Monday, January 27, 2014

Chronic Relapsers Misinformation

These are some rough estimates and truisms.. 10 % of people will have problems with an illicit substance. A proportion of those who avoid problems ‘spontaneously’ quit.  The earlier one quits substance abuse, the greater the success rate. Drugs and alcohol and other addictions are ‘fun’, ‘fun and trouble’ and finally just plain “trouble’.
Abstinence is the most successful ‘treatment’ for addiction. The WHO advocates that all harm reduction approaches should only serve as stepping stones to abstinence. There have been countless horror stories associated with ‘controlled drinking’ and clearly to date there are no good stories of ‘controlled crack’ use. The whole ‘control’ movement is as historic as ‘just say no’.
In studies of those who do ‘abstinence based’ therapies up to 80% achieve 5 year or more recovery. Dr. Marc Gallanter’s Harvard studies of doctors in recovery in AA shows 80% recovery up to 50 years after the last drink, decades of abstinence.  I personally know hundreds of people who once had severe addictions that cost them health, jobs and relationships but today are decades drug or alcohol free with successful careers and relationships.  Most of them are members of 12 step programs or churches.  Indeed addiction is described as a ‘spiritual disease’ by some and ‘cancer of the brain' by others.
The first ‘remission’ marker is one year.  The DSMV considers a person in full remission with a year of abstinence.  Most others including Dr. Vaillant of Harvard saw that the disease effects were significantly present for 5 years of abstinence when finally  a person potential for relapse was no greater than an as yet unidentified person’s risk of developing addiction.
In a famous Montreal study, 50% of those who returned to drinking, were able to avoid returning to their previous level of drinking, somehow maintaining ‘harm reduction’ without descending into their former abyss.  Interestingly a Holland study showed that people abstinent for 15 years who returned to drinking, 70% were able to maintain ‘harm reduction’.  While one in two odds of redeveloping a life threatening illness aren’t actually encouraging, and even a 30% chance of devolution at 15 years doesn’t look bright, this does suggest that the original disease appears to ‘burn out’ with abstinence over years.  The modern research on neuroplasticity and adaptation certainly takes into consideration the increasing information of the effects of ‘intoxication’ on the brain.  All research to date shows that those who achieve abstinence have the best life course, physical and mental health.
Note the word ‘toxic’ in intoxication. Addiction is associated with altered consciousness, dissociation and impaired mental capacity, the effects of which can last hours or days or , with marijuana for instance, weeks after the chemical brain trauma.  By contrast with alcohol, where there is social drinking where a person does not drink to toxicity (1-2 drinks)  with drug addiction, all drugs are used for the ‘effect’ :’chemical drunkeness”, “getting high”, ‘being stoned’.  People drank as a beverage whereas drug abuse is done to achieve 'toxicity'. Drug abuse alters consciousness. It impairs brain functioning. Enhancement of one function is countered by loss of other capacities as with drunkeness.
Addiction is like slavery.  A person is freed by abstinence but with relapse return to their slavery with the attendant lack of hope, lack of faith in their ability to get free, increased cynicism about their potential but more significantly increased negativity about ‘freedom’ itself despite the high success of those around them.  Their relapse and the associated depression that is usually concomitant in time is associated with severe 'cognitive distortions'.
Fruitflies were the great genetic tool of genetic research since they shared 70% of human DNA and had short life expectancy. Thanks to the overwhelming success and the extraordinary numbers involved in the recovery from cigarettes, Cigarette addiction and recovery have taught us as much about ‘addiction recovery’ in general as fruit flies taught us about human genome.
When people relapse they have already progressed through the Motivational stages of Prochaska from Precontemplation, Contemplation, Determination and into Action.  Unfortunately ‘relapse’ commonly throws a person back from the Action phase to the pre contemplation phase for a period of time.
In this phase they tend to be extremely negative and blame the treatment failure on a variety of usually inconsequential or irrelevant factors.  Rarely will they early acknowledge that they were no longer following a program.  Relapse is the outward manifestation of the 'thinking disease'  which is the precursor to actual substance abuse.  Mostly people begin by minimalizing their own previous difficulties with alcohol or drugs, begin to grandiosely believe that things will be 'different' this time round and delude themselves into believing that they can 'control' their drinking or drug use despite no personal evidence of their being able to maintain this in the past.
One of the prime criticisms of Alcoholics Anonymous was ironically the ‘god’ issue.  Addicts worship their alcohol and substance, living a ritualistic religion surrounding their death bound existence.  However in research with obese people, 12 step programs weren’t initially recommended but rather it was suggested that the grossly obese go to the gym. In contrast to alcoholics and addicts who are highly adept at ‘excuse making’ (the disease of alcoholism being personified as ‘cunning, baffling and powerful) the food addict, those grossly abese, simply said, “I don’t want to go to the gym’.  When advised to go to Overeaters Anonynous, they never mentioned the 'god problem's but  simply said “I don’t want to go out”.  It's refreshing to work with obese people in that they don't tend to waste their 'energy'  on 'excuses' despite their equivalent difficulties with stopping their compulsive food use.  At best they'll tell you they have a 'metabolic' problem.
It has long been known that alcoholics and addicts will go anywhere for a drink or drug and never complained about crosses in the room or pictures of the queen or president as long as their drug of choice was available there.  In the ‘contemplation’ phase of motivation they would complain about the colour of the paint if it convinced people they personally were the exception to the rule that recovery is good. The fact is, a person who has relapsed, has lost hope in themselves.
Psychiatrists long ago knew that with those who were ‘suicidal’ and had similarly lost hope in life, especially the chronically suicidal, needed the psychiatrist to ‘lend them their ego’.  We make decisions that suicide is not good for a person.  Similiarly those working in recovery who are successful maintain the idea that recovery is good for a person, much like thinking oxygen is.  Those who don’t, have been found to be associated with a very poor outcome measures as we saw with those who had a poor view of the suicidal. Outwardly the caregiver could go through the motions but at the covert and passive aggression level they were and are best recognized by their high death rates.
Much of the push for ‘harm reduction’ has been associated with a similar phenomena. The caregivers and those who promote harm reduction most are often ‘burnt out’ or always had a very negative view about the addicts and alcoholics.  One psychologist described this as 'caregivers and victims'.
It's even worse when those promoting harm reduction have an obvious 'conflict of interest'.
A recent Welsh study showed that Harm Reduction proponent counsellors  gave the success rate for recovery of their charges at less than 20% , but when these same people were in ‘abstinence’ based programs they achieved greater than 60% success.
This separation between those caregivers with hope and those without was also shown in cancer treatment.
Palliative Care is a program developed first for cancer therapy where the person’s disease was so severe and all alternatives for cure were tried without success and no successful treatment was known for the type of cancer the person had.  Palliative care is compassionate but it would not be if it was offered as a first choice or 'alternative therapy'.
Lack of success is not the case in addiction therapy.  Alcoholics anonymous has an 80% success rate 5 year and decades beyond but the ‘program’ is like the ‘birth control pill’.  If one takes the birth control pill once it is highly likely to fail.  This is the reason research did not identify the factors of high success in AA. Researchers simply asked people if they’d been to AA or NA. It’s common for people to go and not return, like those who asked if they used the condom for birth control might say they had but leave out that they’d only used it once in their life, and not the year they got pregnant.  The Navy Pilot program showed that 5 year 80% success with AA required a minimum of 3 meetings a week. The recent Scottish study which confirmed the 80% success rate included ‘home group’ and 3 meet ings and having a sponsor for instance to indicate ‘actual involvement’. As one person commented, a lot of people attend basketball games but you're more likely to find out how basketball is actually played and become good at the game yourself if you join the folk down on the court with the ball, rather than talking with drunk in the bleachers.
Relapse was associated with:
1) stopping or  reducing frequency of meetings. I often think this isn't different from any form of education since I meet people who despite having gone to university haven't read a book since and seem a hell of a lot stupider than people without a university degree continued studies.  With HIV treatment we need people to continue to take medication or they will die. We don't question the validity of the life saving 'medications' because people are 'noncompliant'.  We work on improving follow up and compliance but we are most impressed with our 'success' in developing treatments for HIV and Aids when at first there were no treatments. Since the 1930's we've made major strides in developing successful treatments for addiction and recovery.  Commonly people's lives are enriched in recovery and complacency returns.  Then stress occurs.  That's when all the 'tools of recovery' are thrown out.  I personally love the Dr. Martin Luther King quotation. "it's going to be a tough day so I have to spend more time on my knees".  When people have more stress, activity, change or success in their lives they usually need more 'recovery' activities, not less.
 2) Returning to previous association with drug abusers.  Recovery has been shown to be as “contagious’ as addiction. Having one abstinent friend in ones friendship circle reduces the chance of relapse by 25%.  People who relapse commonly begin to associate again with 'slippery people, places or things'.  Dr. Bob and Bill Wilson recognized that alcohol was ubiquitous in their society so said that recovery had to occur in the community. However it was also true they didn't recommend people avoid people in recovery and spend their nights in 'speakeasies'. In treatment today people are advised to avoid crack houses, dealers, and especially paraphernalia, as we know that 'jonesing' something not seen so much with alcoholism, but common in cocaine addiction does occur for up to a year after abstinence.  This phenomena is like we see with PTSD and the 'trauma' of addiction and the associated lifestyle. People with addiction today are often starting their addictive lifestyles earlier and have a world of hurt by the time they get into recovery with much less life experience, education or positive communities to fall back on.  
3) Commonly people recover from addiction but then have ‘expectations’ which are highly unrealistic.  Expectations have been called ‘preformed resentments’ and while AA and NA and other recovery programs treat the disease of addiction they specifically describe the need for members to get outside help with other issues.  These issues commonly include financial management advise, job advise and job training,  relationship counselling, pastoral care, anger management and a wide range of ‘maturity’ issues which are not achieved by addicts whose addiction stunts emotional, intellectual and social growth.  A person who has been hanging out with ‘potheads’ may stop their addiction but it takes time to develop a strong and positive friendship network , the kind that gives meritorious advice that makes life in general more successful and rich.  Increasingly the isolation of addiction is associated with the isolation of the internet following the positive experience of recovery in treatment.  Internet addiction then leads back to chemical addiction.
4) Attending a treatment centre may help establish abstinence and break the slavery to addiction but commonly just as with education there is a need for more advanced treatment education. Some treatment facilities like Betty Ford have programs for continuing education and also are set up for return of ‘sober’ or ‘abstinent’ members to work on more advanced issues like ‘emotional sobriety’.
5) Commonly ‘cross addiction’ leads to relapse. This is especially true with sex and gambling addictions which then lead to a return to chemical addictions.

It is critical to recognize that the ‘excuses’ that addicts and alcoholics give for relapse are usually time and ‘disease’ specific.  I’ve asked people who achieved abstinence after several initial failures what was the key. Almost invariably  I have heard that they really didn’t want to stop their addiction but had only planned to stop for a while to get somebody off their back. It's hard to accept having a lifelong disorder. I see the same difficulties with diabetics. No one questions the benefit of 'insulin' but all those who treat adolescent diabetics have seen the same problems we see addicts have coming to terms with the limitations of disease and the need to learn new methods of self care.
Often people in recovery get success but then the ‘boredom’ of everyday living lacks the ‘drama’ of the previous chaotic lifestyle and they solve the ‘little problem’ by creating a ‘big’ problem. Anyone who has 'worked on long term relationships' knows how the 'little things' if not addressed can grow into bigger things.  So often over time the 'little resentments' and 'lack of honesty' and 'living a lie' grow to a point where they taint the good life and recovery and relapse follows.  Recovery isn't a white knuckle affair but a lifestyle which is 'happy, joyous and free' because life is to be 'lived' not merely endured. This has been called 'emotional sobriety' and 'spiritual awakening'. It was always recognized that people who drank or did drugs has an 'underlying' predisposition or greater level of anxiety or sensitivity and had to learn new coping mechanisms for fulfillment.  When a person becomes an addict it is 'normal' for them to drink, drug or abuse. It is not 'normal' to be abstinent for an addict or alcoholic. To be abstinent requires them to daily live a life which promotes well being beyond that available by their previous lifestyle which 'lead' to addiction.

The ‘treatments for addiction’ are to date superior than most of the treatments for physical illness when they are applied and managed as recommended.  The problem which occurs with addiction is the same as doctors are finding with all the chronic diseases or diseases of lifestyle.  Indeed the treatment of chronic disease is increasingly learning from the successes first seen in addiction. The advances brought forward by 12 step programs are actually being translated to ‘accountability’ groups and used in the "normal' work place.
AA and NA introduced the concept of ‘anonymity’ as a ‘spiritual foundation’. They didn’t want people to speak of their personal success at a time when people’s relapse caused people to question the success of prevention and abstinence treatments.  Today there is overwhelming evidence of success of prevention and addiction treatment but increasingly vocal chronic relapser misinformation.
We used to hear “I stopped smoking but I didn’t feel any better’ in the first weeks of people quitting smoking.  They then used this ‘excuse’ to continue smoking.  However, now, with millions having lasted that first year of recovery we hear endless numbers of former smokers saying what a relief it is to them to be no longer be a slave to cigarettes. This is true of 80% of those who maintain abstinence from substances for five years.  Then those who relapse stand a very good chance of achieving long lasting recovery with appropriate treatment and relapse prevention programs developed for the individual relapser.

I liken this in my work to people with bladder infections. The vast majority get better with one antibiotic. A number relapse and the the antibiotic works again but there are those who need a different antibiotic and even those who we simply find it best to keep on antibiotics indefinitely.
The one week detox program has now had the 28 day program and there are recovery treatment programs which last 2 years. This was the same with mental illness where patients with similar psychosis were unsafe for themselves or others even with 1 week, one month or 3 months programs and they benefitted for a year long recovery in asylums.
All of these approaches standard in the scientific medical treatments are the same as we use with great success in the treatment of addictions.
Part of the success in treatment of mental illness was the recognition that substance abuse, like marijuana, alcoholism or harder drugs were all interfering with the learning and recovery process from mental illness. When I reviewed the suicide completion statistics in one program I found that though there were many who were at one time suicidal it was almost only those who had addictions
that completed suicide.

I’m commonly asked to see people suffering from depression or anxiety and almost all the time the family physician and especially the parents,( especially the mothers) , rarely know how severe the patients addiction to alcohol or marijuania, crack, methamphteamine or heroin is.  The patients tell me because I ask very directly and am highly trained in recognizing the signs of dissimulation that the alcoholic or addicts uses to ‘guard’ their ‘secret’.  
Relapse is treatable but the best solutions to treating relapse are to be found from those who once were ‘chronic relapsers’ and succeeded. I liken this obvious reality to our collective human experience with climbing Mount Everest. For centuries people ‘failed’ and we learned ‘how to fail’ from the ‘failures’ and eventually when people climbed ‘Mount Everest’ we learned how ‘best to climb Mount Everest from those who "succeeded."

Today the ‘harm reduction’ groups are arguing not only that Mount Everest can’t be climbed but that we should listen to people who either have never seen a mountain or may never have got to a base camp.

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