome.

Just a thought…