03/2/21

Recognizing and Caring for PAWS

I’ve been using Terence Gorski’s material on relapse and recovery for most of my career as an addiction counselor. One of the timeless and helpful topics is his discussion of PAWS—post-acute withdrawal syndrome. He talked about PAWS within Staying Sober, a book he co-authored with Merlene Miller in 1986. There is a briefer discussion of his PAW symptoms in a booklet, The Relapse Recovery Grid embedded in his presentation of the Phases of Relapse. I even found something on Facebook, on April 5, 2012: “Post-Acute Withdrawal Syndrome – What You Need to Know.” Let’s see how Gorski’s description of PAWS holds up after 35 years.

According to Gorski and Miller, PAWS is “a bio-psycho-social syndrome. … It results from the combination of damage to the nervous system caused by alcohol or drugs and the psychosocial stress of coping with life without drugs or alcohol.” They grouped PAW symptoms into six types that continue to appear in other presentations of PAWS, a few of which we will look at later. Their six types of PAW are: an inability to think clearly, problems with memory, emotions that range from overreaction to numbness, sleep-related problems, physical coordination problems and stress sensitivity.

Gorski said difficulty thinking clearly was the most prominent symptom, where addicts who just completed acute withdrawal (detox) regularly have problems with simple problem-solving and decision-making. At this time in recovery, individuals often have difficulty with abstract concepts and problems concentrating. They also have rigid and/or repetitive thinking patterns. Memory problems are particularly frustrating in early recovery, as they are evident when someone is trying to learn new skills and behaviors to support their abstinence.

Stress, the sixth symptom, seems to worsen memory problems. In The Relapse Recovery Grid, Gorski said problems managing stress are two-fold. First, there is brain dysfunction from long-term alcohol or drug poisoning. Second, as the brain becomes overloaded, it shuts down temporarily. The first evidence of this is seen in emotional numbness.

When emotionally numb, recovering people cannot recognize the minor signs of daily stress. When the stress does break through into consciousness, they tend to overreact. Stress sensitivity causes them to amplify, magnify and intensify whatever feelings they are experiencing. When they do recognize stress, they are not able to relax. They get so tense that they are not in control of themselves. Sometimes the stress is so severe they can’t function normally.

Although physically stable enough to be free from the medical supervision of detox, individuals may have continued physical symptoms of withdrawal in sleep difficulties and physical coordination problems. Sleep problems can continue for months, sometimes longer. “The most important thing to understand about PAWS is that each person must work through it in their own time. Nervous system damage typically requires from six to twenty-four months for recovery.”

One of the advances over the past 30 some years with addiction research has been the growing understanding of the importance of neurotransmitters to developing and treating alcohol and drug dependence. Neurotransmitters are naturally occurring chemical substances that act like messengers, transmitting a message from one brain cell or neuron across a gap called a synapse to another brain cell. And when you do something to stimulate or alter one neurotransmitter, you usually disturb several others. The neurotransmitters important to addiction are: serotonin, norepinephrine, endorphin, endocannabinoids, (yes one for cannabis or marijuana) GABA, glutamate and dopamine. They are released from the sending neuron and absorbed by the receiving neuron. See the following graphic.

Naturally occurring opioids or endorphins reduce the amount of GABA released. Reducing GABA increases dopamine. Dopamine is the neurochemical that reinforces the brain’s desire to repeat a certain behavior by signaling we are about to have a pleasurable or meaningful event. It is also involved in energy and attention. When our dopamine levels are low, our energy levels are low.

Norepinephrine is responsible for attention and alertness. Glutamate is the main excitatory neurotransmitter. Serotonin has over 17 kinds of neuronal receptors and can both excite and calm us. Some serotonin receptors, when activated, increase anxiety and alertness, others are more calming. Endocannabinoids are involved in regulating mood, appetite, pain, cognition and emotions. Acetylcholine is another neurochemical that activates nicotinic receptors.

Cocaine, amphetamines and alcohol use reduces the uptake of dopamine (reinforces euphoric activity and tells us to remember it) and increases the amount of glutamate (major excitatory neurotransmitter). In high doses, they also inhibit monoamine oxydase A (MAO-A). In other words: “Large surges of dopamine ‘teach’ the brain to seek drugs at the expense of other, healthier goals and activities.” The person’s body has adjusted to having excessively high amounts of dopamine and glutamate and excessively low MAO-A. Our brain seeks to maintain a neurochemical balance, so it alters its structure as it seeks a balance or a “new normal.” Without the drug (cocaine, amphetamines, alcohol, etc.) anymore, it doesn’t have enough receptors for the glutamate and dopamine, and it has too many receptors for the monoamine oxydase.

Drugs and neurotransmitters activate the same receptors. The following table lists the neuronal receptors involved in drug actions.

Drug	Neuronal receptor
opioids	Endorphins (4 types)
cocaine	Dopamine (5 types)
Prozac, SSRIs	Serotonin (over 17 types)
nicotine	Acetylchloline (8 types)
cannabis	Endocannabinoids (2; CB1, CB2)
benzodiazepines	GABA? (5 types)
alcohol	GABA? (5 types)

In summary, with chronic substance use, the brain comes to rely on the drug to maintain the high degree of pleasure associated with the artificially elevated levels of neurotransmitters in its reward circuits. The brain then adapts to these high neurotransmitter levels by making new receptors or decreasing the production of neurotransmitters. This leads to depression or anxiety and cravings if drug use stops and neurotransmitter levels return to normal because there are now too many receptors for normal levels of neurotransmitters.

The Hazelden Betty Ford Foundation discussed Post-Acute Withdrawal Syndrome, describing it as the brain recalibrating itself after active addiction. “Think of the withdrawal syndrome as the brain’s way of correcting the chemical imbalances suffered during active addiction.” They suggested that PAWS occurred most commonly and intensely in people with alcohol and opioid addiction, as well as those with an addiction to benzodiazepines. They expanded Gorski’s six symptoms, adding urges and cravings, irritability or hostility, fatigue, anxiety or panic, depression and lack of initiative. Like Gorski, they suggested some coping strategies for getting through PAWS.

YouTube has multiple videos of Terence Gorski and his work on relapse prevention. Just go to YouTube and search for “Terence Gorski.” There are also multiple videos on PAWS. I will only note two, one from Vertava Health, that is about 12 ½ minutes long: “What Is Post-Acute Withdrawal Syndrome (PAWS)?”And one from AllCEUs Counseling Education by Dr. Dawn-Elise Snipes, that is 53 minutes long, “Post-Acute Withdrawal Syndrome (PAWS) in Addiction Recovery.”

In the Vertava video, it said PAWS symptoms often present themselves to people after they detox from drugs and alcohol. The symptoms are often hard to see, as they are more psychological than in acute withdrawal. “This is a pain that can’t be measured. But it can be just as big a risk for relapse.” In PAW, the brain is trying to re-acclimate to a normal state, “where it would have been prior to the drug or alcohol use.” One of the speakers essentially repeated Gorski’s six types in saying there can be an increased stress response, irritability, inability to control emotions, anxiety, depression, difficulty thinking clearly or an inability to focus, difficulty completing tasks that used to be easy to do, memory problems, sleeping problems.

PAWS, when you hear that anacronym, it sounds like something you want to play with. But in all actuality, it’s something that’s gonna play with you. It’s going to get you before you get it, if you are not aware of it. I mean it will come up behind you and attack you. You have no idea it’s coming.

AllCEUs is an online educational organization offering over 900 free videos on mental health and addiction issues on their YouTube channel. Professional counselors can view ALLCEU videos for various continuing education and online certification training needs. Dr. Snipes gives a thorough and understandable talk on PAWS in “Post-Acute Withdrawal (PAWS) in Addiction Recovery.” She said after people get past the acute withdrawal phase, they will have some days where they feel pretty good and some days when they can re-experience symptoms they felt during detox. They need to know this is normal. And they have to have a plan to deal with these symptoms because in the past they used as a result of experiencing them.

PAWS, post-acute withdrawal syndrome, is the result of changes in the brain after you stop using drugs and alcohol. As Judith Grisel put it in Never Enough, “The brain’s response to a drug is always to facilitate the opposite state; therefore, the only way for any regular user to feel normal is to take the drug.” Even prescription medications can produce PAWS. Acute withdrawal occurs up to about two weeks after the person stops using drugs or alcohol; Post-acute withdrawal symptoms begin after acute withdrawal and can occur for up to one, or sometimes two years, after stopping.

Terence Gorski indicated PAW symptoms peak in 3 to 6 months and then declined over time, with stress sometimes triggering a spurt of PAWS. PAWS is influenced by age, gender, the length of time a person was actively using, the amounts of drugs used, physical health and any underlying mental health symptoms. How old a person was when they began using is also important because they may have done some permanent damage to their brain. Their brains may not be able to fully return to pre-using levels of functioning.

Think of PAWS as the brain’s way of correcting the chemical imbalances suffered during active addiction. Your brain needs to slowly reorient itself. There are two possible outcomes here: either resume drug use to get the additional artificial boost to the neurotransmitters, or don’t use and wade through the time and process of the brain healing itself.

Post-Acute Withdrawal symptoms can include:

•emotional outbursts or numbness (lack of emotion)

•anxiety or irritability

•depression or anhedonia (inability to feel pleasure)

•difficulty dealing with stress

•fatigue

•problems sleeping

•memory problems making it hard to learn new things

•trouble thinking clearly, making decisions, or solving problems

•and balance, dizziness and physical coordination problems

The symptoms in bold are the six types of PAW symptoms identified by Terence Gorski over thirty years ago. People may have more depression and anhedonia (the inability to experience pleasure) if their drug of choice was a stimulant like cocaine or meth. If their drug of choice was a depressant (opioids, alcohol, benzodiazepines) they may have more anxiety and irritability. Stress and fatigue occur with low dopamine.

Sleeping problems can include strange dreams or changes in sleeping patterns. serotonin, one of the neurotransmitters that gets out of balance with chronic drug use, breaks down in the body to make melatonin, which helps us drift off and stay asleep. In early recovery you also need to reset your circadian rhythm, a natural, internal process that regulates the sleep-wake cycle. Up-and-down serotonin levels can lead to sleep problems; anxiety can interfere with sleep. It’s important to realize this and be mindful of things people can do to improve their sleep problems, like lower their caffeine intake, exercise, practice mindfulness. Memory problems make it hard to learn new things. When dopamine is low, it influences our concentration is low. When norepinephrine levels are low, our concentration is low. The brain is worried about recovery—rebalancing and repair; it’s not trying to focus on learning new things.

Adenosine is a neurotransmitter to be aware of. As it builds up in our brain, it causes us to be sleepy. Deep sleep at night clears out the adenosine. In early recovery because of PAWS, people don’t get good sleep. When they don’t get good sleep, the adenosine doesn’t get cleared out and contributes to them feeling foggy the next morning. Caffeine binds to adenosine receptors and keeps the adenosine from binding to the receptor and making us feel sleepy; it makes us more alert.

Interventions to help people in early recovery with their PAWS, to help them self-regulate, include meditation and deep, focused breathing, relationships with sober support people, exercise, sleep, restabilizing their circadian rhythm, awareness and mindfulness (self check-ins) pleasurable activities, eating healthfully, relaxation. In early recovery people are fatigued and tired, because of low dopamine, but too much sleep messes up the circadian rhythm and your brain doesn’t know when it’s supposed to sleep. Naps should be limited to between 20 and 45 minutes so they don’t go into a deep sleep state. Encourage people to go to sleep at a regular time. Mindfulness is an important part of preventing relapse. As the person grows in their awareness of the sometimes, subtle changes that occur, they can do something about them. Eating healthfully is important, because most neurotransmitters are made in your gut. Relaxation is both physical and mental. What things do people do for relaxation? Relaxation and GABA go hand in hand.

In summary, according to Dr. Snipes PAWS is an expected issue for at least the first year in abstinence as the brain and body recover. PAW symptoms are the result of the brain’s neurotransmitter system being disrupted by drug and alcohol abuse. In early recovery, it is not helpful or realistic to ignore or minimize PAW. A primary goal in early recovery should be to minimize stress.

There are a multitude of voices today talking about the dangers of PAWS to someone attempting to get clean and sober. While there are more specifics on the effects of PAWS to the neurotransmitter systems in the brain, Gorski’s discussion of how to recognize and care for PAWS still holds up after 35 years.

06/6/17

Preventing the Relapse Process, Part 2

Recovery can be likened to walking up a down escalator. Imagine an escalator that stretches so far up that it disappears in the distance. As every child knows the trick to walking up one is to climb faster than the escalator is pulling you back. You could climb so far up this imaginary escalator, that you would no longer see the bottom. But the moment your climbing effort is less than the downward pull of the escalator, you begin moving back towards that bottom. That’s what relapse is like.

You might even be objectively climbing up the escalator, but if it isn’t enough to counter the downward pull, you have only delayed the inevitable. You have to be climbing as least as fast as the escalator is pulling you back to not lose ground. And that is what relapse prevention is like.

Relapse is a process, not an event. The last thing that happens in a relapse process is resuming alcohol or drug use. Depending on the effort you made to progress up the escalator of recovery, your relapse process could take a long time to play out. I’ve known people who identified patterns of relapse that stretched over years of their abstinent lives before they resumed active drinking or drugging. Perversely, this can be a message of hope and not hopelessness. If your relapse process takes months or years to lead you back to active drinking or drug use, then you have months or even years to recognize the problem and prevent it from getting any worse.

In the first part of this article we looked at coping with problems or stuck points in recovery and the high risk factors and trigger events that increase the likelihood of relapse if they are handled incorrectly. This discussion on relapse applies the thinking of Terence Gorski on relapse and relapse prevention, particularly his use of the Relapse/Recovery Grid in Passages Through Recovery and the booklet, The Relapse/Recovery Grid. There are also several articles using this material available on his blog, Terry Gorski’s Blog, including: “Understanding Relapse and Relapse Prevention.”

“The general direction towards relapse is from denial and evasion to high-risk lifestyle factors.” We left off a discussion of the relapse process in Part 1 with a description of high-risk situations and trigger events. High-risk factors make you vulnerable to trigger events, which can be “anything that causes sudden stress, pain, or discomfort.” They can be internal or external triggers. The interaction of high-risk situations and trigger events determines how the Relapse Process advances.

When there are relatively few high-risk factors in a person’s life, it will take a greater stressor to trigger the internal dysfunction of relapse. Conversely, with more high-risk factors, even a minor event can trigger internal dysfunction. “As internal dysfunction increases, the ability to manage reality gets worse, and more problems develop.” This internal dysfunction in early recovery is post acute withdrawal (PAW). See “Recognize Your PAWS” and “Manage Your PAWS.” Or you can read Gorski’s Comprehensive Guide to PAW here.

Internal Dysfunction

When under high stress, many recovering people begin to have difficulty thinking clearly, managing feelings and emotions, and remembering things. One of the main culprits leading to these problems appears to be a tendency to overreact to stressors. . . . Eventually the ability to sleep restfully is disrupted. This heightens stress and fatigue to the point where people become accident-prone.

Thinking problems can range from difficulty concentrating or thinking logically, to racing, repetitive thoughts. The person isn’t always clear about how things affect or relate to each other. “They have difficulty deciding what to do next to manage their lives and recovery.”

Feelings and emotions can range from being very sensitive to being numb. Strange or “crazy feelings” can occur for no apparent reason, leading the person to think they are going crazy. “These problems in managing feelings can cause recovering people to experience mood swings, depression, anxiety, and fear. Sometimes in this situation a mood disorder is diagnosed and treated with medication. Ironically, this could exacerbate the internal dysfunction of relapse. The person often doesn’t trust their emotions and seeks to ignore, stuff or forget them.

Memory problems interfere with learning new skills and retaining new information. Remembering what you just read can be difficult. “The new things they learn dissolve or evaporate from their mind within minutes.” Taking classes or learning a new job skill can be tough when this is happening.

Sleep-related problems can crop up. This could mean trouble falling asleep, trouble staying asleep, and even unusual or disturbing dreams. Restful sleep may be difficult to come by, leading to exhaustion or tiredness during the day.

Problems managing stress begin with a failure to recognize the minor signs of daily stress. So when stressors become evident, there is a tendency to overreact to them. “Stress sensitivity causes them to amplify, magnify, and intensify whatever feeling they are experiencing.” At times, they get so tense and the strain is so severe, they can’t function normally.

This internal dysfunction can lead to feelings of shame and guilt; feeling you are doing something wrong in recovery or not working a good program. This can lead to not talking honestly about what you are experiencing. These warning signs of relapse get stronger the longer they remain hidden. “Secrets keep you sick.” If you try and fail to manager them alone, you may begin to feel hopeless.

External Dysfunction

Problems in living emerge from a failure to manage the internal dysfunction issues of a relapse process. “Now problems arise at work, at home, with friends, and with fellow members of the program.” If there is a person (like a sponsor) or a situation (like a meeting) that might call on you to take an honest look at yourself, you begin to avoid them and isolate. If asked how you’re doing, you get defensive or lie. Impulsive actions, doing things without thinking them through can happen.

Confusion, overreaction and crisis building occur. “Here, people may begin to have problems cause by denying their feelings, isolating themselves, and neglecting their recovery.” You get upset with yourself and others. You can be irritable and overreact to little things. Relationships become strained; conflicts arise. Stress and anxiety increases. At this stage, denial locates the problems in others or outside situations.

Loss of Control

Active addiction is often described as a loss of control. I find it helpful to distinguish between two kinds of loss of control: the loss of control over thinking, feeling or behavior; and the loss of control over drug or alcohol intake. Here the first sense of loss of control is activated. I describe this stage of the relapse process as feeling like a deer caught in the headlights. There is poor judgment; an inability to take action; an inability to resist destructive impulses.

Recovering people lose their ability to control their thinking and behavior. Judgment is impaired. They often know what they need to do but can’t do it. They begin to have cravings and self-destructive impulses and find the more and more difficult to resist. They consciously recognize the loss of control, but believe they can’t do anything about it.

Far too often, this is the first awareness the person has that they have slipped into “relapse mode.” They see how severe their problems have become; how unmanageable life has become and how little power they have to solve their problems. “By this time, they have become so isolated that it seems there is no one to turn to for help.” Feelings of powerlessness to resolve problems leads to believing you are useless and incompetent.

Feeling trapped by pain and inability to manage life, they feel their options are reduced to going insane, committing suicide or using drugs or alcohol. There is no sense that anyone or anything can help. Twelve Step meeting attendance stops, if it hasn’t already. Tension can lead to terminating a relationship with a sponsor of counselor that used to be helpful.

People can only live with debilitating stress for so long before they collapse. Some people collapse physically and develop stress-related illnesses such as ulcers, gastritis, back pain, hear disease, or cancer. Others collapse emotionally … [or] become suicidal.

Lapse/Relapse

“When faced with the limited alternatives of physical or emotional collapse, suicide or chemical use, using can seem like the sanest choice.” Assumed here is the person does know, or did know from experience when they were using in the past, that it’s likely they would again lose control over their use. Either they are so desperate that they convince themselves they will only use for a short while in a controlled way, or they impulsively act when an opportunity to use presents itself. This initial use will often produce intense feelings of guilt and shame for the individual.

Sometimes active using is a lapse—a short time period, perhaps even one night or a few drinks. Other times the active use spirals out of control and can go for months or years. Returning to a loss of control over use can be slow or rapid. Often the person quickly returns to using as much as they did before.

The goal of relapse prevention is to interrupt the above-described process as quickly as possible. The further the relapse process progresses, the more difficult it is to stop. Identifying and resolving stuck points (see part 1), avoiding as many high-risk factors as possible, and neutralizing trigger events are the best interventions. Next would be catching and addressing internal dysfunction, then external dysfunction and finally loss of control before the relapse into active chemical use. Remember that when you successfully intervene in a relapse process at the beginning, you need never risk actually picking up.

This is part 2 of my article, “Preventing the Relapse Process.” Part 1 describes stuck points, high-risk factors and trigger events connected to the relapse process and it can be found here.

05/26/17

Preventing the Relapse Process, Part 1

Relapse is a terrifying experience for an addict or alcoholic to go through. And what seems to be most terrifying, is not being able to see it coming. Hindsight will recognize a few obvious mistakes, but often there is a haunting question: “What am I missing?” Learning to understand relapse and how to prevent it are essential pieces to the recovery puzzle. Relapse doesn’t have to be part of recovery, but recognizing the process when it occurs is essential.

Gerald finally agreed to admit himself to an addictions treatment center. He had relapsed into active drug and alcohol use two years ago after having eight years of abstinence. At the time of his relapse, he was the manager of a sober living residence that housed 10 to 12 men who needed a supportive living environment in early recovery. He didn’t recognize any one thing or event that triggered his relapse. But the guilt after picking up was more intense then he imagined was possible. He was the guy at meetings who always said he put his recovery first.

He acknowledged he had been going through the motions for a while. But that had happened to many others he knew who didn’t pick up. There was the usual recognition of slacking off on going to meetings and growing more impatient with others asking him if he was “all right.” But he honestly couldn’t pick out any one thing or a series of events that led to his relapse.

He had wracked his brains trying to think of what he should have done differently, but he couldn’t see where he went wrong. Privately he was terrified. What if it happened again and he didn’t see it coming that time either? He was afraid he wouldn’t make it back again.

There is no better place to start helping Gerald than with the resources developed by Terence Gorski for understanding and preventing relapse. His Relapse/Recovery Grid has been one of my most regularly used tools when I work with individuals to address their alcohol or drug problems. You will find it in at least two places. The first is within his book, Passages Through Recovery and the second is in his booklet, The Relapse/Recovery Grid. Another helpful resource is Terry Gorski’s Blog, where Terry has made a wealth of his material available. I haven’t seen a reproduction of the 8 ½ by 11 inch Relapse/Recovery Grid available on his blog, but in several articles like “Understanding Relapse and Relapse Prevention,” you will get a good synopsis of the Relapse Process summarized on the bottom half of the Relapse/Recovery Grid.

Gorski said relapse is like knocking over a line of dominoes. It is a process of one unresolved problem leading to another, and then another and another—until you have a major crisis, where using alcohol or drugs to deal with the pain seems like a reasonable choice. “The answer to avoiding relapse is to learn how not to tip over the first domino, and take care of the little problems in life.” If the dominoes have already begun to fall by the time you realize what’s going on, then you want to stop the chain reaction quickly, “before the dominoes start getting so big and heavy that they become unmanageable.”

One way the domino analogy is not always accurate is in the amount of time involved in a relapse process. Someone with stable recovery can take a long time to move through the stages of a relapse process before they ultimately use drugs or alcohol. By stable recovery, I mean someone who is in what Gorski calls the Maintenance Stage of the recovery process. This is where the person is maintaining a recovery program, coping effectively with day-to-day issues in life, continuing to grow personally and spiritually, and coping effectively with the crises and transitions that occur in life. I’ve known an individual who said her relapse process started four years before she actually used drugs again.

Perhaps a bit counter intuitively, this longer time for relapse to result in active drinking or drug use can be helpful IF the person recognizes the problem (or stuck point in Gorski’s discussion of the relapse process) and copes effectively with it. This necessitates the use of RADAR to address the stuck point: Recognizing there is a problem; Accepting that it’s normal to have problems and get stuck in recovery; Detaching or backing off to gain perspective on an unsolved problem; Accepting help from others—asking them for help with your problem; and Responding with positive action will help you get over the stuck point and avoid a further slide into the relapse process.

Failing to address a stuck point leads to ESCAPE: Evading or denying the problem or stuck point; failing to cope with the Stress that comes with evading the problem; turning to Compulsive behaviors to cope with the pain and stress; Avoiding others, especially those who see and tell you about your ineffective strategies for dealing with the problem; developing new Problems from the process of stress, compulsive behavior and isolation; and ultimately Evasion and denial of the new problems—see how it’s been working so well for you so far.

Instead of recognizing you are stuck and need help, you try to tell yourself everything is okay; you are coping effectively. But there is a buildup of pain and stress that can result in using other compulsive behaviors to cope.

To cope with the pain and stress, we begin to use other compulsive behaviors. We may begin overworking, over-eating, dieting, or over-exercising. We can get involved in addictive relationships and distract ourselves with sex and romance. These behaviors make us feel good in the short run by distracting us from our problems. But they do nothing to solve the problem. We feel good now, but we hurt later. This is a hallmark of all addictive behaviors.

Then something happens. Usually it’s something you would handle without getting upset. But this time you’ve had it; you’ve hit your limit and something snaps inside. Gorski said one person said it was like a trigger going off in your gut and you go out of control. But this is not actively drinking or using … yet. “When the trigger goes off, our stress increases, and our emotions take control of our minds. . . . When emotion gets control of the intellect we abandon everything we know, and start trying to feel good at all costs.” There was just one too many stressors that weren’t addressed, so a trigger event initiates the internal dysfunction of the Relapse Process.

The Relapse/Recovery Grid lists several high-risk lifestyle factors that increase the likelihood of something triggering the Relapse Process. “These high-risk factors don’t cause relapse; they simply increase the likelihood that it will occur” by making you vulnerable to trigger events. The high-risk factors include personality stressors (perfectionism; or controlling); high-risk lifestyles (trying to do too much or doing too little; or doing the wrong things); social conflict and change; poor health maintenance (poor nutrition, a lack of exercise, relaxation or socializing) or other illness; an inadequate recovery program. “The ‘wrong things’ could be occupations, activities, and people that don’t fit with natural preferences and talents.” Gorski said these high-risk factors were identified from research into the lifestyles of people who had relapsed.

The trigger events listed in the Relapse/Recovery Grid include: high stress thoughts, painful emotions, painful memories, stressful situations and stressful interactions with others. Gorski said that just about anything could become a trigger event, but these five things trigger internal dysfunction more than others.

Some recovering people put themselves under increasing amounts of stress, and they keep adapting to it as they go along. As their tolerance goes up, they block their awareness of stress. Suddenly they hit their limit. They experience one stressor too many, and become dysfunctional.

Irrational thinking is the most common trigger. All-or-nothing thinking, black-and-white thinking fits here. When something goes wrong, you think Nothing ever goes right. If there is a risk of failure in doing something, you quit before it happens. This kind of thinking is irrational.

Emotional pain can point to something wrong with how you are thinking or acting. It signals “a need to examine what is wrong.” If you dismiss painful emotions for too long, they often come back with a vengeance.

People will often experience stressful or traumatic events in an active addiction that cause them extreme emotional or physical pain. Being reminded of these events can lead to disorientation, confusion, anxiety or other symptoms for no apparent reason. This will then increase stress and trigger internal dysfunction.

“Any situation that a person is not prepared to cope with may be stressful.” Recognize this reality and seek to avoid them, if at all possible, by being prepared. The level of stress is inversely related to your preparation: it goes down as your preparation goes up. In situations where you can’t be prepared, learn some stress reduction skills, such as relaxation breathing. See “Using Stress Management in Relapse Prevention Therapy (RPT)” and “Stress Self-Monitoring and Relapse” for more on this.

Stressful interactions with others are common for recovering addicts and alcoholics. They often have high stress people in their lives, meaning people who cause them stress. Often these high stress interactions occur with family members or people the addict or alcoholic is close to. Their stressful behavior, ironically, is often caused by their fear of a relapse with the addict.

This is the first part of my article, “Preventing the Relapse Process.” Part two will describe the four phases of the Relapse Process and it can be found here.

03/4/16

Managing Stress in Recovery

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.

01/19/16

Stress Sensitivity in Addiction and Relapse

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.

11/9/15

Managing Your PAWS

The presence of some brain dysfunction is common with recovering alcoholics/addicts. Some studies have suggested that 71% to 96% of individuals perform in the impaired range of various psychological tests. McGrady and Smith in a 1986 article, “Implications of Cognitive Impairment for the Treatment of Alcoholism,” said: “Given the bulk of evidence, it is reasonable to conclude that cognitive impairment is a concomitant of alcoholism.” An “Alcohol Alert” by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicated that even mild to moderate drinking could affect cognitive functioning. But although it stood to reason that cognitive impairment could impede recovery, “evidence has not conclusively shown this to be the case.”

However, a study by Fein et al., “Cognitive Impairments in Abstinent Alcoholics,” published in Addiction Medicine found: “The most significant determinant of the presence of cognitive deficits in persons recovering from alcoholism is the time elapsed since their last drink.” When the time period was controlled, different patterns emerged. They classified the abstinence time into three time periods. The acute detoxification period could last as long as the first two weeks of abstinence. The intermediate abstinence period was from the end of the detoxification time through the first two months. The long-term abstinence period extended from two months to five years of abstinence. The general pattern of deficits in these three time periods is shown within Table 1 taken from Fein et al.

Alcohol use has well-documented effects on attention, concentration, reaction time, motor coordination, motor speed, judgment, problem solving, learning and short-term memory. Because these impairments are substantially reduced with detoxification, neuropsychological testing during this time period is of little value. “It is the residual deficits in patients following detoxification that are relevant to the diagnosis of cognitive impairment.”

Fein et al. stated that sensitivity to the possibility of cognitive impairments in abstinent alcoholics was essential to informed treatment planning. Individuals with deficits to learn new information were at a disadvantage in intensive treatment programs. They could be seen as “unmotivated” or “not ready to stop drinking” rather than “impaired.” They suggested early treatment focus on enforced abstinence and be supportive, rather than make the patients learn new material or think analytically about their experience. As cognitive functioning improves, these patients may begin to participate in the more educational and insight-oriented aspects of treatment.

We note that the Alcoholics Anonymous program is appropriate to the cognitive limitations of newly abstinent alcoholic persons. The focus in Alcoholics Anonymous is on maintaining abstinence from alcohol within the context of acceptance and support. New initiates are told to come to as many meetings as possible (“90 meetings in 90 days”), with- out an expectation that they become fully indoctrinated into the culture of the program (“fake it until you make it”). Indeed, during the initial period, the emphasis is on behavioral change rather than on understanding or a change of attitude.

The apparent discrepancy between the NIAAA statement and the Fein et al. study may be explained by an observation made by Terence Gorski of how symptoms of post acute withdrawal (PAW) associated with the brain dysfunction from alcohol/drug use may contribute to many cases of relapse. According to Gorski, “Post acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals.” Too often these “sobriety-based symptoms” of alcoholism and drug addiction are neglected or ignored. See “Recognizing Your PAWS” for more information on PAW symptoms. Or you can read Gorski’s Comprehensive Guide to PAW here.

PAW symptoms are not the same in everyone. There can be a wide variance from person to person in how severe they are, how often they occur and how long they last. Gorski suggested there were four patterns in PAW symptoms. If they get better over time, that is a regenerative pattern. If they get worse, he says it is degenerative. If it stays the same, that is a stable pattern. If it comes and goes, that is an intermittent pattern.

The most common pattern of PAW is regenerative and over time it becomes intermittent. It gradually gets better until the symptoms disappear and then it comes and goes. The first step is to bring PAW symptoms into remission. This means bringing them under control so that you are not experiencing them at the present time. Then the goal is to reduce how often they occur, how long the episode lasts, and how bad the symptoms are. You must remember that even when you are not experiencing them there is always the tendency for them to recur. It is necessary to build a resistance against them – an insurance policy that lowers your risk.

Stress triggers and intensifies PAW symptoms. Conversely, lower stress means less severe PAW. So learning to manage stress will help you manger PAW. Mindfulness meditation has been shown to be very effective in reducing stress levels. In How God Changes Your Brain, Andrew Newberg and Mark Waldman noted that animal studies have shown how mild, short-term or chronic stress impairs memory by disrupting dendritic activity. “If the situation that is causing the stress is removed, function is restored.” Intentional relaxation, as with deliberately scanning each part of your body to reduce muscular tension and fatigue will not only relieve bodily tension, it will interrupt the release of stress-stimulating neurochemicals.

When all is said and done, you are responsible for protecting yourself from anything that threatens your sobriety or anything that triggers post acute withdrawal symptoms. Reducing the stress resulting from and contributing to the symptoms of post acute withdrawal must be of prime consideration for you. You must learn behavior that will protect you from the stress that might put your sobriety in jeopardy.

Good nutrition plays a role in stress reduction and managing PAW. Gorski suggests a high protein, complex carbohydrate meal plan. Eat three well-balanced meals daily. Eat three nutritious snacks to stave off hunger, which is a stress producer. Potato chips, candy and other high calorie low nutrient foods are no-nos. Avoid foods high in sugar and limit your caffeine intake. Also use multiple vitamins, vitamin B-12 and broad-spectrum amino acids.

Regular aerobic exercise helps to reduce stress. “Many recovering people will testify to the value of exercise in reducing the intensity of PAW symptoms. After they exercise they feel much better, find it easier to concentrate and remember, and are able to be more productive.” Exercise will stimulate the release of neurochemicals that help relieve pain, anxiety and tension.

In The Emperor’s New Clothes, Irving Kirsch reported that studies of physical exercise as a treatment for depression have shown several surprising findings. Exercise is more beneficial for moderate to severe depression than it is for mild to severe depression. These benefits seem to be long lasting, if the person continues to exercise regularly. Twenty minute three days per week is enough to produce the antidepressant effect. But Gorski suggests daily exercise because of its added value in reducing stress.

According to Gorski, spirituality is an important tool in managing PAW symptoms. “Through spiritual development you can develop new confidence in your own abilities and develop a new sense of hope.” Using the principles of the AA/NA program to increase your conscious contact with your higher power is an important part of this spiritual development. You simply have to be open to the possibility of a Higher Power and be open to experimenting with a form of communication with that Power. There isn’t a required structure to that communication.

Try reading Greenberg’s and Waldman’s book, How God Changes Your Brain for suggestions on how meditation can be practiced from a nonreligious point of view. Greenberg has done research that has showed neurological changes in the brains of praying nuns that was nearly the same as that in the brains of Buddhist monks meditating. This evidence confirmed their hypothesis that the benefits gleaned from prayer and meditation may have less to do with a specific theology “than with the ritual techniques of breathing, staying relaxed, and focusing one’s attention upon a concept that evokes comfort, compassion, or a spiritual sense of peace.”

A final area in managing PAW is living a balanced life. “It means your are healthy physically and psychologically and that you have healthy relationships.” You have time for your job, your family, and your friends, as well as your own growth and recovery. It also means wholesome living. It needs a strong social network that nurtures you and encourages a recovery-oriented lifestyle. The two primary goals in any person’s recovery are to establish and maintain a recovery-oriented lifestyle and to establish and maintain a sober support system.

It [balanced living] means having a balance between work and play, between fulfilling your responsibilities to other people and your need for self-fulfillment. It means functioning as nearly as possible at your optimum stress level, maintaining enough stress to keep you functioning in a healthy way and not overloading yourself with stress so that it becomes counterproductive. With balanced living, immediate gratification as a lifestyle is given up in order to attain fulfilling and meaningful living.

11/2/15

Recognizing Your PAWS

I knew a woman who was staying in a six-month drug and alcohol residential treatment center. She began to forget where she left her cigarettes. At first, it was just frustrating and kind of embarrassing. She would check the cafeteria; the living room; the group room. She’d go upstairs to her bedroom. She’d ask other residents if they saw her cigarettes. She’d check outside at the picnic table where the residents smoked. After awhile, she began to worry that she was losing her mind and even became fearful she could end up in a mental hospital.

There was a guy in his thirties who worked out with free weights in his basement. He’d been doing this since he began playing sports in his teens, but got away from it when his drinking became more important. After a few weeks of abstinence, he decided to start lifting again and went down to his basement. He started out with a fairly light amount of weight and intended to do some bench presses. But he almost dropped the bar on his windpipe. He spent a few days worried that his drinking had physically damaged him to the point that he didn’t have the strength and coordination to lift weights.

Both of these individuals were in the early stages of recovery and both were experiencing problems with post acute withdrawal (PAW) symptoms. Learning about PAW helped each of them see that they weren’t losing their mind, nor had they caught some degenerative muscle disease from their drinking and drug use. The material on PAW that I’ve found to be most helpful is that published by Terence Gorski. He discusses PAW symptoms and how to manage them in Staying Sober, and Straight Talk About Addiction, which are available through Amazon or Herald House Independence Press. You can even find a free comprehensive guide on PAW, excerpted from Staying Sober, on Terry Gorski’s Blog.

“Post acute withdrawal is a group of symptoms of addictive disease that occur as a result of abstinence from addictive chemicals.” PAW symptoms can appear as early as 7 to 14 days into abstinence—just as the person stabilizes from any acute withdrawal symptoms they might experience. They are a combination of the damage done to the nervous system from alcohol and drugs and the psychosocial stress of now trying to cope in life without drugs and alcohol. Gorski said there are six major types of PAW symptoms: 1) inability to think clearly; 2) memory problems; 3) emotional overreactions or numbness; 4) sleep disturbances; 5) physical coordination problems; and 6) stress sensitivity. The PAW Comprehensive Guide on Terry Gorski’s Blog has a helpful discussion of each of these PAW symptoms.

The symptoms of PAW typically grow to peak intensity over three to six months after abstinence begins. The damage is usually reversible, meaning the major symptoms go away in time if proper treatment is received. So there is no need to fear. With proper treatment and effective sober living, it is possible to learn to live normally in spite of the impairments. But the adjustment does not occur rapidly. Recovery from the nervous system damage usually requires from six to 24 months with the assistance of a healthy recovery program.

Gorski noted that research has also shown that PAW symptoms can go through cycles or crop up without any triggers or stressors going on. The classic pattern of slips that seem related to PAW cluster around sobriety dates—30, 60, 90 days; 6 or 12 months. They can occur without an obvious pattern or trigger. People in recovery from long-term opiate or stimulant use have reported times of PAW symptoms for no apparent reason for up to ten years after their abstinence. “Individuals who intend to have consistent long-term recovery must learn to recognize these symptoms and learn how to manage them.”

A helpful tool to do this can be found in Gorski’s Staying Sober Workbook, the Post Acute Withdrawal (PAW) Self Evaluation. I encourage people in early recovery to make a copy of their PAW self evaluation, date it and then hold on to it. If they later experience a time when PAW symptoms reemerge, they can compare it to the earlier time when PAW was in full bloom. This can be helpful in judging just how dangerous the most recent time of PAW is to their recovery. If a stressor after one year of abstinence can trigger PAW symptoms at the level of intensity you were having with only two or three months of abstinence, that’s crucial information for someone in recovery to have.

The booklet The Relapse/Recovery Grid by Gorski is an excellent summary of both his Developmental Model of Recovery and the Relapse Process. There is a handy grid that provides you with a comparison of both the Developmental Model of Recovery and the Relapse Process. I’ve found this grid to be very helpful when doing psycho-educational presentations on both recovery and relapse. One of its features relevant to our discussion here is how the above noted PAW symptoms are the heart of the initial stage of the Relapse Process, Internal Dysfunction. Here is the introductory paragraph on Internal Dysfunction:

When under high stress, many recovering people begin to have difficulty thinking clearly, managing feelings and emotions, and remembering things. One of the main culprits leading to these problems appears to be a tendency to overreact to stressors. Scientists call this neurological augmentation. Many recoverying people refer to this as stress sensitivity. People perceive light to be brighter, sound to be louder, and touch to be intrusive. They startle easily and quickly, and become distracted by things that happen around them. Eventually, the ability to sleep restfully is disrupted. This heightens stress and fatigue to the point where people become accident-prone.

This illustrates the importance for someone to recognize, monitor and manage PAW symptoms throughout recovery. The person who can effectively do so increases the likelihood of never lapsing or relapsing into active drug or alcohol use again because they are neutralizing a relapse in its initial phase. Also look at “Managing Your PAWS.”

09/7/15

Preventing and Stopping Cravings

Not all addicts and alcoholics struggle with cravings in recovery. And not all addicts and alcoholics experience them with the same intensity. But knowing how to recognize the sets ups and triggers for a craving are crucial skills for those in recovery who do experience them. Otherwise, it’s like living through a drug and alcohol-themed version of Groundhog Day.

On his blog, Terence Gorski described a three-stage model to manage cravings without them leading back to active drug or alcohol use. Two previous articles “Ready to Cope with Cravings” and “Getting Set to Cope with Cravings” reviewed the three stages of Gorski’s model to understand cravings. This final article of the three part series describes how to prevent cravings and stop them once they do occur.

Craving is not an inevitable process. They can be prevented if you follow a few simple guidelines. And they can be managed without a return to active drug use. Gorski suggested five preventive measures against craving.

First, develop and maintain a structured recovery program that keeps you in regular, continuous, daily contact with other recovering people.
Second, know what your triggers are. “Identify the things that activate the craving and learn how to cope with those triggers.”
Third, know and avoid your set-up behaviors; learn how to cope with them if you can’t avoid them.
Fourth, dismantle euphoric recall—intentionally include where the “fun” of the high will eventually lead you. Remember where it took you in the past.
Fifth, stop awfulizing sobriety and put an end to magical thinking.

Despite your best efforts, you may still experience cravings. Remember that they are a normal symptom experienced by most addicts in recovery. While there are a fortunate few who have minimal or no problems with cravings in early recovery, they are the exception, not the rule. So if you have cravings, stop them from leading you back to active drug use by practicing a few simple steps.

First, recognize the craving. This may seem obvious, but sometimes the craving is mild and appears to be something you can “white knuckle” it through until it’s over. “Many addicts fail to identify mild craving as problematic and wait until they are full-blown, severe cravings before taking action.”
Second, don’t panic if you have one. Remember that cravings are normally experienced by addicts in recovery. It doesn’t mean you are doomed to resume active drug use or that you aren’t doing enough for your recovery.
Third, get away from where you are. A craving might be activated by an environmental trigger. You may have thought a situation wouldn’t be a trigger, only to discover once you are in it, that it triggers you. GET OUT OF THERE and go to “an environment that supports recovery.”
A fourth step you can take is to talk the craving cycle through with someone. “If you talk it through, you don’t have to act it out.” Honestly talking the process through from beginning to end can discharge the urge to use because you are mentally removing yourself from it. It’s like you have a video of the process that you are reviewing. You stop, rewind, fast-forward, and go frame by frame with the recording of what happened to discover the timeline and cause-and-effect chain reaction of what led to the craving.
Fifth, distract yourself. Divert attention from the craving by engaging in other productive, positive activities that require your full attention.
You could do some aerobic exercise, a sixth action step to cope with cravings. Aerobic exercise can stimulate brain chemistry that reduces cravings.
Seventh, you can try meditation or relaxation. Cravings are often intensified under high stress. “The more a person can relax, the mower the intensity of the craving.”
Eighth, you can eat a healthy meal to nourish your brain.
Ninth, remember they are time-limited and will eventually pass. Most cravings won’t last more than two or three hours. If you persist in the steps suggested here to the point of getting fatigued enough to fall asleep, many people wake up with the craving gone.

It is possible to understand drug craving and to learn how to manage craving without returning to use. A model that allows people to identify set-up behaviors, trigger events, and the cycle of craving itself, and intervening upon this process has proven effective in reducing relapse among addicts.

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. You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/31/15

Getting Set to Cope with Cravings

On his blog, Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage of set-up behaviors was discussed in a previous article, “Ready to Cope with Cravings.” This article will review the next two stages, trigger events (The Set Stage) and the craving cycle (The Go Stage).

The Set Stage

There are four main triggers that can activate immediate, powerful cravings during the Set stage, according to Gorski. Thinking triggers arise out of the mind-set or pattern of thought that follows the person into early recovery. Abstinence doesn’t magically make them disappear. Feeling triggers often come from sensory cues—seeing, hearing, touching tasting or smelling something that reminds the person of their drug of choice. “It also results from experiencing feelings or emotions that were normally medicated by use.” Behavioral triggers stem from behaviors and rituals that were previously associated with drug use. Situational triggers include relationships or circumstances that used to be associated with using.

There can be some overlap between set-ups and triggers. What distinguishes them in the discussion by Gorski seems to be the ability of a trigger to activate the immediate experience of a craving cycle.

Euphoric recall or fantasy that continues unchecked could become a thought or feeling trigger. Listening attentively as someone describes his or her own struggles with past addictive behavior or current struggles with set-ups or cravings can lead to a thought trigger. Seeing movies that portray drug use can initiate a strong craving. Intravenous drug users can be triggered when their blood is drawn. Alcoholics can be triggered by hearing someone snap open a soda can.

Certain situations, rituals or behaviors that become associated with using can become behavioral or situational triggers. Think here about the principles of classical Pavlovian conditioning. One person I knew couldn’t listen to a certain CD, because he has regularly listened to it when he was high. Another individual discovered that sitting and thinking in a particular chair in their home was a trigger, because that was where she had sat when she drank. Another person avoided the cleaning supply isle in supermarkets because they had used chore boy scrubbers to make their crack pipes.

The often-repeated mantra to avoid People, Places and Things associated with addiction will include all the above categories of set-ups and triggers. But the nuance of addictive experience means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics. Not all thinking, feeling, behavioral or situational events will immediately trigger a craving cycle with all alcoholics and addicts. Not all People, Places and Things put addicts and alcoholics equally at risk of cravings or relapse. The failure to acknowledge this will potentially awfulize recovery (one of the psychological set-ups).

Using Gorski’s stages of set-ups and triggers, I’d suggest that any person, place or thing associated with addiction should be considered to be a set-up. Careful examination, discussion and analysis of these set-ups will determine whether they have a greater or lesser potential to become a trigger and activate a craving cycle for the individual. The earlier a person is in recovery, or the more stressful or unstable the life of a person with longer-term recovery is, the more careful they should be to avoid set-ups. The more stable the person’s life and recovery is, the greater nuance they can have in their exposure to set-ups. Any set-up that carries the potential to become a trigger for the individual should be avoided. The diversity of experiences when using, even among individuals with the same drug of choice, means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics.

The Go Stage

The third stage of craving is the actual craving cycle. Here the obsessive thoughts to use triggers a compulsive desire to get high, with physical cravings for the drug and then actual drug seeking behavior occurs.

When an obsession becomes activated, the person experiences a loss-of-control with their thinking. “Intrusive thoughts invade their mind and they can’t turn them off.” The obsession will quickly become a compulsion. Despite knowing it would be dangerous to use drugs, in a compulsion the person has an overwhelming urge to get high. This obsession and compulsion leads to full-blown physical craving, which can be quite powerful. The person may have a rapid heart beat, shortness of breath, perspiration; even an actual sense of tasting smelling, or feeling the drug they are craving.

Attempting to manage the cycle of obsession, compulsion and craving, the person begins active drug-seeking behavior. They might return to their old hangouts; call up old drug using friends. In other words, return to people, places and things associated with addiction. This exposure to more triggers intensifies the craving cycle. Ultimately, the person becomes overwhelmed with this cycle of obsession-compulsion-craving and they return to active drug use.

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 the second of a three-part series on coping with cravings. The other two articles are “Ready to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/17/15

Ready to Cope with Cravings

Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage was what he called Set-Up Behaviors—“ways of thinking, managing feelings, and behaving that increase the risk of relapse.” The second stage was Trigger Events—“events that activate the physiological brain responses associated with craving.” The third stage was the Craving Cycle—“a series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.” For ease of remembrance, we will refer to the first stage as “Ready,” the second stage as “Set,” and the third stage as “Go.”

Within the Ready stage, Gorski described physical, psychological and social set-ups that can lower the individual’s resistance to craving. At the Set stage, he said there were four primary kinds of triggers that could immediately activate a craving: Thoughts, Feelings, Behaviors and Situations. The Go stage, what Gorski called the Craving Cycle, was obsession, compulsion, physical craving and drug-seeking behavior.

There is often a progression from Ready, to Set, to Go—but not always. For example, euphoric recall is one of the psychological set-ups within the Ready stage, but these memories can be powerful enough to immediately activate a craving cycle (the Go stage). Here the memory is a “thought trigger” in the Set stage, one that immediately triggers a craving. Conversely, sometimes there can be set-ups—say socializing with drug-using friends—that don’t trigger thoughts, feelings, behaviors or situations that lead to a craving cycle. But such “misses” can give a person a false sense of security about future opportunities within this kind of set-up. The next time, you may not be so lucky.

The Ready Stage

Physical Set-Ups

Gorski said there are five common physical set-ups for cravings. The first is Brain Dysfunction from Drug Use. “Mind altering drugs [including alcohol] damage the brain” when they are misused or abused. I would add that all drugs with mind-altering properties should be included here. The obvious drug classes are the benzodiazepines and opioids. However, I’d also include the antidepressants and the antipsychotics.

Current antidepressant medications typically modify levels of serotonin (or sometimes norepinephrine) in the brain. Antipsychotics generally work by blocking a dopamine receptor referred to as the D2 receptor. This receptor has been suggested in research to be related to compulsive eating and cocaine abuse. Carleton Erickson, in The Science of Addiction, indicated there were fifteen separate receptor subtypes of serotonin involved in chemical dependence, and five separate dopamine receptor subtypes. Neurontin (gabapentin) effects levels of the neurotransmitter GABA, which is influenced by benzodiazepines. GABA dysregulation also plays a part in alcohol dependence. My point is not that all addicts should taper off of their psychotropic medication. But in learning to manage and cope with cravings, they should consider the potential influence of their medications.

The second physical set-up is poor diet. Simply put, “Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.” Gorski adds that many individuals have coexisting eating disorders.

A third physical set-up for cravings is the excessive use of caffeine and nicotine. Gorski noted how both caffeine and nicotine, which are low-grade stimulants, could increase the likelihood of having a craving.

The fourth physical set-up is a lack of exercise. “Regular aerobic exercise is a protective factor against craving.” It can reduce the intensity of cravings.

A fifth physical set-up is poor stress management. Stress management activities such as meditation, relaxation exercises, regular periods of rest, relaxation and sleep are all helpful ways to manage stress. When people do not manage stress appropriately in recovery, they set themselves up for cravings during the times of stress that often occur in early recovery.

Psychological Set-ups

Euphoric recall occurs when an addict “romances” past times of drug use. They remember and magnify the pleasurable experiences of past use, while blocking out the painful and unpleasant memories. Spontaneous recollection of past “fun” times is common. To avoid euphoric recall leading to a craving cycle, “play the whole tape.” Don’t stop at the fun times, intentionally add where the pain and unpleasantness of past use fits into the story.

Awfulizing abstinence is another set-up. Here the addict attends to all the negatives and perceived losses about getting sober, while blocking out thoughts of the benefits. This leads to a mistaken belief that “being sober is not nearly as good as using the drug.”

In magical thinking, the addict sees drug use as the solution to their problems. Gorski said this was a combination of euphoric recall (Remember how good using was) and “awfulizing” sobriety (how awful it is that I can’t use). I’d suggest that an individual is also in magical thinking when their using history has demonstrated a clear inability to control drug or alcohol use, but they continue to harbor thoughts that when XYZ happens, they could try social or controlled using again.

This will lead to empowering the compulsion. The person exaggerates the power of the compulsion by telling themselves there is no way they can resist the craving; they can’t stand not having the drug. I’ve seen a subtype of this psychological set-up where the person will convince themselves they wouldn’t be able to resist the compulsion to use again if “X” disaster or crisis happened to them.

Gorski sees the psychological set-ups listed above as leading to the fifth and final one of denial and evasion. Here the addict rejects or denies that their actions could be setting themselves up to have a craving. They may deny that they need the help of a recovery program or treatment. “This denial does not go away simply because they are not using the drug.” Because denial is largely an unconscious process, many addicts believe they are doing the best they can; that they are making the right decision for their life and recovery when, in fact, they aren’t.

The stress of the instability and unmanageable circumstances that often occur in early recovery could lead to this as well. Awfulizing the obligations of early recovery or their lives, such as time away from work and family for treatment or meetings, possibly changing jobs or colleges, fear of financial consequences from not working, etc., can lead to this set-up.

Social Set-Ups

Socializing with drug using friends can be a stumbling block for addicts. Trying to negotiate abstinence without losing the ability to go around certain people who they used to drink and drug with is a major problem for some people. A potential loss of the relationship seems unthinkable at the time. Even when the active user voices support of the individual’s desire to establish and maintain abstinence, the contact may not be a good idea. For one thing, knowing the person is high, or has drugs close by can be a trigger for craving.

One of the reasons that an addict, particularly in early recovery, is drawn to socialize with their using friends is the desire to be with other people who understand them—how they think and what they struggle with. This is why social isolation is so dangerous for someone in recovery. This also points to a couple of the benefits to active participation in AA or NA—these are places where the person can share their fears, doubts and struggles without fear of rejection. And they can form new friendships with people who can relate to how they think and feel.

When open and honest self-disclosure is replaced by superficial communication, the person in recovery gets into trouble. They neutralize another benefit of active participation in self-help groups—the ability to get feedback and reality checks from others who understand how they think and feel about an issue. The lack of honest, heart-felt communication with other people who understand addiction is another social set-up.

If the above lack of honest sharing with others continues, it can lead to isolation from other people in recovery. This can happen through decreased meeting attendance and/or avoiding sober social situations with other recovering addicts. Another contributing factor here is if conflict of some sort occurs and becomes a justification for why the person avoids a particular meeting, or why honest sharing of what they are struggling with is not talked about. Unresolved conflict is another social set-up.

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 the first of a three part series on coping with cravings. The other two articles are “Getting Set to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Category Archives: Gorski