Archives for April 2017

A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Intended to supplement medical and professional care for substance use disorders, this guide offers a brief, straightforward distillation of the latest information and research on addictions recovery self-care.

Organized in a series of three handouts, the guide offers compassionate, supportive assistance to individuals with substance use issues who are already receiving medical and professional care. Professionals and concerned others may want to offer it as a link or printed packet. Passages are stated simply, but link to authoritative sources for corroboration and further exploration.

Self-help does not equal treatment. Substance use disorders are complex conditions requiring medical and professional care.

The handouts were originally written by the author as personal guidance after extensive reviews of the research on addiction, hence the use of the pronoun “you,” but they are for informational purposes only and are not a substitute for individualized medical or professional advice. Individuals are urged to consult with qualified health care professionals for personalized medical and professional advice.

Anyone is welcome to use this information and a printable packet in .pdf form – 2,700 words, 6 pages – is available here. Original segments of this post were first published by The Fix here, here and here. The .pdf was last updated 5/3/17 and this post was last updated 5/3/17.

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A Brief Guide to Evidence-Based Self-Care for Recovery from Addiction

Handout 1

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”

1.  Who you are does not cause addiction.

2. Nothing bad you have done, nor good you failed to do, caused addiction.

3. You do not deserve addiction, nor do you deserve not to have addiction. It’s just an unfortunate condition having no moral value one way or the other.

4. You are not the problem. Addiction is the problem. Let’s see what we can do to solve or improve this for your unique, individual situation. And we’ll do this with compassion. As Maia Szalavitz writes, “To return our brains to normal then, we need more love, not more pain.”

We need more love, not more pain

“…we need more love, not more pain.” – Maia Szalavitz

5. Get medical care for the medical condition of addiction. Forced abstinence can result in dangerous withdrawal symptoms, decreased tolerance and increased craving, an intolerable emotional and mental state, and risk of a dangerous, potentially deadly, return to use.

6. Symptoms of addiction can appear as thoughts, words, and actions perceived as irrational, anti-social, and immoral. Addiction is not, in and of itself, a thought problem, a moral problem, a spiritual problem, a mental illness, or a behavior problem. Addiction is not a personality type. It’s a brain condition, contentiously defined, uncertainly located, and uncertainly targeted for treatment, but detectable in the brain at the minutest level.

7. Unfortunately, at this time, we know of nothing you can specifically do on your own to immediately and directly treat, cure, or reverse malfunctions in brain structures associated with addiction. Until we can identify exactly which brain structures and circuits to treat with medications, stimulation or probes, and what beneficially modifies them, for now, other than directly through the medications we know of, we’ll have to use indirect means.

8. However, what can directly administer care to brain structures is protecting them from problematic substances. That’s why obtaining medical care and professional help to assist with abstinence or harm reduction is critical. Over time, helpful changes may occur in the brain in the absence of overwhelming or damaging substances.

9. Focus maximum effort on becoming aware, very specifically, of what helps you stay abstinent and what does not. If you’re practicing harm reduction, discover what helps you use less, less often, or use less problematic substances. Acute awareness takes painstaking attention, but the logic is simple. If you can become aware of inner and outer conditions that precede use, you may be able to do something about them. If you don’t know, you can’t.

10. Needing or wanting to abstain, and firmly deciding and being resolved to quit, unfortunately – as you know from former heroically determined efforts to quit followed by heartbreaking returns to use, all explained by the brain science of addiction – aren’t sufficient to achieve abstinence.

11. You must learn what each substance did for you or meant to you, how you related to it, how it worked for you, and how it eased or enhanced your experience or your life. Discovering this, and finding alternate ways to get your needs met, is difficult but worthy, essential work. Again, the logic is simple. If you can learn what substances did for you, and find alternate ways to get most of that done – regrettably, possibly never again to the extent substances did – you’re more likely to be able to do without them.

12. Repeat: Go to a doctor. Although medical treatments for directly treating the brain for most substance use disorders are currently unknown (however, methadone and buprenorphine directly affect brain areas involved in opioid use disorder), several medications can be helpful with creating the stability necessary for intensive self-learning. In addition to being assessed for medication-assisted treatment (MAT), ask to be screened for mental illnesses and physical illnesses that might be causing conscious and unconscious stress and distress, the primary precursors to a return to use. (If you don’t have health insurance and can’t afford to self-pay, try to find local organizations that will help you get health insurance or help you with costs for medical care.)

13. Abstain from self-judgment. Become aware of a learned pattern of self-harshness, now nearly automatic. It feeds shame, a primary source of inner distress. Self-discernment is a compassionate process of discovering one’s strengths. In contrast, self-judgment cruelly weakens, reduces and demoralizes. As Maia Szalavitz urges, treat yourself for addiction by loving yourself, getting evidence-based care, and respecting the gravity of this illness and the heroic effort required to overcome it.

Turn towards reality and truth

Turn towards reality and truth, not away from them.

Handout 2

“Addictive disorders are a major public health concern, associated with high relapse rates, significant disability and substantial mortality. Unfortunately, current interventions are only modestly effective. Preclinical studies as well as human neuroimaging studies have provided strong evidence that the observable behaviours that characterize the addiction phenotype, such as compulsive drug consumption, impaired self-control, and behavioural inflexibility, reflect underlying dysregulation and malfunction in specific neural circuits.”
– Spagnolo and Goldman, 2017

“[W]hat if the negative thinking patterns, feelings, and behaviors that keep them stuck have powerful, unconscious advantages serving vital, even life-preserving purposes?”
David Burns, 2017

“People may not have caused all of their own problems, but they have to solve them anyway.”
Marsha Linehan , 2012

1. Expect to feel shock, grief, rage and other strong emotions over the before-and-after states addiction brings to your life. Practice self-kindness and self-compassion and find others who can support you when you experience these.

2. Seek stability. Become aware of how you define stability, what individually helps you achieve and maintain stability (emotionally, mentally, physically, occupationally, relationally, situationally), and try to make these happen for yourself. Suppression, repression, avoidance and obfuscation can backfire and destabilize. Turn towards reality and truth, not away from them. (If you have concerns about whether or not what you’re thinking is real or true, see #5 below.)

3. Get counseling. At this time, it is not known if counseling directly treats the brain in an efficient, targeted way for addiction. (For opioid use disorder, for example, multiple studies fail to prove that counseling with medication increases abstinence rates over medication alone). But counseling can help people maintain abstinence, often by assisting with awareness. The main precursors to a return to use are stress, distress, and environmental cues. Environmental cues include being around substances, in situations, and with people associated with use. Make sure the counselor offers an evidence-based therapeutic approach. The Surgeon General’s report, Facing Addiction in America, lists cognitive behavior therapy, CBT, as the top evidence-based counseling approach for assisting people with addiction maintain abstinence or harm reduction. Dialectical behavior therapy, DBT, also included in the report, is increasingly proving effective as well.

4. The more you can 1) learn to become aware of, and regulate, your inner experience of feelings, thoughts and physical sensations – optimally for you individually, not by someone else’s methods or criteria, 2) discover what needs you personally have and what uniquely and healthily meets them, and 3) help yourself avoid environmental cues or manage exposure to them, the more likely you are to be stable and, therefore, the less likely you will be to use.

5. Run even your simplest ideas by others before taking action. Your thinking may not be as clear as it will be in the future.Consulting others will help protect you from error.

6. Seek contact with people who help you clarify your feeling and thinking, who are non-judgmental, and with whom you feel safe and supported. Become aware of how you feel about yourself when you’re talking with anyone and everyone. If you don’t feel good, however you might define “good,” that’s stressful and potentially destabilizing. Find a way to have limited or no contact with those with whom you feel unsafe and unsupported, at least in the short-term.

7. Listen for fact vs. opinion when people talk with you about addiction. Are they sharing the latest science  and research reports on addiction or are they sharing opinions based on beliefs, personal experiences or outdated information? If they’re sharing an opinion, do they acknowledge it as such and explain how they derived it? Or are they stating opinions as facts? Practice caution and care with what you let into your tender, vulnerable mind and heart.

8. Practice engaging, disengaging, and shifting your attention. Discover and focus your attention on what is preferable to you, rather than attempting to force your mind to think what you believe will please or protect, or letting it grind in patterns that have simply become habitual rather than helpful. This power over your attention can give you enormous power to enjoy your life, to assist yourself with enjoying the company of others, and to increase others’ pleasure in your company. Impossible as it sounds, exercising your power to focus your attention may exercise brain functions atrophied from substance use. Many people with substance use disorders have experienced trauma and find using the mind for meditation distressing. Meditation, therefore, may not be advised. Marsha Linehan, inventor of dialectical behavior therapy, DBT, recommends what she terms “mindfulness” instead. A simple, DBT-based mindfulness practice involves using your attention to observe what’s going on within and without and to describe those to yourself. (Here’s a brief YouTube video of Marsha Linehan explaining mindfulness, part of a series of videos on the core principles of DBT.)

9. Become aware of what helps you feel better. Whether it’s just for a few moments or for longer, become aware of what uniquely helps you via your senses – sight, hearing, smell, touch, taste – to ease, reassure, and comfort yourself. Google the term “self-soothing” and you’ll find lots of ideas to try.

10. Believe that you, yourself, can do this. In addictions recovery circles, you may hear about admitting powerlessness, surrendering, relinquishing control, and the dangers of “self-will.” The opposite is true. The more self-aware you are and the more self-power you see yourself as having – the more “self-efficacy” you possess – the more likely you are to stay abstinent. You be you.

11. Practice “love love”  not “tough love” with yourself and others. “Tough love” is a euphemism for smiling while wielding a 2″ x 4″ of hostile methods to exert psychological control. Practice self-kindness and other-kindness. And distance yourself from those who profess to be treating you with the “tough love” they think you “need” or “deserve.” In fact, with the whole concept of “tough love,” practice hostility. But briefly. Then compassionately self-regulate and return yourself to recovery-enhancing stability.

Seek out supportive others

Seek out supportive others.

Handout 3

“…but seven years is long enough and all of us
deserve a visit now and then
to the house where we were born
before everything got written so far wrong”
– Peter Meinke, “Liquid Paper”

“The most natural way for human beings to calm themselves when they are upset is by clinging to another person.”
– Bessel van Der Kolk, M.D., The Body Keeps the Score

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt

“I don’t believe in getting ‘in the moment’ and then exercising will-power. I believe in avoiding ‘the moment.’ I believe in being absolutely clear with myself about why I am having a second drink, and why I am not; why I am going to a party, and why I am not. I believe that the battle is lost at Happy Hour, not at the hotel. I am not a ‘good man.’  But I am prepared to be an honorable one.”
Ta-Nehesi Coates

“It’s my life. Don’t you forget.”
Talk, Talk

1. Attach to yourself. Discover the curl within you of your truest self, “before everything got written so far wrong.” Gently begin to view yourself as someone with whom the vulnerable essence of you can feel safe. Many people with addiction have experienced abuse and neglect from caregivers  and have attachment challenges. What shouldn’t have happened did, and what should have happened didn’t. They may feel undeserving and unqualified to care for themselves. They may believe they can’t be entrusted with themselves and fear the piece-of-shit messages they’ve heard all their lives might be true. Given what many people have been through, having these beliefs is sadly understandable. Still. Kindly and protectively begin to identify yourself more by who you are, and less and less by what you’ve done or what has happened to you.

2. Take care of yourself. Try to imagine finding the truth of who you are showing up as a foster child on your doorstep right now. What do you need?! What do you want?! Remember the best of what you’ve learned, experienced and observed. Start with basic needs. Do you need to be invited in or given some time to adjust? Do you need something to eat, a nap, something interesting to do, a hug? Experiment and see what seems to work. What a huge responsibility! But what a relief! Finally, finally, after all that’s gone down, you can have your own consistent, kind, reliable, present, attentive caregiver who knows you better than anyone else on the planet and who wants the best for you, no matter what. And you don’t have to be a perfect self-caregiver. Good enough will do. Addiction – like life – is a 24-7 condition and others aren’t always available. But you can be there for yourself. Whenever you need or want to, you can cling to your own good-enough self.

3. Seek out supportive others. Social connection can assist with abstinence. Stress and distress are part of human relationships, but the benefits of de-stressing need to outweigh the costs of stressing. No gathering with others will leave you stress-free. The goal is to find people with whom – enough of the time – you can feel good enough and safe enough to feel stable.

4. Try a variety of places and situations in which people gather in groups without use of problematic substances. Consider asking someone you trust to accompany you. Become aware of how you feel afterwards. If you feel neutral or better, you might return. If you feel worse, try another group, or, perhaps, try it a few more times and see. Keep visiting groups of any kind, whether recovery support groups, community groups, or hobby groups, until you find places that feel safe, supportive and helpful. If you don’t find established groups that are a fit for you, try to find individuals with whom you can meet one-on-one or in small, informal groups.

5. To further develop stability, establish priorities, schedules, routines and budgets. Figure out what you can do at the same time each day that’s helpful and do those things. Become aware of foods that fuel you and create a menu for yourself featuring those foods. Note which physical activities support your overall energy level throughout the day and do those. Figure out how much it costs to be you and find ways to supplement what’s missing and to modify spending for shortfalls. Discover the uniqueness that is you and set yourself up individually to thrive as only you would know, understand and be able to do.

6. Use “enough” vs. “all” as a standard. While you may want to examine your values, principles and beliefs more closely and decide what might work best for you individually going forward, for now, strive to get enough of your needs met enough of the time, to feel pretty good enough of the time, and to be with people with whom you usually feel safely supported. Since no one can deliver “all,” expecting all one’s needs to be met all of the time will result in disappointment which is stressful and destabilizing.

7. Stigma is real. Give yourself private time to take care of yourself and to feel better before you consider whether or not to share your condition with others. Keep your circle of confidantes thoughtfully selected and discuss your motivations and the pros and cons of self-disclosure with trusted others when you feel or think you might want to share your situation with others.

9. Do your homework, honey. Whether self-assigned or suggested by trusted sources, research reports that those who do therapeutic homework fare better than those who don’t.

10. You are a unique individual with an individual case of addiction. What helps you with your particular case will be unique to you. You are the expert on that and, ultimately, you are the decider. As you should be. Even if you have the regrettable condition of addiction, it’s still your life, your one precious life.

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Anne Giles, M.A., M.S., is the founder of Handshake Media, Incorporated. She is a counselor and writer and lives in Blacksburg, Virginia.

The opinions expressed here the author’s alone and do not necessarily reflect the positions of clients, employers, co-workers, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Complex and Interacting Factors Predispose People to Addiction

Complex and interacting factors can predispose people to developing addiction, defined by the National Institute on Drug Abuse as “a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.” Genetics, psychology, psychiatry, and sociology are contributing to a more complicated understanding of how and why addiction develops in 1 in 7 people, or about 14%.

Detail of collage, Mary Wilson Burnette Giles, 1963

Genetics and Epigenetics

Genetics is well-known as the field that studies DNA, or the amino acid code that serves as a blueprint for living creatures. Epigenetics, being a newer sub-field of genetics, is rather less well-known. Epigenetics is a field examining the chemical compounds and proteins that attach to DNA, and influence how and whether the DNA is translated. For example, certain proteins can turn genes on or off, or modify how much protein is made from (i.e. translated from) a gene. Epigenetic changes often happen due to environmental influences throughout a person’s life, and are heritable.

An estimated 40-60% of addiction risk is genetic, but researchers don’t know yet which specific genes are at the root of the risk. This is in part because, in the case of addiction, each suspected gene has a very small influence, but all the genes together seem to have a very large influence. To identify all of the small influences of the individual genes would require experiments with very large sample sizes.

The question of which genetic factors predispose people to developing addiction is further complicated by epigenetics, such that a person’s risk may be increased or decreased depending on his or her environment. The drug itself, social interaction, or stressful life events can all alter a person’s epigenetics so that the person is at higher risk for addiction. Because of these interactions between genetics and environment, so far it is impossible to say exactly how much of addiction is due to nature (genetics/inherited epigenetics) and how much to nurture (environment/experiences). It is safe to say that people are or become predisposed to developing addiction, probably due to both genetic and epigenetic variables.

Mental Illnesses and Personality Disorders

People with addiction can have co-occurring mental illnesses and personality disorders, for which they may have been self-medicating when they developed addiction. Some of the genetic risk for addiction may be indirect, via a genetic risk for other disorders.

“In fact, the majority of genetic influence on substance use outcomes appears to be through a general predisposition that broadly influences a variety of externalizing disorders and is likely related to behavioral undercontrol and impulsivity, which is a heterogeneous construct in itself.”
Dick 2016

One study found that 28% of people with alcohol use disorders (AUDs) and 47.7% of people with drug use disorders had at least one personality disorder. Specifically, 18% of people with substance use disorders (SUDs) overall (including AUDs) have antisocial personality disorder, a rate more than four times that of the general population, which may be the source of the myth of the “addictive personality.”

Disorders that are commonly comorbid with addiction include:

  • Anxiety and mood disorders
  • Schizophrenia
  • Bipolar disorder
  • Major depressive disorder
  • Conduct disorders
  • Post-traumatic stress disorder (PTSD)
  • Attention deficit hyperactivity disorder
  • Antisocial personality disorder

When these disorders precede the development of addiction, they are said to be precursors, and may contribute to overall addiction risk. We cannot say yet, however, whether any of these precursors have definitive, causal influence in the development of addiction.

Trauma

PTSD is one of the disorders most commonly comorbid with addiction, and warrants special emphasis. The relationship between trauma and addiction is very strong, and trauma is suspected to be a causal influence in the development of addiction. An estimated 66% of people with SUDs have experienced trauma, and about half have PTSD.

Trauma may include emotional, sexual, or physical abuse, and is especially damaging for children. Adverse childhood experiences (ACEs) are known to increase addiction risk, with children who have experienced 5 or more ACEs 7 to 10 times more likely to develop addiction. Even one ACE before the age of 15 doubles a child’s risk of addiction, based on a study of the population of Sweden. People who develop PTSD or experience trauma symptoms following community violence are also known to be at elevated risk for developing addiction.

Personality and Temperament

While there is no one addictive personality, certain personality and temperament traits are associated with higher rates of addiction.

“Yes, some stand out because they are antisocial and callous – but others stand out because they are overly moralistic and sensitive. While those who are the most impulsive and eager to try new things are at highest risk, the odds of addiction are also elevated in those who are compulsive and fear novelty. It is extremes of personality and temperament – some of which are associated with talents, not deficits – that elevates risk. Giftedness and high IQ, for instance, are linked with higher rates of illegal drug use than having average intelligence.”
Maia Szalavitz

Some of these personality traits may be or become severe enough to be diagnosable as a personality disorder, but in other cases a person may simply be prone to feeling anxious or hopeless, or being impulsive or sensation-seeking. These traits would also be accurately described as being precursors to addiction, possibly increasing addiction risk.

Attachment Security

Attachment theory has been studied for decades, beginning with research on infant-parent relationships, and expanding to research on adult relationships.

Attachment theory examines the quality of infant relationships with their caregivers, and correlates these relationships with the quality of relationships people have later in life. Basically, the more securely an infant bonds with a caregiver, the more secure that infant will feel in other relationships later in life.”
– Addiction Recovery with Others is Easier than Recovery Alone

Some theorize that addiction is an attachment disorder. Dr. Philip Flores is the founder of this idea, arguing that people with poor attachment are suffering from emotion regulation difficulties, and are essentially unable to regulate their self-esteem and relationships without healthy attachment. He posits that people suffering from insecure attachment use substance or behaviors to substitute for healthy relationships, which seem at first to help but ultimately exacerbate their problems.

We do not know whether Dr. Flores is correct, but we do know that insecure attachment styles are associated with addiction and with poor emotion regulation, as well as with other mental illnesses. Insecure attachment may therefore be considered to be another precursor to the development of addiction, in close association with the risk factors of co-occurring mental disorders.

Recently, researchers are exploring whether oxytocin (the neuropeptide and hormone thought to be responsible for social bonding) and social attachment may protect against addiction and stress. The neurological systems for stress coping and for social attachment overlap, and these researchers hypothesize that oxytocin is responsible for the transition people experience from wanting/searching for social attachment to liking/loving a person.

“The authors suggest that through dopaminergic, serotonergic and endogenous opioid mechanisms, oxytocin is involved in shifting the balance between wanting and liking in corticostriatal loops by facilitating consolidation of social information from ventral reactive reward systems to dorsal internal working models that aid in prospectively selecting optimal actions in the future, increasing resilience in the face of stress and addiction.”
Tops et al., 2014

Essentially, Tops et al. suspect that the process of developing familiarity and liking for other people, with the help of oxytocin, helps people to cope with stress, and makes them more resilient and less likely to become addicted.

Socioeconomic Influences

Poverty is a source of chronic stress, which may increase a person’s risk for mental illnesses. Fatal opioid overdose rates and emergency room visits are strongly correlated with unemployment rates, increasing 3.6% and 7% respectively for each 1% increase in unemployment. People in poverty are more likely to become addicted, in part because people in poverty are more likely overall to develop mental illnesses. Furthermore, mental illnesses may make it harder for a person to gain or keep employment and/or housing, which could lead to further or worsening poverty.

“Growing international evidence shows that mental ill health and poverty interact in a negative cycle in low-income and middle-income countries.”
Lund et al., 2011

Poverty is also known to have intergenerational influences, with chronic stress and poverty having epigenetic (therefore heritable) impacts on, for example, a person’s ability to cope with stress.

Other social-environmental influences may put someone at increased risk for addiction. For example, being surrounded by many people who use drugs tends to increase a person’s risk of developing an SUD, because the drugs are more available and people are more likely to use together more often. Furthermore, drug use in the home may result in more stressful situations, including poverty, that in turn put other people in the home at higher risk for addiction or other mental illnesses. Especially in cases of social isolation and poverty, such as in some rural areas of America, almost everyone in a community may develop addiction (e.g., the recent opioid epidemic).

Physiological Influences

Some people metabolize alcohol differently than others, and so are at higher risk for addiction. Some people are at heightened risk because of sleep disturbances or poor sleep quality. Others are at risk because of physical pain. People with physical disabilities, and/or traumatic brain injuries, are also known to be at higher risk for addiction. Women and men are equally likely to develop addiction, but sex, gender, race and ethnicity may influence the course addiction takes.

Developmental Stage

Adolescents are at higher risk for developing addiction, though many end up “aging out,” and recover on their own once their brains have developed. Human development is highly influenced by social environment, as well as genetics. If many of the above risk factors coincide with adolescence, a person is more likely to develop addiction.

Because of extreme variability in the precursors and predisposing conditions influencing the development of addiction, we may never have a one-size-fits-all treatment solution. By understanding all of the complex and interacting variables that predispose people to addiction, however, we can begin to determine which people are at highest risk, identify risks that we can mitigate, and create individualized treatment plans to ameliorate addiction, co-occurring mental and physical disorders, and life stressors.

Photo: Detail of collage, Mary Wilson Burnette Giles, 1963

This post was last updated 5/4/17.

A Packet of Evidence-Based Addictions Recovery Guidance

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