Managing Stress in Recovery

© marigranula | 123rf.com

© marigranula | 123rf.com

People in recovery are particularly vulnerable to stress. In Using Stress Management in Relapse Prevention Therapy (RPT), Terence Gorski pointed out that effective stress management was not only critical for avoiding a resumption of drinking or drugging in the first two weeks of abstinence, but it was also important for individuals in recovery “to learn how to recognize their stress levels and use immediate relaxation techniques to lower their stress.”  Regular, heavy use of alcohol and drugs will likely have toxic effects on the brain, and in turn will create symptoms that cause stress and interfere with effective stress management.

The role of stress sensitivity in addiction and relapse has received a well-deserved amount of attention in the professional literature. Another article here, “Stress Sensitivity in Addiction and Relapse,” looked at some of the findings of Mary Jeanne Kreek and George Koob on the topic. A third researcher who has done extensive research into stress and its influence on addiction is Rajita Sinha of the Yale School of Medicine. You can watch her lecture on: “Clinical Neurobiology of Stress and Addiction” on YouTube. You can also read a couple of her published articles, “New Findings on Biological Factors Predicting Addiction Relapse Vulnerability” and  “Chronic Stress, Drug Use, and Vulnerability to Addiction.”

In her “New Findings” article, Sinha presented data that demonstrated high drug cravings are related to both stress and drug cues in addicted individuals when they are compared to social drinkers. The research findings indicate: “that alterations in physiological stress responses are associated with high levels of stress-induced and cue-induced craving and distress states.” These alterations were marked by increased emotional stress, heightened craving in abstinent addicted individuals compared to social drinkers. Refer to Figure 2 in the article for a chart comparing the findings. Sinha also noted a series of stressors that are associated with addiction vulnerability—the risk of developing an addiction and the risk of relapse. Table 1 in her article summarizes the types of life events chronic stressors, etc. associated with addiction risk.

The types of adverse events significantly associated with addiction vulnerability were parental divorce or conflict, abandonment, forced to live apart from parents, loss of child by death or removal, unfaithfulness of significant other, loss of home to natural disaster, death of a close one, emotional abuse or neglect, sexual abuse, rape, physical abuse by parent, caretaker, family member, spouse, or significant other, victim of gun shooting or other violent acts, and observing violent victimization. These represent highly stressful and emotionally distressing events, which are typically uncontrollable and unpredictable in nature.

An early recovery issue common to both alcoholics and addicts is Post Acute Withdrawal (PAW). Gorski described PAW as “a bio-psychosocial syndrome that results from the combination of brain dysfunction caused by alcohol and drug use and the stress of coping with life without drugs or alcohol.” PAW disrupts the person’s ability to think clearly, to manage feelings and emotions, as well as to manage stress and self-regulate behavior.

Stress negatively effects brain function in early recovery. As the level of stress goes up, the severity of PAW symptoms increase. And as PAW symptoms get worse, individuals in recovery begin to lose their ability to effectively manage stress. The result is that they are in regular, constant states of high stress that bounces them back-and-forth between emotional numbness and emotional overreaction. High stress then becomes linked with cravings because during active drug use, the addict or alcoholic self-medicates with alcohol or drugs. “So one of the first steps in managing craving is to learn how to relax and lower stress without using alcohol or other drugs.”

The severity of PAW depends upon the severity of brain dysfunction caused by addiction and the amount of stress experienced in recovery. It’s not practical to remove yourself from all stressful situations,  so you need to develop ways to handle stress when it occurs. “It is not the situation that causes stress; it is your reaction to the situation.” Gorski then proceeds to describe a simple tool to monitor stress called the Stress Thermometer. Then he described an immediate relaxation technique called Relaxed Breathing to help you noticeably lower your stress in two or three minutes.

In his Relapse Prevention Therapy Workbook, Gorski said the goal is to keep your stress level in the functional range of the Stress Thermometer, between 4 and 6. If your stress drops below a 4, your mind will wander and you won’t be able to stay focused. If your stress level gets to above 6, you will begin to lose focus; then become driven and defensive. “The higher your stress level goes the more problems you will experience.” If your stress level reaches 9 or higher, you may start to use automatic survival defenses such as fight (getting angry, belligerent, or violent), flight (mentally checking out or leaving; not returning), or freezing (becoming compliant; becoming immobilized in whatever situation you find yourself).

Look at his article linked above for a detailed description of the Stress Thermometer. You can also find a graphic rendition of it in another one of his articles, “Stress Self-Monitoring and Relapse.” Gorski commented that when measuring your personal stress, you’ll notice that it is a combination of three things: the intensity of the stressor, your ability to cope with or handle the stressor and your level of awareness while you are experiencing the stress. He added that it was possible to score yourself very low on the stress thermometer even when your stress is quite high.

This happens because you are distracted and involved in something else, like managing the crisis causing your stress. Or because your stress is so high, you are emotionally numb and don’t realize what you are feeling. Another possibility is that you have lived with such high stress for such a long time that you consider it normal. A final possibility is that you have trained yourself to ignore your stress.

The first step in learning to manage your stress is to learn how to recognize and evaluate your stress level through body awareness. Then you learn how to quickly get back to a low stress level by using the Relaxed Breathing Technique. Again, turn to Terry’s description monitoring your stress through body awareness and reducing your stress through Relaxed Breathing in the above linked article.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s Blog, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.


Stress Sensitivity in Addiction and Relapse

© felix Pergande |123rf.com

© felix Pergande |123rf.com

For addicts and alcoholics their drug of choice is often THE method of stress management. Having a difficult time with a rebellious teenager? Drink. Got in a car accident in the midst of a stressful week? Get high. Fired after telling off a demanding boss? Drink. Sometimes the stressor can be as minor as working long hours. Situations like these are commonly heard in recovery. All of the stressors leading to active drinking or drug use described here have happened in real life. Could it be that addicts and alcoholics are more sensitive to stress?

Researchers Mary Jeanne Kreek and George Koob have been systematically collecting evidence on the role of stress in drug abuse and relapse for a number of years. In a research paper published in 1998, Drs. Kreek and Koob noted that a variety of imaging techniques have demonstrated that chronic drug abuse causes alterations in specific aspects of brain function that are persistent over time, and in some cases, may be permanent. These abnormalities could contribute to adverse symptoms that are ultimately relieved by further drug use. In behavioral modification terms, this is known as the process of negative reinforcement—a behavior (drug use) is strengthened by removing or stopping an aversive stimulus (stress).

Initially drug use is motivated by the user’s high, but continued use leads to tolerance—adaptation to the presence of the drug. So another source of reinforcement, “the negative reinforcement associated with relieving negative affective and physical consequences of drug termination” becomes part of the cycle of drug use and addiction. The stress of living life on life’s terms could be magnified by brain abnormalities that result from a person’s increased difficulty coping with stressful situations.

Kreek and Koob have demonstrated in their research that the nervous system of an addict is hypersensitive to chemically induced stress. Steven Stocker, writing for NIDA, the National Institute on Drug Abuse, said Kreek’s research has suggested this hypersensitivity could exist before any initial drug use; or it could result from the effects of chronic drug use of the brain; or it could be due to a combination of both factors.

Stocker described how the stress hormone cycle of the body works. Initially, the body reacts to stress by secreting hormones into the blood and neurotransmitters in the brain. Some of the neurotransmitters seem to be either similar to the hormones, but acting in a different capacity in the brain. As the hormones travel through the body, they alter the metabolism of food so that the brain and muscles have enough metabolic fuel for potential activities such as fight of flight in response to the perceived source of stress. Within the brain, “the neurotransmitters trigger emotions, such as aggression or anxiety, that prompt the person to undertake those activities.”

Normally, stress hormones are released in small amounts throughout the day. But when the body is under stress, the level of these hormones increases dramatically. This process begins with the release of a hormone called corticotropin-releasing factor (CRF) by a part of the brain called the hypothalamus into the blood. CRF travels to the pituitary gland and stimulates the release of another hormone called adrenocorticotropin (ACTH). Then ACTH in turn triggers the release of cortisol and other hormones from the adrenal glands.

Cortisol travels throughout the body, helping it to cope with stress. If the stressor is mild, when the cortisol reaches the brain and pituitary gland it inhibits the further release of CRF and ACTH, which return to their normal levels. But if the stressor is intense, signals in the brain for more CRF release outweigh the inhibitory signal from cortisol, and the stress hormone cycle continues.

You can see a graphic depiction of this stress hormone cycle in the NIDA note written by Stocker. The stress hormone cycle is controlled by a number of other chemicals in addition to CRF and ACTH, among which are neurotransmitters called opioid peptides. These opioid peptides are chemically similar to drugs like heroin and morphine. “Dr. Kreek has found evidence that opioid peptides also may inhibit the release of CRF and other stress-related neurotransmitters in the brain, thereby inhibiting stressful emotions.”

It appears that heroin and morphine will inhibit the stress hormone cycle and thus the release of stress-related neurotransmitters just as the natural opioid peptides do. So when someone uses heroin or morphine (I’d think this could be applied to all or most natural or synthetic opioids), the drugs increase the inhibition of the stress cycle already being provided by the opioid peptides and help with the regulation of an emotional response to stress. Dr. Kreek suggested that individual addicts and alcoholics having difficulty coping with stressful emotions could find that using their drug of choice helps to blunt those emotions, which “could be a major factor in their continued use of these drugs.”

As the effects of opioid drugs wear off, the addict goes into withdrawal. During withdrawal, the level of stress hormones rises in the blood, and stress-related neurotransmitters are released into the brain. Unpleasant emotions are triggered by these chemicals, driving the addict to take more opiates. The short half-life for most opioids (like heroin) lasts only 4 to 6 hours. So opiate addicts can cycle through withdrawal three or four times a day. The constant switching of the stress systems of the body off and on heightens the stress sensitivity of the person. “The result is that these stress chemicals are on a sort of hair-trigger release. They surge at the slightest provocation.”

It seems a similar process could explain what happens to addicts who resume active drug use after a period of extended abstinence. If chronic drug abuse leads to long term or permanent dysregulation of the stress hormone cycle, then stressful periods of life have the potential to trigger dysregulation of the cycle and possibly lead to a resumption of drug use as a way to manage the stress.

I know someone who has said they feel the most “normal” in life when they are high. Chronic dysfunction and stress in their life seems to have repeatedly led them back to active drug use even after periods of extended abstinence. They’ve noticed that when they are happy (times of low stress), they feels the closest to “normal” without the influence of drugs.

In a 2007 review article, Koob and Kreek said relapse to drug addiction days, months, or years after the last use of a drug may be due in part to subtle factors that result from long-term changes or abnormalities in the brain after long-term exposure to a drug of abuse. “These changes may contribute to a general, ill-defined feeling of dysphoria, anxiety, or abnormality and also could be considered a form of protracted abstinence.” Genetic factors and early environmental factors could also contribute to some individuals being more vulnerable to acquiring drug addiction and relapse to drug use after achieving abstinence.

This increased vulnerability to stress, whether it is temporary or permanent, does not make a person “constitutionally incapable” of establishing and maintaining abstinence. But it does point to a serious relapse trigger and relapse warning sign that many addicts and alcoholics will have to actively monitor and manage—their stress levels. An excellent place to get help in managing stress if you are a recovering addict or alcoholic is a blog by Terence Gorski: “Using Stress Management in Relapse Prevention.”  “Managing Stress in Recovery” will describe my musings on Gorski’s model of stress management when I post the article here sometime in the next couple of weeks.