Category Archives: Relapse

Friday Sober Jukebox – Just an illusion

So riffing off of last week’s track it’s another shot of Imagination!  Why this track?  Because in the last week I’ve been flirting with my old life again.

Illusion-1-GlamourousWe moved house and had dinner in the local pub across the road on the first night.  We had AF fizz to celebrate handing in the keys to our old place last Friday and then we had dinner in the pub AGAIN – my suggestion.  I’d not been running all week what with moving and kids summer holidays, meditation had fallen by the wayside and my mind was squirrely.  Wolfie had woken from his slumber, triggered by all the chaos and change and stress and was whispering in my ear – and for the first time in a long time I was listening.  I could feel myself slipping ……..

Chocolate and an early night and I came to my senses.  Went out for a run and this tune popped into my head.  In the warm light of the sunny Saturday morning run I could see what was happening and that I was kidding myself – that it was all just an illusion and I’d almost been suckered.  Almost.  The lesson I learned is that even at almost 2 years sober life can unsettle you enough to think that drinking might once more be a good idea – even if only for a fleeting second a few days in a row.  The door to the idea opens again and you have to be really vigilant to your own sh*tty thinking.  No harm done but even so – phew!

PS If you want a cold bucket of water pouring over you tonight about drinking and its consequences then I recommend you watch this:

Every year more than 250 people die on Britain’s roads as a result of drink driving. In 2014, North Yorkshire Police arrested up to a thousand drivers for being above the legal alcohol limit, and with some of the highest rates of drink driving in the country, all too often North Yorkshire’s traffic officers are faced with the tragic consequences of motorists driving under the influence.

 

Wanting vs liking

I’m fascinated by the processes that inform and drive addiction to substances and behaviours.  The nurse  and psychology graduate in me just loves this stuff and I love to share it because if we can understand it better it gives us more tools to tackle it.  So in the first of two posts I’m going to look at incentive sensitization and then kindling or more simply ‘wanting vs liking’.

wanting vs liking
wanting vs liking

I found an excellent article on the PLOS blog looking at the development of addiction.  This is what they said:

Sometimes, while daydreaming in the shower or in the car, an insight hits you out of the blue. That happened last week. It occurred to me that the best neurobiological model of addiction has a serious missing link. Addiction develops. It grows. A successful theory of addiction needs to be a developmental theory – a theory of neural development.

In my view, the neural basis of addiction is best captured by Berridge and Robinson’s model of incentive sensitization. In a nutshell, these researchers show that “wanting” and “liking” are quite independent, subserved by different neurochemicals, and addiction is characterized by “wanting,” not “liking.” That helps explain why addicts keep on craving – and obtaining – their substance of choice long after it stops being pleasureful. The research supporting the model shows that, contrary to a tenacious myth, dopamine does not cause pleasure. Rather, dopamine is critical for the pursuit of goals, including the behaviors required to reach them and – most important– the powerful motivations needed to execute those behaviors. According to Berridge and colleagues, dopamine gets released from the midbrain in buckets when addicts are presented with cues associated with their substance of choice.

A sight, sound, or memory, reminiscent of that stuff (e.g., a cramp in the gut, the fleeting glimpse of someone who looks like a drug buddy, a scrap of paper dotted with a few flecks of white powder) will activate dopamine release and send it straight to the nucleus accumbens (NAcc; a major component of the ventral striatum) where it induces goal-oriented behavior (when the stuff is available) or craving (when it’s not).  But the power of cues to elicit the addictive impulse must take time to develop. It’s not present the first time you try drugs or booze, or even necessarily the 20th time. This process is therefore called incentive sensitization; because the cues that trigger drug seeking become sensitized over time.

The trouble is, Berridge and colleagues don’t explain how this sensitization takes hold. The cues must be processed somewhere in the back half of your brain (where “perception” first arises) and they must activate the amygdala, the famous limbic structure that produces emotional feelings on the basis of perception. But how do these perceptual and evaluative processes come to trigger the urge, the thrust, the powerful desire that is the essence of approach motivation? That would have to take place in the frontal cortex and its master motivator, the striatum.

Tomorrow we’ll look more closely at the phenomenon of kindling and how the two form a powerful neuroadaptive cycle within the brain.

Experiencing Recovery

Thanks to Paul over at The Alcoholics Guide to Alcoholism for sharing this video originally.  It’s some footage of a presentation looking at the recovery experience given by William White a Senior Research Consultant in the US who I remember seeing interviewed as part of the documentary film The Anonymous People last year

It was the slide at the end that really struck me.  He had done a review of 415 studies in 2012 and found that 5-15% of all US adults were in remission from substance use disorder (SUD, not including nicotine).  That’s 25 -40 million citizens.  Here in the UK that would be 2.5 – 7.4 million.

And more amazingly the rate of recovery was much higher than any statistics I had heard before.  Since 2000 the recovery rate in community populations was 53.9% and 50.3% in clinical studies. So over half were living in recovery and yet the meme that I have always heard is that it is a chronic relapsing condition and that success rates were small.  As William White says this should ‘in and of itself challenge the public perception and growing pessimism around recovery‘.

As Paul said we need this to be the research focus of the future.  As William White says we need to stop studying the pathology of addiction and start researching and following the recovery experience.  I’ll drink something non-alcoholic to that! 😉

 

 

Study on mindfulness based relapse prevention

I’m including this study here because I personally ascribe to this approach and if I think about the sober bloggers that I know, Mrs D in particular, I know that this is a tool used with great success.

Promising signs – but from a single study at a single treatment agency – that integrating Buddhism-inspired mindfulness-based elements creates a more effective supplement to usual (in the US context) 12-step based aftercare than a purely cognitive behavioural approach, helping patients sustain gains from initial intensive treatment.

Summary The featured study tested an intervention based on Buddhism-inspired mindfulness meditation as way of sustaining the gains made by patients who have completed initial intensive treatment. The therapy trains people to focus their attention on emotions, thoughts, and sensations occurring in the present moment and to adopt an accepting and nonjudgmental stance to these experiences. Such controlled attention can be learned through training in meditation, hence ‘mindfulness meditation’. Benefits may for example include the detached self-observation of one’s desires and plans to obtain and use drugs, dissociating these from their emotional force.

Meditation has been incorporated in many therapeutic programmes, commonly in the form of mindfulness-based stress reduction, originally developed for management of chronic pain and stress-related disorders. The usual course consists of eight weekly therapist-led group sessions, one full-day retreat, and daily ‘homework’ assignments. Mindfulness is central to dialectical behaviour therapy developed for borderline personality disorder, acceptance and commitment therapy for mental health problems, and spiritual self-schema therapy for substance use problems. This approach has also been allied with cognitive-behavioural elements, notably in mindfulness-based relapse prevention programmes developed for substance use patients – a version of which was tested in the featured study.

The 286 patients in the study had completed initial 28-day inpatient or 90-day intensive outpatient treatment at one of the two clinics of a US service. Typically they were unemployed men in their thirties and forties who used several drugs with or without alcohol; for just 14% were their substance use problems confined to alcohol.

Authors conclusions:

These findings suggest that the three aftercare options may have been equally effective in the three months after the two relapse prevention programmes ended. After that, these programmes gained greater benefits compared to usual treatment alone, blunting the probability and severity of relapses at the six-month follow-up. By a year after they had ended, the approach incorporating mindfulness elements emerged as preferable to one based solely on cognitive-behavioural elements. Longer-term benefits may be explained by the therapy’s ability to help patients recognise and tolerate discomfort associated with craving or negative emotions and moods. Continued practice in mindfulness over time can strengthen the ability to monitor and address factors contributing to well-being, bolstering long-term outcomes.

Go to the link  below to read the full summary:

http://findings.org.uk/count/downloads/download.php?file=Bowen_S_2.txt

In my personal experience, and that is all it is,  I believe that CBT and mindfulness are a good way to manage long term recovery and minimise the danger of relapse.  I will continue to share what I learn about mindfulness and as I learn more myself over the coming months at Cambridge.  If you’ve been using mindfulness has it been helping you?

Abstinence violation effect

This is something I’ve been thinking about for a while and thought it was about time I wrote a blog about it.  With just a week to go until I hit one year sober I’ve been thinking about what would be the impact of having a drink.  Now don’t get me wrong I am not thinking about having a drink I’m just interested in the whole counting days thing and how it differs to when I gave up smoking.

When I gave up smoking if I lapsed I would think of it as a slip and get back to not smoking.  I didn’t consider it going back to day 1 – I saw my quit attempt and stop date intact with a small blip.  But in the world of giving up booze it is very different and I don’t know where that comes from.  If anyone can share what the source is of this much more ‘all or nothing’ view I’d love to know.  This difference in view between a lapse and relapse has consequences for how we see ourselves and our actions about further drinking moving forward.  If I lapsed and had a drink now it would feel like the whole year had been wasted as I would have to go back to day 1 and that would probably lead to me thinking “well  I’ll keep drinking then”.

It is recognised and called the ‘abstinence violation effect’ (AVE) which is defined as “what happens when a person attempting to abstain from alcohol use ingests alcohol and then endures conflict and guilt by making an internal attribution to explain why he or she drank, thereby making him or her more likely to continue drinking in order to cope with the self-blame and guilt”

The problem with this way of thinking is that a lapse has the potential to become a relapse and then a collapse.  That moment of yielding fully to addiction is what Alan Marlatt, director of the Addictive Behaviors Research Center at the University of Washington, describes as “a form of black-and-white thinking,” says Marlatt. “You blame [your failure] on internal factors that you consider beyond your control.”

Those factors, such as a belief that addiction is a disease that robs you of free will are what derail thousands of quitters and abstainers. You could also call it the “f___ it” effect, the idea that once you cheat, you’ve blown it, so you might as well binge. In traditional 12-step programs for addiction, that line of thinking is encapsulated in the slogan “A drink equals a drunk.” But understanding and overcoming AVE, says Marlatt, is crucial to conquering a problem behavior or dependency in the long term. You have to know what to do when you fall off the wagon to learn how to stay on it.

And this is where my ponderings and Marlatt’s article in Time magazine come together:

While studying cigarette smokers who were trying to quit in the 1970s, Marlatt discovered that people who considered the act of smoking a single cigarette after their quit date to be a complete defeat and evidence of an innate and permanent lack of willpower were much more likely to let a momentary lapse become a full-blown relapse.

Most people who try to change problem behaviors will slip at least once. Whether that slip provokes a return to full-blown addiction depends in large part on how the person regards the misstep. “People with a strong abstinence-violation effect relapse much more quickly,” says Marlatt. A single slip solidifies their sense that they are a failure and cannot quit, creating a self-fulfilling prophecy.

So I guess the question becomes is counting days helpful?  If I was to consider a one off return to drinking as a slip rather than a relapse would it help me get back in the saddle quicker after the event?  This will remain a hypothetical question of course but do we need to change our perspective on counting days and moments of lapse?

7 days to go

PS If you’d like to say thank you for the blog by making a donation to Alcohol Concern you still can!  Go here 🙂

 

Chunking and addiction formation in adolescents

Amy, a US public health nurse and I were discussing after the PHE and alcohol (2) post the issue of catching addiction in adolescents before it became entrenched.  I said in the comments  A great deal of research has been done between smoking cannabis at a young age and the pruning of the neural network that happens at that time in adolescents and how it pretty much locks in the addiction but the same has not been done with drinking. I’d be interested in that as I think many of us started drinking at this young age and I wonder if the same neural network pruning also happens around booze.

Well low and behold if later that day I didn’t read an article discussing exactly that!! I love it when that happens 🙂   The piece by Aeon Magazine was shared on FB and is a debate about the 12 step approach which I am going to side-step and focus on these bits that I found interesting:

Her multiple relapses, according to recent science, are no ethical or moral failing – no failure of will. Instead, they are the brain reigniting the neurological and chemical pathways of addiction. Ruben Baler, a health scientist at the National Institute on Drug Abuse in the US, told me that, once the circuitry of habituation is in place, it cannot be destroyed or fully overwritten. ‘The brain will never go back to a pristine, naïve, drug-free state,’ Baler said. It would be like reversing time itself.

This permanence is the result of a process that researchers call ‘chunking’: a person using drugs or alcohol experiences a burst of the activating neurotransmitter, dopamine, encoding memories and stimuli associated with that high in the brain. As substance use turns chronic, that same networks in the brain are increasingly engaged, and eventually the habit becomes automatic. Baler likens it to riding a bicycle – once the brain knows what to do with the pedals, brakes and handlebars, the action is inevitable. When any part of this chain, or chunking, is triggered – maybe it’s a visit from an addict friend, or the sight of a McDonald’s where you once got high in the bathroom – it can lead to a full-blown relapse. That’s why lifelong abstinence can be such an impossible goal for even the most committed of recovering addicts.

Research describes a powerful chemical inertia that can begin early in life. In 96.5 per cent of cases, addiction risk is tied to age; using a substance before the age of 21 is highly predictive of dependence because of the brain’s vulnerability during development. And childhood trauma drives substance use in adolescence. A study of 8,400 adults, published in 2006 in the Journal of Adolescent Health, found that enduring one of several adverse childhood experiences led to a two- to three-fold increase in the likelihood of drinking by age 14.

Bingo! – this was exactly what we were discussing.  So if you started drinking around the age of 14/15 when your brain is undergoing an extensive growth phase with increased plasticity then it will literally hard wire in the dependence.  And this is what is so worrying as so many young are drinking before 18 and the industry encourages it with their brightly coloured spirit based alco-pops.  They are creating dependence at adolescence.  This is going to sound like a retrograde step but I would encourage the increasing of the age that you can drink in this country to be like the US where it is 21.  I appreciate there are ways round this with false ID’s, I did it too, but it would go some way to protecting the brain during this highly developing stage.  God the more I read and learn the more afraid I become for my children and the greater the urgency feels to do something about this before they reach adolescence ……

29 days to go

Edited to add 20th May 2016:

Hayle will be home to the UK’s first specialist drug and alcohol rehab unit for children

Bosence Farm Community in Hayle, Cornwall will treat youngsters for alcohol, drug and legal high abuse and is scheduled to open in November 2016

Thinking vs feeling

So I’ve been having a bit of a wobble again and it wasn’t anticipated so that always shakes me up more than usual.  It might just be PAWS again and I’m going to start keeping a record, as Prim suggested, but it might be something else and I need to learn from it to be better prepared next time.

When we’re coming up to big sober first events, such as birthday’s, parties and holidays we can anticipate, plan and prepare.  I even wrote a series of posts on relapse and failed to take my own advice in this instance!

What triggered my monumental wobble?  A job interview.  Why?  Because one of the reasons I drank was anxiety and managing it (I know I know, it makes it worse, rebound anxiety and all).  The job interview itself went well but it is the peaks in anxiety both before the interview – what if I say the wrong thing?  and afterwards – what if I said the wrong thing?  that feed my anxiety and this awakens the inner critic.  This quickly spiralled into vanishing self-compassion and positive feelings of self care towards myself and in a desire to drown out the negative chatter I wanted to reach for a drink to make it stop, albeit temporarily.

Perceived wisdom has it that you shouldn’t change anything major in the first year of recovery, and preferably even in the second year, as this can destabilise your fledgling sobriety.  Oh how right that wisdom is and how I should have listened rather than thinking that I was (a) different or (b) stronger than that.  The wisdom is there for a reason and it should be listened to and respected.

Why? Because although you can think about this stuff rationally, in terms of it’s a job interview and I have the skills and competence to deal with this and successfully secure the position, it will not necessarily help you in managing how you feel about the job interview process and putting yourself in situations that trigger your own insecurities in terms of anxiety and stress.

Lesson learned for next time which happens to be today as I have the second round of the interview process this afternoon.  Let’s hope I handle it better than last time! 😉

32 days to go

Relapse Prevention Plan

A relapse prevention plan is something that you can write down that will offer you the best chance of reducing the risk of relapse.

In it you include:

  1. Your relapse signature
  2. What you can do at each stage to cope
  3. Any life or psychosocial events that you feel may have triggered you in the past
  4. A list of people you can turn to for support either by phone, email or within communities

It is important to have documented this and to stick to it because at the time we can get so caught up in the ‘feeling’ that we fail to action any ‘thinking’ and this can lead to us engaging in the very type of behaviour we were trying so hard to avoid.  I found myself becoming very ‘hard of thinking about my drinking’ when a relapse was on the horizon either because I was overwhelmed, or I didn’t want to do it differently, for whatever reason.  Drinking felt almost ‘hard wired’.

Support for me has been the single biggest factor in keeping me on the sober path.  I talk to Mr HOF, I blog on here, I read and comment on others sober blogs, I hang out in sober communities whether it be here in the wider public sober blogging community, or whether in more private communities such as Soberistas, or the Booze Free Brigade on Yahoo, or any other kind of community.   You could attend an AA meeting or organise outpatient support through your GP if that is available.

Recovery is hard and can feel very lonely at times.  It can begin to feel like a relapse is inevitable, but it isn’t.  We always have a choice to pick up or not pick up a drink and I hope that these posts have added to your sober toolkit for the next time wolfie comes a-whispering in your ear  😉

Are there other sober tools I should add to my toolkit to make a relapse preventable?

Psychosocial stress

We all have days where we feel stressed or low and what is important is to learn to recognise what is your normal ‘ups and downs’ and the early warning signs.  For me if I notice a change that goes on for longer than a week then I would become more watchful and mindful.  These changes might be in my:

  • Mood/feelings
  • Thoughts/beliefs
  • Sleep pattern
  • Eating habits
  • Personal care
  • Socialising/relationships

There are some life events that we cannot control and we have to learn to live with them without falling prey to the drinker’s reflex of picking up a drink to cope.  This is not always easy but the longer time goes on the easier I find it to not resort to this old coping strategy.

Things to consider would include:

  • New job/promotion/redundancy
  • Moving house/leaving home
  • Relationship/friendships/family – loss/divorce/death
  • Holidays/social events/outings
  • Birthdays/anniversaries/Christmas/New Year
  • Health issues
  • Major news events

You can reduce your risk of relapse by:

  1. Changing the things you can change
  2. Learning to recognise your sources of stress
  3. Learning better ways of coping with the things you can’t change

Are there any other life events that are stressful that I’ve forgotten that I need to watch out for too?

 

Coping Strategy Enhancement

We all have ways of coping when things aren’t going well in our lives or when we feel stressed.  For me one of those coping strategies was I used to drink.  I used to do other things too like run, read, escape into a film or music, talk to friends and I still do all of those things now – except the drinking 🙂

I didn’t realise that drinking was an unhelpful coping strategy, in fact it had a habit of making the situation feel worse, but it was a habit that I had got used to and I had never tried to find a more helpful way of managing my stress.

So for me getting drunk in the short term was helpful because I was able to forget about the problem and it would allow me to feel relaxed and confident.  But if I overdid it I would feel sick and dizzy, I would do things that would embarrass myself, I might feel more angry or depressed and that would lead to me getting what my friend would call ‘tired and emotional’ i.e. crying, or getting into fights.  I would have a hangover and spend too much money that I could ill afford to spend.

And long term it became an over used coping strategy leading to dependence, it created minor health problems, I offended friends and family, fortunately I never got in trouble with the police (but more by luck than judgement) and it caused money troubles.

So what I needed to do was ‘beef up’ my non-drinking strategies to counter-balance the choice of not drinking!

So I developed new strategies, such as this here – my sober blog.  I also connected with other sober people both real and virtual, I focused my attention on other activities that didn’t revolve around drinking, like the cinema, going for walks, meeting for tea not beers.  You need to think creatively about how you spend your time and where you focus your energies and attention.  You can look at each of your coping strategies and create a decision table to help you decide if what you are doing is positive and helpful or negative and unhelpful, both in the short term and long term.

When you are feeling negative about not drinking I found I had to work really hard at it, and at times it felt like a slog, but ‘faking it till you make it’ does work!  Connect when you don’t really feel like it, reach out when you don’t want to.  My wanting to withdraw was ALWAYS a sign of a relapse in the making.

What coping strategies have you used that I could benefit from? 🙂