Outline of an Initial, Evidence-Informed Treatment Plan for Substance Use Disorder

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), 2014

Treatment Plan Goal: To assist individuals in living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society.

Objectives listed in priority order:

1 – Medical Care

  • Physical exam and diagnostic lab work
  • Assessment for suitability for medications for:
    – Substance use disorders (SUDs), including nicotine replacement therapy
    – Co-occurring mental illnesses
    – Physical illnesses
    – Physical pain
    – Sleep disturbances
    – Nutrition and diet
    – Assessment for neuroatypicality: sensory sensitivity and under-sensitivity (Unbroken Brain, Chapter 4); attention challengesautism spectrum
  • Assessment for suitability for follow-up care, additional treatment, and referrals

2 – Mental Health Care

Mental Health Assessment

  • Trauma (2/3 of all people with SUDs have experienced trauma)
  • Co-occurring mental illnesses (over 1/2 of all people with SUDs have at least one co-occurring mental illness)
  • Current stressors
  • Needs assessment

Counseling

3 – Support Services

  • Connect individuals with social services agencies to assist with current stressors and needs: employment, housing, transportation, child care, legal issues, etc.
  • Income: Assist individuals with finding jobs or applying for disability benefits.

4 – Social Support

  • Interests and preferences assessment
  • Experimentation with diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on individual interests and preferences

. . . . .

The goal of substance use disorder treatment is to assist individuals with living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society. A treatment plan describes how a person hopes to reach this goal, or to get help with reaching this goal, through specific steps, termed objectives.

Above is a brief outline of evidence-based treatment components for an individual beginning treatment for substance use disorder.  This treatment plan is evidence-informed, not evidence-based, because it, as a stand-alone protocol, has not been subjected to research.

I define evidence-based treatment as what research reports works for most people, most of the time, better than other treatments, and better than no treatment. Specifically, that means the treatment is supported by numerous, peer-reviewed scientific experiments with rigorous methods that include control groups, randomization of subjects to experimental conditions, and bias-free samples, with statistically significant results. Some treatments that are evidence-based to work for groups may not be helpful to a particular individual, however. It is an imperative that counselors and individuals continually monitor an individual’s condition and progress while engaged in treatment.

I contrast research data – the evidence resulting from research experiments – with “anecdotal data.” I define anecdotal data as an individual’s personal experience. Data from a sample size of one does not provide sufficient information from which a generalization can be made about a group or population. Principles believed to account for outcomes from inspirational individual stories, practitioner wisdom, or theories based on logic, cannot be safely applied to others without first subjecting those principles to rigorous research.

The content of this treatment plan is based on a synthesis of extensive literature reviews that I and Laurel Sindewald have conducted on substance use disorders and their treatment. The treatment plan is highly informed by Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, released in November, 2016.

The Surgeon General’s Report is current, with three exceptions: In terms of treatment effectiveness, research data does not support inclusion of 12-step approaches or rehab, nor does it support inclusion of naltrexone, or extended release naltrexone, as a primary treatment for opioid use disorder, equivalent to methadone and buprenorphine.

We link to primary sources reporting research data as available, and authoritative secondary sources that cite multiple primary sources. Our reports are here. Since nearly every word in this post could be linked to a source, I have only linked to sources for terms or concepts that may be unfamiliar to some. Feel free to contact me with questions or feedback.

This report may also be of interest:

A Guide for Clinicians to Initial Treatment for Alcohol Use Disorder

Last updated 2/7/18

The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, 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.

A Guide for Clinicians to Initial Treatment for Alcohol Use Disorder

The Surgeon General’s report, Facing Addiction in America, released in November, 2016, recommends a multi-pronged approach to addiction treatment, in this priority order:

1) medical care, initially from a primary care physician (PCP), to be assessed for a) suitability for medications, b) co-occurring or underlying physical conditions that may be causing stress or distress, including physical pain, and c) co-occurring mental illnesses that may be causing stress, distress, or instability.

2) individual counseling;

3) recovery support services (RSS) to reduce life stressors. Based on clients’ individual preferences, recovery-specific support group attendance may be part of RSS.

Alcohol use disorder (AUD) is defined as a disorder of the organ of the brain which requires medical treatment. Given the nature of the substance, abstinence, rather than harm reduction, is the recommended long-term treatment goal for AUD. Unfortunately, unlike with opioids, no safe dosing of ethyl alcohol exists.

The cognitive functions a person with AUD and other substance use disorders would need for abstention are the very ones impaired by the disorder itself: choice, decision-making, and recognizing the need for change, planning for it, and executing it. The neurobiology of addiction compromises the brain’s basal ganglia, extended amygdala, and prefrontal cortex and, thus, under-sensitizes one to pleasure, over-sensitizes one to pain, automates use of the substance to feel normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
– Nora D. Volkow, M.D, Director of the National Institute on Drug Abuse (NIDA), quoted in What We Take for Granted

Other than with 1) medication and 2) time without exposure of the brain to the substance, brain structures and pathways impaired by AUD currently cannot be directly, immediately and efficiently treated for AUD. Therefore, individuals’ self-care efforts and counselors’ therapeutic efforts will focus on supporting abstinence rather than on attempting to directly treat the brain for addiction.

Alcohol use, even in small amounts, can compromise brain functioning and physical health. In those with alcohol use disorder, physical and behavioral symptoms can be life-threatening to themselves and others. Alcohol withdrawal can be a dangerous, deadly medical condition. Even nurses can be challenged by the symptoms. If a client needs emergency care, call 911. If a client needs urgent care, arrange for it.

The following guide applies to clients who are stable and not in need of urgent or emergency care.

Medical Care

Assist individuals with procuring health insurance and making appointments with medical professionals, beginning with the primary care physician (PHP). If the client does not have health insurance, query community sources for assistance.

(This is normally in the realm of case management rather than traditional clinical sessions, but helping the individual make the phone calls and appointments accommodates possible cognitive impairments associated with use and/or early abstinence. If it’s a personal fit for clinicians, they may consider accompanying individuals to medical appointments.)

Ask non-abstaining clients to keep a log of their consumption of alcohol.

Ask clients to make a rank-ordered list of physical symptoms that cause them stress or distress. (Include physical pain and issues with sleeping and/or eating.)

Ask clients to make a rank-ordered list of mental or psychiatric symptoms that cause them stress or distress.

Help clients compile this data: 1) consumption log (if applicable), 2) physical symptoms, 3) mental or psychiatric symptoms.

Coach clients in advocating for evidence-based treatment when they meet with their PCP. Few PCPs have time to stay up-to-date on the latest in addiction treatment given most work overtime to meet the demand for health care which exceeds capacity. Unfortunately, many PCPs continue to hold the belief that alcoholism is a personal, moral, mental, or criminal problem rather than a medical one.

In the brief appointment clients will have with PCPs, they need to try to make these things happen:

1) Ask to be assessed for medical management of tapering and for medical management of potentially dangerous withdrawal symptoms, including a cost-benefit analysis of the risks of outpatient detox vs. highly stressful and disruptive inpatient detox.

Evidence-based guides to self-tapering from alcohol do not exist. This source, however, may be a place to begin for patient and physician to co-create a tapering plan based on the individual’s alcohol consumption log. Attending rehab is not an evidence-based method for achieving abstinence from substances.

2) Ask to be assessed for medications that assist with abstinence, based on use as recorded in the log. For some patients, naltrexone can be prescribed prior to abstinence, potentially improving progress towards abstinence.. (Here’s an NPR story on naltrexone for AUD.)

3) Ask to be assessed for blood work and for other diagnostic assessments to begin to treat the top items on the list of physical symptoms, or to begin to find the origins of the physical symptoms that are most problematic. Present a copy of the physical symptoms list for reference.

4) Ask for a referral to a psychiatrist now to get on the wait list for an appointment (local wait is 6-12 months). Present a copy of the psychiatric symptoms list for reference.

5) Keep the end in mind, i.e. accomplishing the tasks above, and stay self-regulated if – unfortunately possible – moralistic, judgmental, admonishing, shaming or dismissive statements are made by medical professionals during the appointment, or if follow-up treatment is delayed.

6) Make an appointment now for a follow-up visit with the PCP.

“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

Prior to the appointment with the PCP, provide clients with copies of these summary reports on first-line medications for AUD to take with them to offer as reference material if needed:

Fewer than 10% of people with AUD are offered or receive medications to treat the illness. Scientifically sound studies of the comparative efficacy of naltrexone, acamprosate, disulfram and gabapentin do not exist, although one study does compare naltrexone and camprosate. Finding the right medication, or combinations of medications, for each individual takes time.

At risk for premature death from an acute state of AUD, many clients do not have time for trial-and-error experimentation. They may have complicating physical and mental disorders as well. An expert medical opinion, ideally from a physician or psychiatrist, is crucial. We may only have one chance to medically assist a client so we need the most informed, experienced medical advice we can access on the client’s behalf.

Counseling

According to research, individual counseling is more effective than group counseling in helping people with substance use disorders achieve and maintain abstinence. Cognitive behavior therapy (CBT) and related dialectical behavior therapy (DBT), are the therapeutic modalities associated with abstinence. (Here’s a helpful self-directed guide to DBT.) Stress, distress, and exposure to substance-related, environmental cues are the primary precursors for a return to use.

A fundamental skill a person with AUD needs to acquire to increase the likelihood of maintaining abstinence can be termed “self-regulation.” Individuals who can self-regulate emotions, cognitions, attention, as well as moderate ways of relating to self and others, may limit or prevent the escalation of stress or distress to the state of near-dissociation in which a return may occur.

Trained counselors can assist clients with AUD by assisting them with developing self-regulation skills. Therapeutic rapport can help mitigate the stress and distress inherent in therapy and treatment.

In individual counseling sessions, or group sessions if individual sessions are not available, or as a supplement to individual sessions – taking into account cognitive limitations resulting from recent use and/or early abstinence – clinicians can assist clients increase responsiveness (vs. reactivity) to stress and distress, thus to decrease the likelihood of a return to use. Helping clients develop self-regulation requires a shift from focusing on anticipated “people, places and things,” “triggers,” or “choices,” to focusing on using self-regulation in highly unpredictable circumstances, whether with a person, a trigger, or otherwise (see Kaye, et al., 2017).

Since an estimated 70% of people with substance use disorder have experienced trauma, clinicians need to assess for trauma and, if present, given the likelihood of only a few therapy sessions, attempt to provide evidence-based, brief trauma therapy. (Brief interventions are few in number and are still being researched.)

Since approximately half of people with substance use disorder have co-occurring mental illnesses, clinicians need to assess for co-occurring disorders, particularly severe mental illnesses (SMIs) which may qualify clients for additional services.

Since substance use disorder is a 24-7 condition and manifests outside the clinical setting, inform and coach clients on self-care practices that support abstinence.

Recovery Support Services

Query clients about what external factors cause stress and distress in their lives. Ask clients to rank order them, then ask what small improvement would decrease stress or distress in the top three. Take steps to make the improvements happen that are beyond the client’s personal resources or network of connections, or help the client to make them happen.

Assist clients with exploring diverse interest groups, clubs, religious groups, support groups and/or other sources of social connection based on their individual interests and preferences. A sense of belonging, bonding or attachment can be crucial to helping people recover from substance use disorder.

Invite clients to attend support groups. (Choices in the author’s locale for recovery-specific support groups, in order of estimated numbers of attendees per year, are Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery and Celebrate Recovery. Information on local groups is here.)

On a case-by-case basis, support group attendance may be helpful to some individuals with maintaining abstinence. Support group attendance is not, however, an evidence-based treatment for the medical condition of addiction, any more than support group attendance would be treatment for the medical condition of cancer, diabetes, or other dangerous medical conditions.

Connect clients with social services agencies to assist with current stressors and needs such as employment, housing, transportation, child care, and legal issues.

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

. . . . .

Given that only one in ten Americans with substance use disorder receives treatment, and the contact a clinician has with a client may be brief, even one-time only, this guide is intentionally brief. It is a work in progress. It is updated as the latest research on AUD is published and the author reviews it.

“Evidence-based treatment” refers to specific treatment protocols that research scientists, through rigorous research methodology, have found work for most people most of the time, better than other treatments, and better than no treatment. Research, by design, reports on groups, not on individuals.

This guide is comprised of evidence-based treatment components, rather than belief-based or theory-based components. This guide, as a whole, has not been tested by research scientists, and therefore it cannot be termed “evidence-based.” It is, however, meticulously researched to include what the latest research reports is most effective. It is intended for informational purposes only and is not a substitute for individualized medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

The intended audience is counselors and clinicians who provide care for people with alcohol use disorders. Individuals and family members investigating current, evidence-informed alcohol use disorder (AUD) treatment may find the content useful as well.

Disclaimer: The views expressed are the author’s alone and do not necessarily reflect the positions of the author’s employers, co-workers, clients, 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.

For further reading:

Outline of an Initial, Evidence-Informed Treatment Plan for Substance Use Disorder

Additional reports on substance use disorder research and treatment by Handshake Media are here.

Last updated 12/21/17

Some Conclusions about Addiction from a Look at Some Numbers

Substance use disorders

Conclusion: Even when exposed to substances that can be used in ways that cause problems, most people don’t become addicted to them. Most people who develop addiction have problems already.

Note: For an individual, dependence, i.e. experiencing withdrawal symptoms without the substance, is not addiction, i.e. feeling compelled to persist in a behavior despite negative consequences.

Opioid use and opioid use disorder

  • 1 in 100 Americans, 12 and older, met the diagnostic criteria for opioid use disorder in 2015 (0.2 percent for heroin use disorder, and 0.8 for pain reliever use disorder). (Source)
  • 75% of people with prescription opioid addiction obtained the substance from a family member or a friend, not from a doctor. (Source)
  • 92% of people exposed to prescription opioids do not become addicted to them. (Source)
  • 3.6% of people who misuse prescription opioids try heroin. (Source)
  • According to a recent study, over 70% of pain patients who developed opioid use disorder had a prior history of psychoactive drug use. (Source reported here)
  • Heroin addiction is more than three times as common in people making less than $20,000 per year compared to those who make $50,000 or more. (Source)
  • From a 2017 study for approximately 70% of the patients sampled: “Our results suggested that self-treatment of co-morbid psychiatric disturbances is a powerful motivating force to initiate and sustain abuse of opioids and that the initial source of drugs – a prescription or experimentation – is largely irrelevant in the progression to a SUD [substance use disorder].” (Source)
  • Since 2011, overdose deaths from prescription opioids alone are down. Deaths from synthetic opioids, like fentanyl, are up.

Conclusion: Even when opioids – created by pharmaceutical companies – are prescribed by doctors, most people don’t become addicted to them. And socioeconomics matter.

Numbers from the New River Valley of Virginia

  • 16,000+ people in the New River Valley have alcohol and other drug problems. (Source)
  • According to local sources*, in 2015, the New River Valley had 34 cases of opioid overdose. Among those were 3 cases of heroin overdose, and 5 cases of fentanyl overdose.
  • According to local sources, in 2015, 11.4% of New River Valley high school students had misused prescription drugs in the past 30 days to “get high.” The national average is 3.2%. In 2015, 5.6% New River Valley high school students had used heroin at least once in their lifetimes. The national average is 3.2%.

Yearly death total statistics that make – and don’t make – the news in the U.S.

  • Marijuana overdose deaths: 0 (Source)
  • Terrorism-related deaths, U.S. citizens, overseas and domestic: 32 (2014: Source)
  • Opioid-related deaths: 35,000 (2015: Source)
  • Gun-related deaths: 35,000 (2014: Source)
  • Alcohol-related deaths: 88,000 (2015: Source)
  • Obesity-related deaths: 300,000 (Source)
  • Tobacco-related deaths: 480,000 (Source)

Conclusion: The selection of subjects covered by the media may not be due to high death rates.

*Grateful acknowledgement is made to New River Valley Community Services for synthesizing data from multiple sources for this post.

Laurel Sindewald contributed to the research for this post.

This post was prepared as part of a packet of handouts for a talk on the opioid epidemic by Anne Giles for the Montgomery County, Virginia Democratic Party on 8/17/17.

Last updated 10/26/17

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.

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 health 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.

Original segments of this post were first published by The Fix here, here and here.  This post was last updated 7/18/17.

. . . . .

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 handle 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 whom and with what you let into your 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.) Some people find the Headspace app helpful.

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 your attention 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 other people aren’t always available to help. 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.

8. Approach the idea of “acceptance” gently. Research on wisdom posits “five integral components of wisdom: emotional regulation; humor; critical life experiences; reminiscence and life reflection.” Research on emotion regulation equates acceptance and regulation, i.e. rejecting what is upsets; accepting what is calms. Acceptance is not approval, agreement, or taking responsibility for what is or what happened. It’s just a simple acknowledgement: The grass is green, the sun is yellow, and what happened happened and what’s happening right now is happening. Attempting to force, demand, or will oneself into acceptance, or worse, attempting to submit or surrender to acceptance – especially when others behaved unacceptably, even heinously – results in pain. As Maia Szalavitz wrote, our brains need more love, not more pain. Practice radical self-kindness when considering the idea of acceptance, radical or otherwise.

9. 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.

. . . . .

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.

A Packet of Evidence-Based Addictions Recovery Guidance

This post has been moved here.

 

Medication-Assisted Treatment for Opioid Use Disorder – Infographic

Medication-assisted treatment (MAT) with methadone and buprenorphine is the only known treatment – not abstinence, not counseling, not 12-step approaches – to cut death rates from opioid use disorder by 50-70% or more.

“The principle behind MAT is this: Because opioid addiction permanently alters the brain receptors, taking the drug completely out of someone’s system can leave them less able to naturally cope with physical or emotional stress…”

U.S. federal officials decry opioid misuse as a public health crisis, yet federal rules limit access to the only known effective treatment. Due to federal restrictions, few health care professionals are approved to dispense methadone or prescribe buprenorphine. Further, laws dictate how many patients those few can prescribe and, increasingly to whom, in what form, and how much medication can be prescribed. People suffer, even die, on wait lists to receive medication. In contrast, countries that effectively address their overdose crises, loosen, not tighten restrictions. Indeed, Stefan G. Kertesz, M.D. states, “The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder.”

In the event that lack of understanding of MAT may be contributing to restricting access to it, we offer this simple infographic explaining medication-assisted treatment (MAT) for opioid use disorder (OUD).

Medication-Assisted Treatment for Opioid Use Disorder

Medication-assisted treatment (MAT) does not replace one addiction with another. It creates stability by treating the medical condition of addiction. Currently, effective medications for addiction create dependence – negative symptoms from withdrawal if doses are discontinued – but not addiction, which, per its definition, involves continued use despite negative consequences.

Tolerance occurs when people’s bodies adapt to a drug over time, responding less and less to the same dose. In order to have an effect, doses must keep increasing for people to continue to get high, or to keep from getting sick. When people use opioids regularly, therefore, they tend to use more and more of the drug over time. Even if they stop using, then return to use, they are at risk for overdose because illegal drugs are not monitored, and so they may be cut with much more powerful drugs, such as heroin with fentanyl.

(Recent increased rates in drug overdose are due to heroin and illicit fentanyl, not prescription pain medications. Reported deaths in 2015 from opioids by prescription account for under 15%. Of those addicted to prescription pain medications, 75% received them from a family member, friend or dealer, not through medication prescribed to them.)

When people with OUDs enter abstinence-based treatment, or otherwise stop using, their tolerance drops. They may not know their tolerance is diminished, or they may not know how much it has decreased, and if they take an opioid at the high dose they were once used to, they are likely to overdose and die.

People who are given MAT for OUD take an opioid (buprenorphine or methadone) at a consistent dose, which effectively stabilizes them. Once stabilized on an effective dose, they do not experience withdrawals, cravings, or highs. They can provide child or dependent care, hold a job, adhere to treatment, and comply with the law.

In contrast, people who are not on MAT will experience withdrawal symptoms and strong cravings, especially when under stress. People with OUDs permitted only abstinence-based treatment are at high risk for all of the same problems people with untreated addiction are at risk for: recidivism and crime, unemployment, contracting and transmitting diseases, overdose and hospitalization, and fatal overdose. Up to 90% of people with opioid use disorder relapse when not on medication-assisted treatment.

Maintenance may need to be long-term, or even life-long, because while addiction lasts, people who terminate maintenance treatments are at elevated risk for fatal overdose.

The US opioid epidemic has changed profoundly in the last 3 years, in ways that require substantial recalibration of the US policy response…Heroin and fentanyl have come to dominate an escalating epidemic of lethal opioid overdose, whereas opioids commonly obtained by prescription play a minor role, accounting for no more than 15% of reported deaths in 2015…The observed changes in the opioid epidemic are particularly remarkable because they have emerged despite sustained reductions in opioid prescribing and sustained reductions in prescription opioid misuse. Among US adults, past-year prescription opioid misuse is at its lowest level since 2002. Among 12th graders it is at its lowest level in 20 years. A credible epidemiologic account of the opioid epidemic is as follows: although opioid prescribing by physicians appears to have unleashed the epidemic prior to 2012, physician prescribing no longer plays a major role in sustaining it. The accelerating pace of the opioid epidemic in 2015–2016 requires a serious reconsideration of governmental policy initiatives that continue to focus on reductions in opioid prescribing. The dominant priority should be the assurance of subsidized access to evidence-based medication-assisted treatment for opioid use disorder. Such treatment is lacking across much of the United States at this time. Further aggressive focus on prescription reduction is likely to obtain diminishing returns while creating significant risks for patients.
– Stefan G. Kertesz, M.D.

People with opioid addiction can live full lives as family members and citizens. MAT benefits the general public health, employers, law enforcement, taxpayers, and the human beings who need our help.

Infographic by Laurel Sindewald. A printable .pdf version is here.

Laurel Sindewald contributed to this article.

Related reports on addictions treatment, addictions recovery, and addictions policy from Handshake Media, Incorporated:

This post was last updated 5/4/17.

On Counseling and Medication-Assisted Treatment

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health categorizes substance use disorders, a.k.a. addictions, with “chronic and expensive medical illnesses” such as heart disease, diabetes, cancer, hypertension, asthma, arthritis, and chronic pain. The first order of treatment for these illnesses is medical care, primarily through medication. Patients with these illnesses are not required to receive multiple counseling sessions prior to receiving medication.

Challenging Myths about Medication Assisted Treatment for Opioid Use DisorderCounseling and support groups do exist for assistance with these illnesses. But counselors help patients comply with the course of treatment determined by their physicians. Support groups can help people live life while having the illness. But counseling and support aren’t replacements for medication and medical care. Except in addictions treatment.

Counseling is not medical care for a medical condition. We need to give people with the medical condition of substance use disorders (SUDs) medical care first – which may or may not include medication-assisted treatment (MAT) – but which may include stabilizing medical treatment for co-occurring mental and physical illnesses. Confusing medical care with counseling results in what the New England Journal of Medicine reported in December 2016: “Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death.”

With regard to MAT and counseling, my conclusions from reading the research are that for most people most of the time, counseling has no significant effect on abstinence among those receiving MAT for SUDs, whether for opioid use disorder or other SUDs. Counseling may have a larger effect on those with co-occurring SUDs and mental disorders, but those effects would occur over time. People with the medical condition of SUDs do not have time for the possibility that counseling might be effective. They are at higher risk of dying as long as they are not on opioid maintenance medication. They need medical care stat.

From the Surgeon General’s report, page 4-21: “Nevertheless, multiple factors create barriers to widespread use of MAT. These include provider, public, and client attitudes and beliefs about MAT…”

“Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials…Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.”
Cochrane Database of Systematic Reviews, 2014

We need to shift our policies from belief-based practices to what the science reports is best practices addictions treatment for people with substance use disorders: medical care first. Then, we can work on secondary, individualized assistance, perhaps counseling, case management, support groups, or support services according to each client’s case.

. . . . .

“In fact, no rigorous study has ever been able to show that the addition of psychosocial services to opioid agonist therapy alone improves outcomes in the treatment of opioid use disorder.”
Lean Forward, Harvard Medical School, May 2017

“Despite the demonstrated efficacy of maintaining abstinence by treating patients with opioid agonists, patients can remain on clinic waiting lists for months, during which time they are at risk of premature death. The use of interim treatment with buprenorphine without formal counseling while patients remain on waiting lists may mitigate this risk during delays in treatment.”
New England Journal of Medicine, December 2016

“Unfortunately, despite decades of research, it cannot be concluded that general group counseling is reliably effective in reducing substance use or related problems.”
Surgeon General’s Report, November 2016

“The commonly held belief that opioid agonist treatment alone is inferior treatment to such treatment combined with psychosocial treatment (which many will understand to mean counseling) is not supported by the research evidence and it results in limitations on the use of these effective medications.”
Journal of Addiction Medicine, July/August 2016

“[T]here is little empirical evidence suggesting which psychosocial treatments work best in conjunction with medication-assisted treatment as there are relatively few studies comparing the differential effectiveness of various psychosocial approaches (eg, CM [contingency management], MI [motivational interviewing]) for individuals receiving medications for the treatment of opioid addiction.”
Journal of Addiction Medicine, March/April 2016

“Patients who received only psychological support for opioid dependence in England appear to be at greater risk of fatal opioid poisoning than those who received opioid agonist pharmacotherapy.” – Addiction, November 2015

“Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods…OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction.”
– Journal of Substance Abuse Treatment, October 2015

“Supplementing standard medical management with cognitive-behavioural therapy did not further reduce opioid use or promote abstinence among primary care patients being maintained on buprenorphine.”
Drug and Alcohol Findings, 2013

“For the considered outcomes [retention in treatment and use], it seems that adding any psychosocial support to standard maintenance treatments do not add additional benefits.”
Cochrane Database of Systematic Reviews, 2011

“Consistent with results from a previous study of predominantly heroin-dependent patients receiving buprenorphine-naloxone in a primary care setting, individual drug counseling did not improve opioid use outcomes when added to weekly medical management visits.”
Archives of General Psychiatry, 2011

“We conducted a 24-week randomized, controlled clinical trial with 166 patients assigned to one of three treatments: standard medical management and either once-weekly or thrice-weekly medication dispensing or enhanced medical management and thrice-weekly medication dispensing…All three treatments were associated with significant reductions from baseline in the frequency of illicit opioid use, but there were no significant differences among the treatments.”
New England Journal of Medicine, July 2006

The Comprehensive Addiction and Recovery Act (CARA) requires that an MAT treatment provider be able to provide or refer patients to counseling. Other than this wording in CARA – “appropriate counseling and behavioral therapies” – neither mentions the type, length or number of sessions of counseling required. Wisely, for an individual, the law does not require him or her to receive counseling in order to receive MAT. Unwisely, in Virginia, Medicaid patients are required to receive SUD counseling in order to be covered for either methadone or buprenorphine.

Image: Challenging the Myths about Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD) from The National Council for Behavioral Health

Laurel Sindewald contributed to the research for this report.

Last updated 7/30/2017.

Addiction Is Not a Choice

Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health makes the current discussion we have about addiction, i.e. helping people with addiction “make better choices,” “make better decisions, or “understand the consequences of their behavior” – whether coerced through drug court or supported through counseling – well-meaning but, unfortunately, irrelevant. Addiction compromises all of those functions in the brain.

The brain no longer does what it needs to do in a person with addiction, just as a pancreas no longer does what it needs to do in a person with diabetes. Medical care for a brain illness – not tough lovearrest, commitment to a mental institution, or recovery support services – needs to be the first order of treatment, including assessment for suitability for medications. Medications need to be prescribed by qualified medical professionals, not by non-qualified court officials or lawmakers.

Surgeon General: I'll stand up for recovery with you

We would rush our neighbor with acute diabetes to the doctor. Why don’t we rush our citizens with an acute brain disease to the doctor as well? Because, at essence, contrary to scientific evidence, we still believe addiction is a choice. We believe that if people with addiction could just see the errors of their ways and would work hard on those errors (rather than be lazy, immoral, selfish, self-indulgent, or inadequately faithful or spiritual), addiction would go away.

Working hard on one’s ways may help one live a better life. Might working hard to be a better person alter the brain in targeted ways that reverse or  ameliorate addiction? Possibly. Neuroscience research may ultimately support that. Certainly on ways to live a better life, many people, both with and without academic or medical credentials, can offer helpful guidance. But, for now, what we know is that addiction is a medical condition, 1 in 7 Americans is expected to get it, a person dies of a drug overdose every 19 minutes in the U.S., and only a fraction of those who need help are receiving it. For this dire medical condition, insufficiently treated such that a public health crisis has occurred, medical care is an imperative.

Do no harm” is a principle of health care. By stubbornly holding onto the concept of “choice” – in spite of the data that says we’re simply wrong to do so – we’re harming, even killing, our own citizens when we require them to, at essence “be better and do better,” rather than provide them with medical care.

May the Surgeon General’s report inform and direct the treatment we provide our fellow citizens struggling with the grave and dangerous medical condition of addiction.

. . . . .

On 11/17/16, the U.S. Department of Health & Human Services issued Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.

Here’s a link to the YouTube video of the 3-hour presentation of the Surgeon General’s report.

Here’s Maia Szlavitz’s commentary on the Surgeon General’s report.

This post is an updated and expanded version of my letter to the editor about the Surgeon General’s report published by the Roanoke Times on 12/13/16.

Applications of Neuroscience Findings to Addictions Treatment

The article annotated and excerpted below, published in 2013, offers a conceptual framework through which to apply the findings of neuroscience to addictions treatment. It may be explosively important. Translating its offerings into practical applications will be difficult. The article is lengthy, written in highly technical language, weighs in at 9,300+ words, and cites 182 sources.

My intention is to attempt, however, to do just that. The work by Eric Garland, et al. – new research funding was just announced 9/6/16 –  could have weighty implications for individuals with substance use disorders (SUDs) and for SUD treatment professionals. My intention is to continue writing about addiction and addictions treatment as simply and directly as I can.

To that end, I have excerpted, annotated, added explanatory links to, and re-formatted the conclusion from Mindfulness Training Targets Neurocognitive Mechanisms of Addiction at the Attention-Appraisal-Emotion Interface and intend to link to this post from other writings.

We offer the following speculative, hypothetical account [demonstrating the conceptual framework described in this paper that applies findings of neuroscience to addictions treatment] based on our clinical and research experience using MBIs [mindfulness-based interventions] to treat persons diagnosed with substance use disorders.

When a recovering addict with a history of using drugs to cope with negative emotions encounters a cue associated with past drug-use episodes while in the context of a stressful environment (e.g., walking past a bar after getting in an argument with a work supervisor), this encounter may activate cortico-limbic-striatal circuits subserving drug-use action schemas. [In other words, the encounter may activate brain structures related to feelings, thoughts and behaviors associated with drug use. The authors write, “The urge to seek intoxication from addictive substances is driven, in part, by reactivity to substance-related stimuli [cues] which have been conferred incentive salience [priority importance], and is magnified by negative affective states.” The authors define “drug-use schemas” as “memory systems that drive drug seeking and drug use through automatized sequences of stimulus-bound, context-dependent behavior.”].

After completing a course in mindfulness training, the addict may become more aware of the automatic addictive habit as it is activated, allowing for top-down regulation of the precipitating negative emotional state and the bottom-up [brain structured-based reactivity] appetitive urge. [“Top-down regulation” is not to be confused with “willpower” or  “suppression” which, according to neuroimaging research, actually results in “hypoactivation in cognitive control circuits.” Attempts to suppress urges, paradoxically, result in 1) increased urges, 2) decreased resilience with regard to emotionally stressful events which is correlated with return to use, and 3) depletion of cognitive resources, thus increasing the likelihood of a return to automatic behavior to use vs. conscious behavior to abstain.]

Specifically, the individual may engage in mindful breathing to first disengage from and then restructure negative cognitive appraisals, thereby reducing limbic (e.g., amygdala) activity, autonomic reactivity, and dysphoric emotions related to the stressor. Concurrently, the individual may become aware of when his attention has been automatically captured by the sight of people drinking in the window of the bar, and, through formal mindfulness practice, activate fronto-parietal mediated attentional networks to disengage and shift focus onto the neutral sensation of respiration.

During this process, as sensations of craving arise, the individual may engage in metacognitive [the ability to become aware of, and direct, one’s thoughts] monitoring of these sensations, and in so doing, facilitate prefrontal down-regulation of limbic-striatal activation. [Author Maia Szalavitz uses the metaphor of a “volume control” to explain a person’s ability to up-regulate or down-regulate his or her own inner state.] As mindfulness of craving is sustained over time without drug-use, the sensations of craving may abate, promoting extinction learning to weaken associative linkages between conditioned addiction-related stimuli and the attendant conditioned appetitive response. [If “appetite” for drinking or using is present, but is not satiated with the anticipated reward, the tie between use and the reward lessens over time.]

Once working memory has been cleared of active representations of substance use, the individual may shift attention to savor non-drug related rewards, such as the sense of accomplishment that may arise from successfully resisting the temptation to drink (i.e., self-efficacy), appreciating the beauty of the sunset on the walk home without being clouded by inebriation, or the comforting touch of a loved one upon returning home safe and sober. [“Savoring” is defined by the authors as “selective attention to positive experience.”]

Through repeated practice of regulating addictive responses and extracting pleasure from life in the absence of substance use, the individual may re-establish healthy dopaminergic tone [to replace atrophy resulting from substance use] and foster neuroplasticity in brain areas subserving increased dispositional mindfulness. [“Dispositional mindfulness” is defined as awareness of, and attention to, what one is feeling and thinking in the moment.]

Ultimately, mindfulness may facilitate a novel, adaptive response to the canonical “people, places, and things” that tend to elicit addictive behavior as a scripted, habitual reaction. In so doing, the practice of mindfulness may attenuate [reduce the power of] stress reactivity and suppression while disrupting addictive automaticity, resulting in an increased ability to regulate and recover from addictive urges.

Posts that link to this post:

  • Forthcoming

Want to Help Our Community? Volunteer for SMART Recovery

For those beginning to discover they’re doing something they want to stop – or have tried stopping something and are having trouble – SMART Recovery welcomes all. Whether one struggles with alcohol and other drugs, smoking, gambling addiction, Internet addiction, sexual addiction, self-injury, problematic eating behavior, problematic relationships, or issues with other substances and activities, SMART Recovery meetings are the place to gather and talk with people addressing similar challenges.

What science is telling us and we know from personal experience is that we do better making changes with support from others!

If you’re interested in helping your community address its challenges with addiction, I invite you to train to become a SMART Recovery discussion host.

Based on my professional and personal assessment, holding SMART Recovery meetings is the closest we can get to community-wide, evidence-based, group-based addictions recovery assistance using resources already in place.

Welcome to SMART Recovery!

If we can, as a community, host SMART Recovery meetings every day at different times all over the area, we can provide free, near-treatment-level assistance to our people with addiction challenges. We don’t need to form task forces, write grants, or lobby public officials. We just need community members to do the training and sign up as hosts with SMART Recovery, and for community organizations with buildings to offer spaces for meeting locations.

  • SMART Recovery discussion meetings are free and open to anyone in the community.
  • Volunteers hosts DO NOT have to be in recovery from addiction to serve. Any community member – from the mayor to the maki maker to the mechanic – can serve as a discussion meeting host.
  • While discussion meetings are not generally facilitated by experts or licensed professionals, meetings focus on learning skills termed “tools” and are guided by trained hosts, thus extending the therapeutic value beyond more sharing-oriented support group meetings.

Here’s more information:

If you’d like to experience in-person what a SMART Recovery meeting is like, this meeting is open to all and you are welcome to attend:

Sundays, 4:00 PM, New River Valley Community Services, 700 University City Boulevard, Blacksburg, Virginia.

We’re compiling local recovery support resources here.

If you have any questions, feel free to contact, Anne Giles, [email protected], 540-808-6334.

(If you email me and don’t receive a reply, please check your spam folder. If you don’t see a reply in your spam folder, please phone or text me and we’ll connect that way!)

Hope to join you in volunteering with SMART Recovery!