Tag: relapse prevention

10/31/17

Mistaken Beliefs About Addiction Relapse

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The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?”

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

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.

06/6/17

Preventing the Relapse Process, Part 2

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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.

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 websites.

01/19/15

The Yin-Yang of High Risk Situations

Jin and yang mask by sognolucido
Jin and yang mask by sognolucido

We’d discussed a plan to keep Andrea as safe as possible. Her brother had urged her to come to the family Christmas celebration and she didn’t feel she could say no. Many of her family members were drinkers, but she was going with her fiancée and neither one of them would be drinking. Most family members knew she’d just got out of rehab at the beginning of December and were supportive of her abstinence. Her brother had vowed to tell their heavily drinking uncle to keep his distance from her. She also wanted to show her family what the sober Andrea looked and acted like. Last Christmas has been a disaster.

She had talked ahead of time to her sponsor about going and agreed to call her at least once during the celebration and after she had returned home. She arranged with Chad, her boyfriend, and Matt, her brother to approach them and say she had to leave if she felt triggered by anything. Andrea and Matt rode together to the party, so they could leave whenever they needed. Her sponsor had also told her about a late night meeting she could get to as well. The party was great. She wasn’t triggered. Even Uncle Al seemed to have been more sober than usual.

A few days later, she had a phone call from a friend’s mother telling her that the woman’s niece had overdosed the night before. Andrea had known the woman, and even talked to her when they met at the grocery store, just after Andrea had got out of rehab. Although she was freaking out on the inside, she felt she had to listen to the friend’s mother and try to comfort her. Andrea still felt guilty that she had introduced the woman’s daughter to heroin. The first anniversary of the girl’s death from a car crash had come while Andrea was in treatment.

When Andrea got off the phone fifteen minutes later, she was shaking. She didn’t want to call her sponsor again; they’d talked earlier in the day and she knew her sponsor was going to be at a family dinner. She told Chad what had happened and said she was going to take a walk to clear her head—alone. Down the block, she decided to walk to the convenience store for a pack of cigarettes; she was almost out. Standing in line with her back to the front door and replaying the conversation with the friend’s mother in her head, she didn’t see a drug dealer she knew until he tapped her on the shoulder and called her name.

Andrea was in two situations that could be dangerous to her recovery. The first was one of her choosing; the second she didn’t see coming. Nevertheless, they both fit what Terence Gorski would describe as a High Risk Situation (HRS). Gorski said that a high risk situation is: 1) any experience that causes you to either move away from support for your recovery; or 2) leads to you going around people, places and things that would support your return to addictive use. He then specified this yin-yang of people, places and things and addiction further by giving a list of ten criteria:

To be more specific, a high risk situation can be described as any experience that meets one or more of the following criteria. The more criteria that are part of the experience, the higher the risk of starting addictive use.

Andrea’s first situation, going to the family Christmas party, would have met numbers 2, 3 and 4 on Gorski’s list. She was around people who would support her return to drinking (Possibly Uncle Al, maybe others who didn’t understand why she couldn’t just one drink to celebrate). She had easy access to alcohol. She was around other people who were acting out on their addiction (at least Uncle Al). But she had a plan to minimize the high risk criteria.

As Gorski noted in his article, having a plan to extract yourself from a high risk situation and then getting in contact people supportive of your abstinence can help you get away from it without using. Andrea went with her fiancée, who also wasn’t drinking. Her brother and others at the party knew she was abstinent and were supportive of her recovery. She had a plan to get to a meeting if indeed she did start to have thoughts or cravings to use. She told others of her planned emergency exit strategy. She went into a high risk situation with a plan and got out without using.

The second situation is less obviously a high risk situation because of the chance encounter Andrea had with the drug dealer. Does this mean she can never be out alone? Gorski said that in relapse prevention there are “Apparently Irrelevant Decisions that put people in high risk situation that seem to happen by chance.” In Andrea’s case, she felt she needed to try and comfort her friend’s mother even though she was freaking out inside. She should have ended the conversation or had Chad try and console the woman. She also chose not to call her sponsor—even though it made sense not to do so at the time. She went out alone and then decided to go for cigarettes—again alone—while she was still upset by her phone call.

These seeming irrelevant decisions on her part led to Andrea being alone while she was around a person who would support her drug use and even supply what she needed to get high. All the while she was still struggling to control strong feelings and emotions from her phone conversation. She also had limited options available to cope with or get out of the situation. The scenario doesn’t say what she did, but even before we speculate how she could respond, Andrea has met five of Gorski’s ten criteria. And remember, the more criteria that are part of the experience, the higher the risk of using.

Andrea are her situations are fictional, but the various pieces of each of them have really happened to people I’ve known in early recovery. Sometimes it can almost feel like an improbable scene scripted in a bad Hollywood movie. So how does Andrea keep herself prepared for the unexpected high risk situation? Simply reverse Gorski’s two yin-yang criteria—move away from people, places and things that support your return to addictive use; and put yourself around the people, places and things that support your recovery. Apply it to Andrea’s situation and see what you think she should do.

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.