Monthly Archives: July 2016


surrenderSo today my family & I fly to Australia for a month.  A hard earned & saved for treat for over 1000 days sober (1043 today to be exact!)  I can’t quite believe we’ve achieved this many days or this extended holiday.  As with my other breaks it will also be a cyber holiday so I’m leaving this post up until I return and linking a copy of my e-book here for you to download while I’m away should you want to:

Free ebook here 🙂

My online course is self-directed so remains available during this time but can I direct you to Udemy if you have any technical issues.  Equally any comments on the blog or emails sent to me during this time will not be responded to until my return at the end of August.

Plus I’d like to thank a member of the BFB Yahoo for this blog post they called Surrender and if you’d like to read more of their writing you can do so here (she’s on day 145 now!)  Over to them and see you in a month 🙂

Good morning BFBers

Today is day 30 for me. It’s been a ride and a half and I am so grateful for the support of this group. The longest I have ever gone without alcohol with the exception of three pregnancies and a few military deployments was 11 days out of the last 20 some years. Ridiculously, I used to congratulate myself on going more than 24 hours without a drink and never could have fathomed a whole month. Yet, here I am.  And I feel deep down that I will never drink again. I made myself a promise that if I could make it this first month that I would come clean and share my story here.  There are obviously years leading up to all of this, but this is how I came to SURRENDER.
Thirty days ago I drank an entire bottle of whiskey in an attempt to “feel better” after I had a series of unsettling events. I see it all now as what it was: a painful wake up call from God. The day before my last drink, I had worked a twelve hour shift in the ER, 10 of which were spent taking care of a patient who was an alcohol overdose who was found unresponsive by her family. She had aspirated (inhaled her vomit into her lungs), then had an anoxic (lack of oxygen) brain injury and a stroke as a result. She was 4 years older than me and will probably never wake up again. She left three kids.
Instead of coming home and recognizing that situation as a cautionary tale and using it to examine my own drinking, I did what I always did after a rough shift: I drank. I drank about 5 shots of whiskey and then restlessly went to bed at 0300. My sweet son who has a lot of sensory issues and learning disability had a giant meltdown about his socks the following morning which, in my probably still intoxicated state I did not handle well. I yelled at him which made it all worse and he went to school feeling misunderstood and sniffly.  I sat down after taking the kids to the bus feeling like an utter failure, trying to shake the images of my patient the night before. Her kids crying at the bedside, her slack jaw, the medications I was using to keep her alive, the rhythmic hiss and whoosh of the ventilator that was breathing for her.  So… I drank some more. A lot more.
I fell asleep, and was awakened by my phone ringing; the school calling to tell me that I had forgotten to get my 5 year old off the bus. I stumbled to my car, looking like God knows what and went into the office.  I could hear my words slurring, burst into tears when she came out of the nurses’ office and made some probably unintelligible statement to all of the office ladies that I wasn’t feeling well and had laid down and not heard my alarm. I have no idea why they didn’t call the police or why they let me take my daughter.  Unless the idea that I, a mom with three kids at that school who is active and “together” could have possible been severely intoxicated at NOON was just too difficult to imagine.  Maybe they truly believed that I did have the flu or something.. I drove home the 0.8 miles to our house (yes, I’ve measured just how far I drove drunk with my precious daughter in the car), remember trying to make her a PB and J. I took another shot to  manage the guilt I felt when I realized that instead of jelly, I had dumped out a jar of olives onto the sandwich and had to start over.  That was the last shot in the bottle, so of course I opened the second. I made her a sandwich and then I don’t remember anything after that.  Apparently, my subconscious knew that I was in trouble because I called my husband (I don’t remember) and told him he needed to come home right away because I was messed up.
The next thing I remember was lying in the tub vomiting up my guts, with my husband trying to get me up and out of the shower. Me crying that I just wanted to die and finally saying out loud to him over and over “I’m an alcoholic.” Then passing out again.
I finally woke up at 11 pm that night in my bed, feeling like I’d been hit by a truck. I had bruises on my entire body; my face was throbbing.  I looked down and realized that my left knee was completely dislocated. It was like looking at someone else’s knee. I literally felt nothing; just thought, “huh, pretty sure my knee cap shouldn’t be sticking out the side of my leg.” I stood up shakily and it popped back in. I hobbled to the bathroom to see my face. My lip was swollen, my right front tooth was broken and the whole side of my face was purple.. I have no idea how I sustained those injuries.  My first thought was of my kids. I asked my husband where they were and he told me “you made R lunch, called me and set her up with a movie. She was watching Strawberry Shortcake when I got home an hour after your call. The other two are fine. I was here when they got home.”
I see all of those things now as Divine providence. The school staff should have called the police. I was in a grey-out when I drove my daughter home and didn’t crash or hurt anyone. I could have killed both of us driving like that. I gave myself a concussion smashing my face into something because I was too intoxicated to stand. I knocked out my front tooth and tore a ligament in my knee.  I could have been more severely injured, passed out, aspirated and been just like my patient the day before.  It had been building for a while and my husband had never seen me like that. And though the signs were probably there if he had been looking, he never noticed. What a spectacular reveal!  Like whipping that curtain away from Oz, everything was out in the open, warts and all and now this is the new reality.
My thoughts during that first night were so full of shame that I just wanted to die. I was in severe physical and emotional pain. I didn’t want to see my kids in the morning, knowing that I had failed them so utterly.  Whatever any one tells you or what you want to believe, this disease is PROGRESSIVE…  over the last two months that I drank I had reached the point that I had become the clichéd slurring, falling down mother who endangered her child, and endangered other people on the road with me. I never would have imagined that a few ” You deserve it/ Mommy’s time out” glasses of wine (which became bottles which became day time drinking which became binge drinking vodka or whiskey because I had so much tolerance) after my children were in bed would swallow me whole; destroy my self-respect, make me a caricature, a failure and shatter every illusion of perfection or control I had ever clung to. And all of that happened in the span of two years. To anyone on the outside, I looked like a “together” mom of three adorable kids who is a damn good nurse, a tough lady with a great sense of humor who has survived a lot of tough times in life, the tall redhead with the quick wit who has a reputation for being able to handle anything.  Except I couldn’t handle alcohol anymore. And I felt like a fraud. If anyone knew….
If you are struggling with moderation, thinking you can control it, I am here to tell you that if you are truly an alcoholic, this disease will not allow you to do that indefinitely.  At some point, down the road, and I can’t tell you when it will be for you…Something will happen. That feeling of dread you have, that worry about being a news story, or being the next Diane Shuler… That is the voice of God telling you to STOP NOW.
That first morning, hurting and hungover, it was clear that I could either choose death or choose to accept  the idea that I could never, ever drink again.  I was living on grace and borrowed time. Because I should have been in jail or dead.  So I chose SURRENDER.  If you are reading this and haven’t gotten to that place yet, I beg you to accept that you may not be given the choice later.  So pick life.
Ironically, the last two days have been the hardest of these 30. I’m struggling with sleep again, feeling down and lacking energy. My anxiety is flaring and I had two panic attacks in the last few days where I honestly thought I was having a heart attack… But fortunately I’m able to recognize all of this as symptoms of PAWS. So, I’m pushing through, trying to rest when I need it, giving myself slack and working on doing a LOT of breathing and pausing.  The biggest thing I’ve learned in this last month is that just because I’m feeling something uncomfortable, I don’t have to fix it immediately.  I’m a person who hates unresolved things… always had to fix everything the very second that it cropped up. And if I couldn’t fix it, then I would just drink to feel better about it. Now, I’m finding that I don’t have to have knee-jerk reactions, don’t have to sacrifice my own well-being to make others feel better, or manage their emotions to the detriment of myself. I don’t have to “fix” it all right away. It can just BE for a while.
This of course makes me very uncomfortable and uneasy. But I have that little voice in the back of my head that says ” This sucks, but did you DIE?” Nope. Still alive and ticking. This month has been rough. Lots of firsts, some easy, some very difficult. But I’m still here, taking it a day at a time. Knowing that drinking just isn’t an option has freed me to get to the real work of unraveling myself.  Which is scary and some days like today I just don’t want to go there. The same stresses exist. I’m still suffering career burn out. I still have three kids and no local family support. My son still has very very bad days that throw everything into disequilibrium.  My husband still has PTSD and is too proud to get help. My marriage is still very rocky and probably even more so now that my husband who is a normie can’t understand what the big deal is and why I’m not just magically all better now I’m not drinking. If anything, all of this hurts a thousand times more because I’m not anesthetizing myself anymore. But I’m not drinking.
I know I can’t control and fix all of that so for THIS DAY, in this moment I will pause and  just be grateful that I’m sober.  I’m finding that though painful, this coming back to life is indescribably worth it.  I know that all of this hard work, these tough (often invisible) moments will be worth it. Because I am also open to the good things: laughter, joy; the million small details you can’t see when your edges are blurred.  I’m not sure I will ever come to a place where I can be “grateful” for being an alcoholic.  I still struggle with a lot of shame and regrets. But perhaps as this journey progresses I will eventually see it as a gift.
In the mean time, thanks for listening. Thanks for “getting” what it means to have the courage to unflinchingly take stock and face this disease.  And I hope you can be encouraged by reading my story.  Because if anyone as stubborn as me can finally learn to let go, there is hope for you.
Surrendering On

Sober Friday Night Buzzword Bingo – Intoxigenic

intoxigenicSo it’s the day before we fly to Australia and when you read this I’ll be packing and then heading out to see ‘Tears for Fears’ live and then on to Heathrow for our flight.  I heard a new word in July so it seemed apt to end with this and the research that coined the phrase – intoxigenic.  Hard not to think of Britney Spears and her tune ‘Toxic’ when I hear this word!

The image about profit motive is to set the scene because at the end of the day the drinks industry is driven by this motive and nothing else.  They have share holders to please and when your product is alcohol the only way to do that is to sell more booze and not care too much about where that sale comes from.

The research article that triggered this post is titled ‘An exploration of alcohol advertising on social networking sites: an analysis of content, interactions and young people’s perspectives’

Here’s the research abstract:

Young people increasingly communicate and interact via social digital media such as Social Network Sites (SNS), where they discuss and display alcohol-related content. SNS have also become an important aspect of the alcohol industry’s multi-platform marketing strategies, which may contribute to the creation of intoxigenic digital spaces in which young people learn about alcohol. This paper presents findings of a content analysis of the extent, nature, and user interaction with SNS-based alcohol marketing for brands popular among young people in the UK. It provides a systematic analysis of both official and user generated marketing content on brand Facebook and Twitter profiles, and user interaction with such content. Findings from peer group interviews (N = 14) also present young people’s (N  = 70) perspectives and experiences regarding alcohol marketing on SNS. New SNS engagement marketing strategies extended existing multi-platform brand marketing. Young people interacted with such strategies as part of their identity-making practices, yet through a discourse of immaturity distanced themselves from certain brands, online marketing practices and the idea that their own actions were influenced by marketing. Local night life economy marketing appeared more meaningful and relevant to young people and led to further interaction with brand marketing. Implications of the findings are discussed in relation to the influence of alcohol marketing on young people, and the implications for current regulatory frameworks.

And this was the conclusion:

Alcohol marketing on SNS was entangled with young people’s cultural and identity-making practices in ways that created greater relevance and meaning. However, marketing strategies were dependent on young people negotiating brand material, with some connotations (e.g. immaturity) hindering rather than encouraging interaction with marketing content and use. We have further highlighted how the emerging use of SNS in alcohol brand and venue marketing has extended the aim of marketing from influencing consumers through the transmission of meaning through visual and discursive codes, to encouraging consumers to act in certain ways as active participants in marketing content creation and the use of consumers online social networks and relationships to gain added value and wider audience reach (Carah 2014, 2015). With an apparent lack of prominent alcohol health campaigns on SNS (Atkinson et al. 2010; 2015) it is important to further consider how such marketing messages might be modified by public health orientated actions on SNS (Westgate & Holliday 2016), whilst considering the challenges SNS marketing poses to current regulatory codes designed to solely monitor the content of official brand marketing.

So complex relationships between social media, culture and identity that is only just beginning to be understood.  You can bet your bottom dollar the industry is spending huge amounts of money researching this to make sure they maintain their profits as driven by their profit motive.

Conversely this new study provides preliminary evidence that use of alcohol warning advertising reduces urges to drink:

Viewing alcohol warning advertising reduces urges to drink in young adults: an online experiment

[Open access] Tobacco counter-advertising is effective at promoting smoking cessation. Few studies have evaluated the impact of alcohol warning advertising on alcohol consumption and possible mechanisms of effect. This pilot study aimed to assess whether alcohol warning advertising is effective in reducing urges to drink alcohol, if emotional responses to advertising explain any such effect or perceived effectiveness, and whether effects differ among heavier drinkers | BioMed Central, UK

And this article shows a desire to escape the intoxigenic environment:

No drink, no drugs: what’s drawing young people to teetotal festivals?

At the start of Buddhafield festival, over 1,500 revellers – many of them non-Buddhists – chant Buddhist mantras in unison. The effect is hysterical, manic: one regular says “it’s as if everyone is on something”| Guardian, UK

So much to think about and time for a rest – a month, my longest time away from the blog yet!  Stay safe sober warriors and finally a tune which I’m hoping to hear live later 😉


No shit sherlock!

benchgirlPerhaps it’s because I’m demob happy about heading off to Australia imminently but this research report that appeared in The Telegraph in May has been renamed by me ‘no shit sherlock!’ as it seems so f*cking obvious that this would be the outcome here in Blighty …… (#benchgirl photo used in its honour!)

How round-the-clock drinking did increase binge culture after all  

The relaxation of licensing hours intended to cut binge drinking in Britain by ushering in a more “continental” approach actually led to an increase in heavy alcohol consumption, the first study of its kind has shown.

Analysis of official health data by economists found that while average drinking volumes rose only marginally following the extension of opening hours a decade ago, the chances of some people drinking heavily increased dramatically.

The likelihood of drinkers downing almost six pints in a single night surged by 36 per cent after the abolition of the traditional 11pm drinking-up time, the paper presented to the Royal Economic Society found.

And the chances of someone consuming more than 16 units in a night – the equivalent of a bottle and a half of wine – jumped by 29 per cent in the wake of the reforms (see yesterday’s post which underlined this fact)

The researchers, from Lancaster University, said the findings could also be linked to worsening physical and mental health for some drinkers.

The study draws on data charting the nation’s drinking habits in 2003 and 2009, directly before and after the licensing changes came into force in late 2005.

That suggests that a more recent apparent decline in overall alcohol consumption in the UK is not, as some have previously argued, the result of the liberalisation of licensing hours but some more recent social or economic trend.

Under the reforms, introduced by Tony Blair, pubs and clubs can apply to stay open up until 5am in some cases.

By April 2006, the first time full figures were available, more than 50,100 venues in England and Wales had been granted extended licences while by 2010 the figure had risen to just under 79,000 – or 61 per cent of the total.

It was hoped that by staggering closing times people would no longer “drink against the clock” and therefore consume not only more than they otherwise would have done but more quickly.

The findings were drawn from data provided in the Health Survey of England and other studies which ask large samples of the population to estimate how much they have drunk in a particular week and how much on the heaviest session.

Overall the researchers calculated that for every extra extended licence per 1,000 people average consumption edged upwards by 0.1 units.

But they found that the proportion of the population likely to consume at least 12 units on their heaviest night rose from around 10 per cent to almost 14 per cent in the wake of the reforms.

“This suggests that increase late night availability has substantial effects on alcohol consumption across the distribution of drinking,” the paper concludes.

“Moreover, these increases are sizeable.”

“Given that there is no evidence in diminution of this effect at higher levels of consumption where alcohol harms may be concentrated, this provides an initial indication that the extension of availability may have led to negative health outcomes.”

The lead author Professor Colin Green, an economist at Lancaster University Management School, said: “For the first time we see evidence that there was a moderate increase in average consumption on a given night as a result of extended hours licences which hides larger increases at higher consumption levels.”

But official figures have pointed to a more recent general drop in drinking levels in England and Wales particularly among the young, leading to speculation of a major social change driven by the influence of a new “sober generation”.

But Prof Green was sceptical.

He said: “With all these statements about massive cultural change and all young people becoming teetotallers – I would give it another 10 years.”

1 – 0 to the Drinks industry then and well done Mr Blair for helpfully enabling that <sarc>

I shall see you in a month’s time when I return from Oz!  As Prim said ‘the HOF clan are literally conquering the world since we got sober!’ 😉

The complexity and challenge of ‘dual diagnosis’

quadrant_dual_diagnosisSo this is an extra post squeezed in before I go away as it’s too important to miss!  It’s a great drug and alcohol findings research article about the complexity and challenge of dual diagnosis that I have written about before here.  To the left is an excellent diagram of ‘the quadrant model of dual diagnosis’.  It’s a lengthy read and I have shared it in full because it’s valuable and well researched.

With as many as three quarters of their clients suffering from mental health problems, deciding how to respond is a major concern for Britain’s drug and alcohol services. The issues are many, long-standing, and generally unresolved. Should substance use services take the lead in coordinating their clients’ care, or should this be taken on by psychiatric services? Is either willing and able to take on both issues and deal with mentally ill substance users, or would a better option be to create new integrated services?

People with coexisting mental health and substance use issues often have high support needs, and poor treatment outcomes. There are various barriers to the provision of appropriate support, but equally many opportunities and occasions to improve the lives of those affected.

Dual diagnosis: more complex than the name suggests

The term ‘dual diagnosis’ is used widely, but not often consistently. The World Health Organization defines it as “the co-occurrence in the same individual of a psychoactive substance use disorder and another psychiatric disorder”, whereas the UK National Institute for Health and Care Excellence (NICE) refers to “young people and adults with severe mental illness who misuse substances”. What these two definitions have in common is a leaning towards the severe end of experiences of mental health and substance use issues. The everyday use of the term dual diagnosis is much broader, describing the presence of coexisting mental health and substance use issues, where the person may or may not have a formal diagnosis of, or meet the formal criteria for, mental illness, substance use disorder or dependence. In fact, many people categorised as having a dual diagnosis do not have a diagnosis, and many people have more than the two problems or support needs that ‘dual’ diagnosis implies. Rather than thinking of people with dual diagnosis as having two support needs, it may be more useful “to acknowledge that they have complex needs”, both directly related to and extending beyond their substance use and mental health. It is because of this that some working in the field have advocated either moving away from the term dual diagnosis altogether, or adopting the broader, more inclusive, everyday interpretation of dual diagnosis to accommodate all who would benefit from treatment that considers their coexisting mental health and substance use problems (regardless of levels of severity or diagnosis).

Mental illness and substance use: which is chicken, and which is egg?

Dual diagnosis has been on the radars of researchers and clinicians for over thirty years. In terms of the complex relationship(s) between mental health and substance use (1,2,3,4) we now understand that (among other things):
Drinking and drug use can aggravate or exacerbate existing mental health problems or symptoms
• People may drink and take drugs to try to relieve the adverse symptoms of mental health problems (sometimes referred to as ‘self-medication’)
• Long-term, heavy drinking can cause damage to the brain which can impair cognitive functioning
• Drinking or taking drugs can induce temporary or longer-term mental health problems in some people, which may subside after the substance use has stopped
• Withdrawing from alcohol and many illicit drugs can produce or mimic symptoms of mental ill health

There has been somewhat of a preoccupation in the literature and in practice about understanding which comes first, the substance use issue or mental health issue – which is chicken, and which is egg? Though the answer to this question may have important implications for treatment, it would not necessarily be the most immediate or pressing concern for patients, and has arguably helped to foster a climate of fragmented services – with mental health and substance use services feeling ill-prepared or unwilling to treat patients where their own specialism isn’t seen as the primary treatment issue.

Which agency should take the lead?

The risks of people with mental health issues developing substance use problems and people with substance use problems developing mental health issues are much higher than the risks of developing mental health or substance use issues within the general population. The high prevalence of coexisting mental health and substance use problems within mental health services is well-documented, with recorded prevalence rates in various UK studies at 32%, 36%, 44%, and 46%. Rates in substance use services could be even higher, with recorded rates of 75% in drug services and 86% in alcohol services. With so many people who are affected by dual diagnosis coming through the doors of both mental health and substance use services, clinicians face a difficult challenge. How can they best serve their patients given that they only hold one piece of the jigsaw?

An influential framework for determining the appropriate approach to treatment and care is the quadrant model, illustrated ( figure) in South Staffordshire and Shropshire Healthcare’s dual diagnosis policy. It describes four presentations of dual diagnosis based on levels of severity: mild substance use and severe mental illness; severe substance use and severe mental illness; mild substance use and mild mental illness; severe substance use and mild mental illness. The provisions for treatment described in the quadrant model focus on one service taking the lead (either substance use or mental health), and then this lead service coordinating care, and seeking advice and support from the other service (either substance use or mental health). This partly resolves where ultimate responsibility lies, but leaves unanswered other questions about the nature and practicalities of the relationship between mental health and substance use services (eg, information-sharing), and also leaves unstated the roles of other support and treatment services needed by people with coexisting mental health and substance use issues.

Department of Health guidance (published in 2002) recommended that mental health services take primary responsibility for people with severe mental illness, as they would be “better placed to offer services such as assertive outreach, crisis management and long term care than the substance misuse services”. For less severe cases not eligible for psychiatric care, substance use services are seen as taking the lead. We can be reassured to a degree that patients often improve after usual substance-focused treatments, possibly because at least some emotional problems are generated by substance use and associated lifestyles. This was why NICE recommended that alcohol services faced with seriously depressed or anxious patients should treat their drinking problems first, and consider referring the patient for specialist mental health care only if psychological conditions persist after three to four weeks of abstinence.

Despite this policy direction, there are many circumstances where people are unable to access mental health or substance use services. Sometimes those with low support needs can fall short of criteria for services, and not receive anything. Where which service should take the lead is unclear or is disputed, the result can be a stalemate where neither service can or will act. The danger of these barriers being unresolved is “service users being shifted between services and falling through the net of care”.

How can we prevent people falling through the gaps?

Coordination or joint working could be the answer. But a number of practical and cultural barriers make it difficult to achieve – sectors and services are guided by different policies, there is often a disconnect between available resources and service user or professional preferences for treatment and care, and there is a shortage of designated dual diagnosis funding. A dual diagnosis handbook published by social care organisation Turning Point suggests that “commissioners might want to explore concurrent funding streams – (eg, for mental health support services and substance misuse) – or look to share budgets to provide social care for vulnerable groups”.

In a recent piece for the Guardian, Professor Liz Hughes, who has extensive clinical and academic experience in mental health, substance use and dual diagnosis, warned that “the UK dual diagnosis scene is running on nothing but goodwill by a few enthusiastic champions”. The challenge is “being able to provide effective services to people with high needs, in a time of unprecedented crisis in mental health provision and loss of mental health expertise within the substance use sector.”

One potential source of new funding comes from the Government’s Life Chances Fund. In January 2016, Prime Minister David Cameron announced that “up to £30 million” would be available for “the development of new treatment options for alcoholism and drug addiction, delivered by expert charities and social enterprises”. This funding pot is based on the model of Social Impact Bonds, designed to leverage funding to service providers, and improve the outcomes of services by making funding conditional on achieving results, rather than inputs (eg, number of counsellors) or outputs (eg, number of counselling sessions). The independent Mental Health Taskforce to the NHS recommends that applicants should “demonstrate how they will integrate assessment, care and support for people with co-morbid substance misuse and mental health problems”.

Integrated services with staff trained and skilled specifically for dual diagnosis clients represent an alternative to independent working, or joint/coordinated working. This seems like the ideal solution on paper – clinicians in these services would have shared values, policies and processes, and there would presumably be no obstacles to information-sharing. However, the evidence about the effectiveness of integrated care has so far been inconclusive. This does not necessarily preclude the development of integrated services now or in the future, but does indicate that “the case for integration [may need to be] based on practice-based evidence rather than evidence-based practice”.

Unique opportunities (and challenges) in prison settings

Dual diagnosis is a common problem in prisons. “Nine out of ten people in prison have a mental health or substance abuse problem – often together – but most do not receive the right care”. Many prisons in the UK apply a “parallel approach” to dual diagnosis, where patient care is provided by more than one treatment service at the same time. The main advantage is that the patient receives specialist help for each of the different aspects of their problem. However, given the overlap of many problems, and the historic compartmentalisation of services (whereby substance use and mental health teams have tended to refer prisoners onto each other, rather than seeking to work together), the parallel approach has been perceived as fragmented care.

Overall, the evidence suggests that prison environments present an opportunity to provide integrated care to people with mental health and substance use issues. The recommendation is that more energy should be put into improving communication, information-sharing and referrals between services, and more research should be conducted into effective psychological interventions for prisoners with a dual diagnosis.

What treatments work?

Partly due to a lack of high quality trials, there has been no compelling evidence to support the use of any one particular psychosocial treatment over ‘treatment as usual’ for people with both severe mental illness and substance use problems (1,2). A recent review of psychosocial treatments for co-occurring cannabis use (the dominant drug problem in the UK among patients new to treatment) and mental health problems found poor results across the board, equivalence among therapies, and a failure to improve on usual treatments. When the authors looked beyond the trials where participants were randomly allocated (ie, beyond the most rigorous trials), they found some evidence for the use of motivational interviewing in psychiatric settings combined with cognitive-behavioural therapy, but little for cognitive-behavioural therapy alone.

Depression plus problem substance use is the most common combination encountered by substance use services. Experts disagree about the best general approach. An Australian study suggested that in some cultures this may differ for men and women – or at least, that for men an alcohol-focus may be a more acceptable and effective way of tackling their depression and drinking, while for women a focus on depression may be preferable. Given the difficulty of identifying which problem is primary, and the risks of getting this wrong (both could have equal weight and/or be independent of each other), guidelines from the British Association for Psychopharmacology say that “pragmatically, both disorders may have to be treated concurrently”. Their freely available resource offers extensive guidance on medication-based treatments for mentally ill problem substance users.

It seems likely that many patients with depression would benefit more from addressing this directly at the same time as addressing problem substance use. One medication-based strategy was tried in a US study which selected alcohol-dependent patients whose depression was judged independent of their drinking. It found that combining sertraline for depression with naltrexone for drinking substantially and significantly promoted abstinence compared to either alone or to placebos, and also helped more with depression. This is, however, not a universal finding. Prompted by that study, researchers in New Zealand tried adding the similar antidepressant citalopram to naltrexone in the treatment of dependent drinkers suffering what for three-quarters was judged to be major depression independent of their drinking. In this case adding the medication led to no significant overall benefits in respect either of depression or drinking.

Establishing what works for patients with a dual diagnosis is not easy given the wide spectrum (and combination) of substance use and mental health problems that exist. The label of dual diagnosis itself can facilitate or impede access to treatment, and its subsequent success. Where dual diagnosis is associated with negative stereotypes it can be stigmatising for services users. Where the term is associated predominantly with severe mental health or substance use issues, it can exclude people with lower level issues who would still benefit from treatment tailored to their coexisting issues. Where the term can be powerful is in raising awareness of the gaps in support for people with complex and coexisting difficulties. Where it can also be beneficial is in promoting a language which emphasises the importance of collaboration between mental health and substance use services.

Where do we go from here?

Progress, a group of consultant nurses and expert practitioners working in the National Health Service (NHS), runs a website offering useful resources about dual diagnosis for service users, carers and professionals. This includes the stories of David, Martha, ‘God’ and Jason (based on the experiences of people with mental health and substance use issues), and information about how to find a member of Progress working near you.

NICE is in the final stages of producing guidance to improve services for people (aged 14 and over) with severe mental illness and substance use problems, not just for their immediate mental health and substance use support needs, but those relating to physical health, social care, and housing. The expected publication is November 2016, but draft guidance is available here. Recommendations include collaboration between services in mental health, substance use, primary care, and social care, as well as organisations in the community and the voluntary sector, and the agreement of a protocol for information-sharing between all relevant services. It also recommends that people with coexisting mental health and substance use issues should be encouraged to stay in contact with services, and be involved (along with their family and carers) in developing their own care plan, which should take into account how their abilities, strengths and past experiences can help support engagement and recovery.

Dual diagnosis is not a single entity but a label for differing constellations of troubling substance use and psychological problems. Present gaps in resources, knowledge and evidence about dual diagnosis are putting a strain on clinicians, and risking many patients getting lost in the system. Historically, the values and treatment approaches of substance use and mental health services haven’t always been aligned. One potentially “binding philosophical strand” going forward is the increasing importance of recovery within both services, with opportunities to define what recovery means for people under the umbrella of dual diagnosis, and create new shared values around these aims.

Completely agree with all of it and look forward to see the new NICE guidelines! 🙂

Heavy drinking at home now typical feature of British life

Drinking OccasionsDrinking Occasionsheavy drinking at homeSo this was an excellent research piece featured by the Institute of Alcohol Studies in May looking at heavy drinking at home.

Researchers from the University of Sheffield have found that ‘pre-drinking’ is a common feature of nights out, and that events which take place exclusively at home – such as dinner parties – involved increased or “higher risk drinking”.

These findings imply that thanks to the availability of cheap alcohol in off-licences premises such as supermarkets, the concept of a heavy episodic pre-drinking routine is embedded among particular British drinking cultures.

The study, published online in the scientific journal Addiction and funded by Alcohol Research UK, looked at detailed drinking diaries completed by a nationally-representative sample of 60,215 adults as part of Kantar Worldpanel’s Alcovision study. In addition to recording how much they drank, participants detailed where and when they consumed alcohol, who was there and why they were drinking, over a seven-day period.

Researchers based at the University of Sheffield’s School of Health and Related Research (ScHARR) then used those diaries to identify eight main types of drinking occasion.

The results showed that between 2009 and 2011, most drinking occasions in the UK involved drinking in the home, including:

  • Drinking at home alone (13.6% of occasions)
  • Light drinking at home with family (12.8%)
  • Light drinking at home with a partner (19.6%)
  • Heavy drinking at home with a partner (9.4%)

Consuming alcohol away from home was less common and included going out for a few drinks with friends (11.1% of occasions) and going out for a meal as a couple or with family (8.6%). The study also found that 10.4% of occasions involved groups of friends moving between home and pub drinking (mixed location heavy drinking) and consuming on average 14 units of alcohol – the equivalent of seven pints of beer or one and a half bottles of wine.

In comparison, almost half of get-togethers with friends or family which take place exclusively at home, such as dinner parties, house parties and watching sport, involved increased or higher risk drinking.

Dr John Holmes, a senior research fellow of the University of Sheffield’s Alcohol Research Group (SARG), and co-author of the study, said: “Far from the stereotypes of binge Britain or a nation of pub-drinkers, we find that British drinking culture mixes relaxed routine home drinking with elements of excess.

“Young people do binge drink on big nights out but we also see heavy drinking among middle-aged couples relaxing at home and among all ages at domestic get-togethers.”

The study defined low risk drinking as consuming fewer than six units for women or eight units for men during the occasion. Increasing risk drinking was defined as consuming 6–12 units (women) and 8–16 units (men) and high risk drinking involve drinking more than 12 units for women and more than 16 units for men. These thresholds are based on a commonly used definition of binge drinking which is 6 units for women and 8 units for men. A unit is approximately 8g or 10ml of pure alcohol. There are approximately two units in a pint of normal strength beer, one unit in a shot of spirits and two units in a 175ml glass of medium-strength wine.

Dr James Nicholls, director of research and policy development at Alcohol Research UK, said “The idea that there is a single British drinking culture is wrong. Drinking behaviours have changed enormously over time, and there are wide variations within society.

“Rather than assuming society is neatly divided between ‘binge’, ‘heavy’ or ‘moderate’ drinkers we should think about the occasions on which people drink more or less heavily – and the fact we may be moderate in some contexts, and less so in others. If we want to address problems associated with drinking, we need to recognise the diversity of how we drink and understand the crucial role that cultures and contexts play in that.”

Katherine Brown, director of the Institute of Alcohol Studies said:

“Two thirds of all alcohol sold in the UK is bought from shops and supermarkets, which is a big change from the traditional British pub culture. The fact it is so much cheaper to drink at home is a huge driver for this shift, which is why tackling cheap supermarket drink would help pubs and also improve the nation’s health.

“The increased availability of cheap alcohol means frequent home drinking is more commonplace, including drinking at home before heading out to a pub or restaurant. This makes it very easy to exceed the low risk drinking guidelines recommended by our Chief Medical Officers, which raises risks of cancer, heart disease and liver cirrhosis. It’s important that consumers are aware of how many units are in their drinks and how alcohol may affect their health so they can make fully informed decisions about their drinking. Having clear labels on alcohol products with independent health information would be a sensible first step in supporting drinkers to make healthier choices, alongside mass media campaigns.”

The research also has an excellent jpg infographic which I am frustratingly unable to link here today so will signpost you to their site to see there!


The bolded section within the text is mine because this to me feels like honest real data.  14 units in one night – so 1 1/2 bottles of wine would have been me ……

And Scotland too it would seem:

Scotland now a ‘nation of home drinkers’

Adults in Scotland have increased their consumption of alcohol for the second year in a row, according to a report | BBC, UK

And a link to the publication that the BBC is talking about:

MESAS alcohol sales and price update May 2016

The alcohol sales and price band analyses have been updated with 2015 data. Infographics that summarise the findings and supporting datasets are available below. These have been published as part of NHS Health Scotland’s ongoing commitment to monitor alcohol consumption and price as recommended in the final MESAS annual report | NHS Health Scotland, UK



Is addiction really a disease?

is addiction really a diseaseA perennial recurring discussion (in my head anyway!) …..  From this week-end’s Observer Marc Lewis  author of The Biology of Desire: Why Addiction Is Not A Disease.

What is addiction? For the majority who have strong opinions on the matter, addiction is a disease. In fact it’s “a chronic relapsing brain disease” according to the American National Institute on Drug Abuse. This definition, born of the marriage between medicine and neuroscience, is based on the finding that the brain changes with addiction. It’s a definition that’s been absorbed and disseminated by rehab facilities, 12-step programmes, policy makers and politicians. It’s the defining credo of the addiction-treatment industry. But is it correct?

A counter argument is gathering momentum. Many are coming to see addiction as a learned pattern of thinking and acting – a pattern that can be unlearned. As a neuroscientist, I recognise that the brain changes with addiction, but I see those changes as an expression of ongoing plasticity in an organ designed to change with strong emotions and repeated experiences. Similar changes have been recorded when people fall in love, become obese, gamble compulsively, or overindulge on the internet. And as a developmental psychologist (my other hat), I see addiction as an attitude or self-concept that grows and crystallises with experience, often initiated by difficulties in childhood or adolescence. Indeed, addiction is in some ways like a disease, but that’s only half the story.

The debate rages on, and it has propagated a good deal of antipathy among addiction experts and the populations they serve. I had a taste of that conflict just last month. I was invited to join a radio discussion that turned ugly when a scientist and proponent of the disease model claimed that anyone who didn’t recognise addiction as a disease was trivialising it. To back this up, he spoke of several of his close friends who had died because they could not stop drinking. While cases like these are heartbreaking, I am compelled to ask: how can we say addicts can’t stop when so many of them eventually do?

It’s an argument that seems endless. But if there’s no right answer, the best answer might be the one that generates the greatest benefits and causes the least harm. For me, that scorecard is filled in by addicts themselves. Many take comfort in the disease label, because it helps them make sense of how difficult it is to quit. But for others, the disease label isn’t just wrong, it’s repugnant – it’s a rationale for helplessness and an obstacle to healing.

“I hated being told I had a disease,” wrote a recent commenter on my blog. “I am not diseased… I don’t have a disease. I had past traumas, environmental factors and learned behaviours… I feel I have learned new things… new skills opened up… new pathways that were underdeveloped.” That’s the crux of the matter for addicts who reject the yoke of fatalism implicit in the disease definition. The first of the 12 steps, admitting that one is powerless, is their point of departure. That’s when they leave their first meeting. And they don’t come back.

Research suggests their intuitions are correct. Several studies have shown that a belief in the disease concept of addiction increases the probability of relapse. And that shouldn’t be surprising. If you think you have a chronic disease, how hard are you going to work to get better?

If we can acknowledge that addiction is like a disease in some ways and very much unlike a disease in other ways, maybe we can stop trying to label it and pay more attention to the best means for overcoming it.

Have to say I agree with him – what do you think?

Edited to add 4.15pm: As a nod to the image of Ewan McGregor as Renton in Trainspotting at the start of this blog and serendipitously launched today 😉

Teaser trailer for Danny Boyle’s Trainspotting sequel – video

How to Face Life’s Challenges When in Recovery

sober hurdlesSo I’ve got a big old set of sober firsts coming up fast.  First sober gig, first sober airport visit, first sober flight, first sober stop over, first sober BIG holiday in a country that is as awash with booze as we are – Australia!!  I am SO EXCITED but also a little anxious so this blog from Faces and Voice of Recovery about facing life’s challenges when sober feels perfect 🙂

Abstinence based recovery isn’t something you just mark off a list with a big check mark— it’s a state of mind. It is with you all the time, which can be a blessing in disguise, because when you engage with the world while in recovery, you can do so with more awareness than you had before. 

However, that engagement means it’s going to feel like life is challenging your recovery at times. The ways you tried to cope with life’s challenges in the past more than likely brought you to this moment. But what do you do when a loved one passes away, you feel like celebrating, or you just want to fit in?

In short, you need to have some tools at the ready for these trying times. Here are some ways to face these challenges with strength and confidence.

1.    Realize you are not alone. Although you might have heard this phrase many times in motivational circles, move it out of theory and put it into practice. If you are at a wedding, look around for the people who are not drinking; you’ll see them. Spend more time at places where drinking isn’t a centerpiece of an activity, such as the theater or your favorite coffee shop. Beyond that, realize that on any given day, more than 700,000 Americans seek treatment for alcohol or drug addiction. You are on the other side of that, so if you stop and look around you, it won’t feel like everyone else is drinking while you’re left out. That is an illusion.

2.    If need be, bring a wingman. If you feel uncomfortable about the presence of alcohol while attending a wedding or other social event, then bring someone with you who is comfortable remaining substance free. You can ask for support from others who know your story, and use your recovery to forge closer relationships through your vulnerability (Yay for MrHOF!)

3.    Create another “pre-game” ritual. For people active in their addiction, getting ready for a night out, a big event or an event they’d rather avoid means having a drink or getting high. However, there are other ways to get ready for an event, from luxurious bubble baths to a stint on the treadmill. Make a list of activities that you do for yourself, from a manicure to a quiet cup of tea, and choose one to be your new “pre-game” ritual. Then relish how good it makes you feel, and you’ll carry that with you to the event.

4.    Before you go, choose a non-alcoholic beverage that you can order. If you’re meeting friends to celebrate or you want to toast the bride and groom, decide what you will order before the event so that there is no hesitation when you get there. Sparkling water with fruit or other carbonated beverages are good choices, and visualizing the order ahead of time will lesson the interaction’s mental weight. 

5.    Exercise more. This is more of a long-term decision, but musician James Taylor, who has been in recovery from an opiate addiction for more than 30 years, says that the best way to come back to yourself is to “sweat it out.” Exercise puts you in touch with your body, releases feel-good hormones, and creates long-term self-care rituals. Exercising regularly also helps manage anxiety so that when stressful events challenge us, they don’t feel as daunting (running shoes packed – check)

6.    Reframe your past behavior. Begin to see your past substance use for what it was: false celebration or false comfort. Was it really “celebrating” if you don’t remember what you said to the happy couple or how you got home? Was it really “comfort” if you woke up the next day with the same problems you had before, but with the addition of a hangover? When you start to reframe your memories of past actions, you begin to see that you are gaining something more than going without. 

All of these tips can really help, but at the beginning of your recovery you may need to forgo certain triggering situations. As your recovery becomes the catalyst for your blossoming life, you might also begin to question why you feel an obligation to attend certain social events. The important thing is accepting that there will be challenges to your recovery and deciding to lean consciously into them instead of acting like they don’t exist. You have consciously chosen to live your best life, and that’s always worth celebrating. 

All ready to go!  Can’t wait 🙂

Friday Sober Jukebox – Poison

HOC-alc-related-deaths-725x381So this is a happy reading chart isn’t it?  Sorry to dampen your mood with this Friday sober jukebox but reality cannot be escaped (especially now I don’t drink the toxic poison that is alcohol or take drugs!).

This is the unlucky for some top 13 health related ways to die from alcohol as recorded in 2014 and how many people actually did die of them within this fair isle.  A veritable drinking game Russian Roulette of choices:

  • degeneration of nervous system
  • polyneuropathy
  • cardiomyopathy
  • gastritis
  • pancreatitis
  • hepatitis

And then the mother-loads of:

  • poisoning
  • cirrhosis
  • alcoholic liver disease

and that’s just the physical ailments which doesn’t include the number three cause of death:

  • mental and behavioural disorders due to use of alcohol

with England winning by a country mile in the nations of the UK stakes.  I have nursed them all and can safely say all of them are pretty awful ways to die and to say these statistics are depressing is an understatement 🙁

This data comes from here:

Drinking patterns in 2016

Alcohol-related conditions were wholly responsible for 307,710 hospital admissions in England in 2013/14 | Russell Webster, UK

So this post is a bit of a fist in a velvet glove bit like this tune aptly titled ‘Poison’ 😉

Urghh – I had to share this somewhere too so it feels apt to do so here:

World’s first alcoholic ice cream van launched

A UK hotel group has launched what it claims is the world’s first alcoholic ice cream van, which requires visitors to display their ID cards | Spirits Business, UK

‘Products on offer include IcePA, a beer-infused Mr Whippy ice cream poured out of a classic pump and served in a pork scratching cone; The Jäger Bombe, a twist on the classic ice cream bombe that features Jägermeister ice cream covered with a layer of energy drink-flavoured ice cream’

Sounds delicious – not 🙁

Why kids shouldn’t sip booze

Why kids shouldn't sip boozeThis was an article in The Guardian in April looking at why kids shouldn’t sip booze.

It sounds like the most civilised way to ensure your children grow up with a sensible attitude to alcohol: allowing them a few sips under the watchful eyes of their parents. After all – the theory goes – that’s what they do in France, where binge drinking has traditionally been less of a problem. But according to the New York Times, this cornerstone of liberal parenting is slowly being sloshed away, with an increasing number of studies showing it can lead to earlier drinking.

They include research conducted in 2015, which found children being given “sips” of alcohol by their parents were more likely to have had full drinks, or got drunk, three years later. A professor who led a 2014 study looking at 452 children in the US said: “Child-sipping is related to early initiation of drinking … Parents should not be providing alcohol to their kids.”

It’s not the first time doctors have sounded a warning on this issue. In 2009 the government’s then chief medical officer was unequivocal, calling the idea of giving children watered-down alcohol a “middle-class obsession” and insisting that childhood should be alcohol-free. But if children were going to drink, the advice continued, then it should be under parental supervision.

Professor Harry Sumnall from the centre for public health at Liverpool John Moore’s University says the evidence is mixed. “Parents want to be the ones to introduce their children to alcohol, they realise it is an important life stage and want to be the ones to frame and shape it. For instance, I remember going to my dad’s rugby club and being bought a shandy.”

Sumnall says that while some research shows this can lead to problems, other studies suggest it is parents buying alcohol for their children and then not supervising its consumption that is more closely associated with later problems.

Establishing rules with children can be helpful, says Sumnall, but he is less sure that offering watered-down wine can prevent binge drinking further down the line in the face of societal influences such as advertising and alcohol pricing.

He says there is one thing that many parents forget: “Children learn about alcohol from their parents. So it’s important for parents to think about their own use.”

Yep.  Role-modelling is the biggest teacher …..

Edited to add: 31st August 2016

Parents who provide children with alcohol: what’s the problem? (Alcohol Policy UK)

David vs Goliath

david vs goliathSo I’m beginning to get demob happy as the kids are finishing school for summer and we are single digit days away from our big sober treat month in Australia!  This feeling was heightened further by a meet up with a close friend in London for a day of leisurely lunching, strolling along in the sunshine, an art gallery followed by  tea and cake.  We were sat discussing the rise of the artisan gin and I was bemoaning how our endeavours out here in the sober blogging world felt very David vs Goliath when right on cue this bus drove past.  I kid you not!!

I feel like I’ve banged on for forever about Minimum Unit Pricing (MUP) and once more it is under discussion within the Scottish Courts with a decision imminent.  So for one last time I’ll mention it here following this news story in the Scottish Press:

Scottish Government incurs £370k legal bill to defend minimum pricing alcohol plan

The Scottish Government has spent over £370,000 in legal fees defending its flagship minimum pricing of alcohol policy against challenges from the Scotch Whisky Association.

Ministers have had to hire top QCs and advocates in a bid to save the legislation after legal action by the SWA – a trade association whose members include Diageo, Highland Distillers and Chivas Brothers.

Its lawyers argued that the measure would create a precedent whereby health concerns were allowed to interfere with the free trade of goods and services.

Alison Douglas, Chief Executive of the Alcohol Focus Scotland, said: “Minimum pricing should have been in place three years ago but the SWA took the Scottish Government to court to protect their members’ sizeable profits. These delaying tactics have not only cost lives but continue to defy the democratic will of the Scottish Government and cost thousands of pounds of public money. It is just not acceptable.”

David Frost, the SWA chief executive, said: “We have opposed minimum unit pricing (MUP) ever since it was proposed by the Scottish Government. The Government expected MUP to be subject to legal challenge, but pressed ahead anyway, leaving us with no alternative but to exercise our right to oppose it in the courts.

David vs Goliath indeed.

And as for that gin bus – Hogarth’s famous painting Gin Lane was situated not far from where we sat in London that day …….

gin lane