Relapse Prevention

"I stopped drinking," he almost shouted at me. "I can't be an alcoholic if I can stop drinking."

Stopping drinking is good but staying stopped is where the rubber meets the road. The WHO early recommended that if a person did not feel they had a problem with drinking but others including their doctor might, or if they had some negative consequence from drinking, they should abstain from alcohol for 1 year (4 complete seasons). This was the acid test in the early days of our understanding of the disease of alcoholism. It was recognised early that true social drinkers could abstain for a year from alcohol without significant difficulty and would. Most others however might say they could but sometime within that year would find they 'needed' a drink. Interestingly too, because of the denial intrinsic to the disease of alcoholism they would have a ready excuse for why it was 'necessary' for them to have that drink. This was of course recognised as 'rationalization' . Failure to go a full year without drinking was sufficient indication to strongly recommend AA to a person who had difficulty seeing their problem as others did.

Long term studies have since shown that those who don't relapse most commonly share five features in common.

First they recognise that relapse is not about short term abstinence but rather refers to long term recovery. These people do not think that a few days without drinking is any kind of proof or certainty that they are 'cured' or don't have the 'disease'. Indeed those who are successful in recovery view the process as one of many years if not a life time. Studies show that of those who have a serious problem and return to drinking at even 3 years of abstinence, 70% will relapse to their former level of drinking or worse and at 5 years, 50% will and at 15 years of abstinence at least 30% will still revert to previous levels of abuse or worse. In contrast to AA literature which does not follow those who do have 'success' in returning to drinking, there is evidence that people can but it is worthwhile to note the odds and the rather long term effects of alcohol abuse on the probability of their succeeding. The scientific studies, simply because of the high cost of such endeavours, in contrast to the AA testimonial evidence, are limited in numbers and lack the lifetime experience. Further it is interestingly to note that those who do return to drinking, do not do overall as well as those who continue to abstain. The other measures of societal success show that abstainers do better physically, socially and occupationally in the long run. Further what the data consistently shows is that return to controlled drinking carries a very high risk of return to previous abuse patterns with the negative social and health consequences.

The second feature about those who do not relapse is that they have developed an aversion to alcohol. This means that they don't romanticize it or even their past association with it. It is clearly seen as a negative and avoided as one might a poison or other noxious agent. As one old fellow of long term sobriety stated, "I learned to respect alcohol. I don't take it lightly. For me one drink could be like flirting with the gorilla. If the gorilla responded the sex wouldn't be over till the gorilla decided it was over."

The third feature was an alternative addiction. Alternative addiction is how this is described in the literature but it's a bit confusing because of the inherrent negative associated with the term 'addiction'. Some have difficulty with the term 'positive addiction' as well. Perhaps, passion is a better word. Those who were successful had replaced their previous worship, loyalty and occupation of drinking and everything associated with drinking with another positive healthy pursuit. For some this is a new found involvement in their work or family, for others it's community service especially those helping other alcoholics and for many a 'hobby' , 'craft' or "sport" is elevated from an interest or 'past time' to a true 'avocation'. The risk for many is 'cross addictions', where by alcohol is replaced by the 'marijuania maintenance' program, gambling, 'sex addiction' or shoppaholism. These activities temporarily reduce anxiety but inherrently like alcohol carry a high risk for abuse.

The fourth feature may in fact be the most important one of all. Those who have the greatest likelihood for long term sobriety and are least likely to relapse have developed a supportive social group of non judgemental non alcoholic friends. This is certainly what AA provides but has also been provided by church, community clubs, and other institutions which have avoided being coopted by the alcohol industry as a place for secondary marketting or merchandising. Colleges in the US have begun to exclude alcohol from their places of higher education just as tobacco dispensers were earlier removed from high schools. Just as alcoholism is a leading cause for dementia and does cause brain damage, recovery is commonly associated for many with advanced education and a new found interest in learning and joining groups associated with these pursuits of interest.

Finally, spirituality has been a key factor in those with long term sobriety, It is a principle feature in relapse prevention. It is different from institutional religion which not ironically has a high density of spirituality but itself is rather frightened of it. Christian spirituality is most evidenced in monasteries and retreats which are separate and not uncommonly at variance with the political organizations that are the basis of religions and commonly serve the role of supporting the state. This gave rise to the famous Marx statement, 'religion is the opiate of the masses'.

However in the Christian church spirituality and religion have long been known as the Martha and Mary debate. Recovery clearly is benefitted by the 'better part' of Mary. Spirituality was also what Carl Jung referred to in his famous "formula" for the early AA members, "Spiritus contra spiritum". It was noted that that the craving for base "spirits" , ie the demon drink, has to be replaced by a higher desire for the so called "holy spirit". Even aetheists have found recovery and solace in spirituality contemplating wholeness versus the isolation and aloneness that comes with active alcoholism. Many are moved and uplifted by routine and regular communion with Mother Nature herself.

As one recovered doctor who'd left the monastery for medicine told me, "Anxiety is a measure of our distance from God but equally a measure of our humanity." From a psychiatric perspective the alcoholic has a predisposing anxiety disorder, or sensitivity, which makes them find alcohol so appealing and when alcohol no longer works for them they have increased anxiety in recovery which has to be dealt with to prevent relapse. Seen spiritually the alcoholic needs to shift the equation closer to God so that they experience less of the existential angst which is inherrent in human existence. Not surprisingly all the spiritual practices such as prayer, ie talking to God, or meditating, listening, chanting, group and individual study of inspirational and mystical works, have all contributed to the reduction in individual anxiety and thereby promote long term recovery and relapse prevention.

As AA recognised early no religion has a monopoly on these practices, to which end AA has as a fundamental tradition that it is not affiliated with any particular group so that aetheists and people of all religions can benefit from a fellowship devoted to helping the alcoholic overcome what they specifically call a 'spiritual malady".

These then are the features associated with long term recovery and in part or whole are incorporated into the very best recovery programs. Individuals and families seeking the greatest likelihood of success should indeed consider them seriously as the denial and rationalization of alcoholism is so strongly associated with the insistence on doing it My way. Indeed that is why the disease of alcoholism has been called the disease of "me". Locally a very spiritual long term recovered member of AA called Milton is fond of saying, "I don't know about alcoholics having a child within, but I'm sure that somewhere deep inside there's an adult struggling to get out". Recovery is that journey and relapse prevention incorporates the proven and tried ways demonstrated to date to effectively increase the likelihood of survival from the disease of alcoholism.

What Just Happened

This is definitely a different kind of dog movie from Beverly Hills Chihuahua. De Niro, Sean Penn, Bruce Willis and Catherine Keener make it a very funny movie. Michael Wincott is hilarious.

Beverly Hills Chihuahua

Paul Johnson, author of Modern Times, Intellectuals, History of Christianity and History of the Jews, in his 2006 book, Creators, gives Walt Disney the greatest laurels. Naturally I only watched this doggie flick to get closer to the genius of Walt and perhaps uncover the meaning of life. The fact that I dressed Stuart, my scotty in lifejackets and rain capes after having Shinto,a cross irish setter english springer with the character of the hero German Shepherd, Delgato had nothing to do with my picking this movie. It was a long busy day and Norman Cousins, author of Anatomy of an Illness, and advocate of humor therapy would clearly applaud my choice. Thanks to Cousins pioneering research watching Groucho Marx as therapy countless followers including myself have dared to prescribe this potentially lethal therapy. I didn't die laughing, watching Beverly Hills Chihuahua though came close, when Montesumo and the countless chihuahua bandidos saved the day. Jamie Lee Curtis was terrific in person while Drew Barrymore's voice as the star Chloe sounded almost type cast. A dog lover's treat for sure, this was a mighty little movie with a whole lot of bark to it.

love me, love my dog - 16th century proverb

Genetics

Genetics is the modern word for fate. It's tarnished name, thanks to American and later German researchers, was 'eugenics'. As the 'reformer is the enemy of anyone who benefits from the status quo' the status quo have the greatest investment in maintaining and indeed insisting they were 'born king'. Modern 'social darwinism' says that 'survival of the fittest' is indeed the psychopathic CEO who through theft and murder acquires wealth and power as one of the "new" master race. If you are poor, maimed, crippled, mentally retarded, etc. you were born that way and indeed 'deserve' your fate. Genetically I must keep my gene pool pure, breed with others of the master race and avoid association where at all possible with those who are 'inferior'. Very, Ivy league.
The novel, Galapagos, by Kurt Vonnegut was a superb exploration of the meaning and significance of genetics and society. Gattaca, the futuristic movie was another such education in the meaning of genetics. Fate is 'fixed' and what is 'fixed' can't be changed and what can't be changed must be 'accepted' and the more one 'accepts' in the outer world the more one politically will ultimately accept the Queen saying 'give them cake!" The 'caste' system of India, was the 'class' system of Europe and today is increasingly the 'corporate reality'.
Fate or determinism come with a price. Blame and praise are lost. Tell that to the smug and grandiose. However the very same who claim their success is through their own efforts would say that the 'loser' failed. If genetics is the puppet master everyone is a puppet. Emerson the father of American philosophy wrote in a mystical sense, "if the redslayer thinks he slays or the slain thinks he is slain, they know not well the ways I keep and turn and toss again."
The new fascists often appeal to 'pseudo buddhism" for their 'zen' of dominance. Things just are, they say and yet these religious 'cherry pickers' would ignore the 'efforts' of the devout buddhists who abhore consumerism and begin their life of discipline from an early age. Trungpa describes the western mind seeking a 'religious smorgasbord".
The same is true of these terrified power mongers who approach science for their own justification desperately seeking any means to abdicate from responsibility and especially blame. How horrible to think biblically that the 'sins of the fathers' are passed on many generations and not just 'genetically' as this might imply but more significantly 'karmically'. Why consider fate and free will and the philosophical and theological implications that follow from in depth analysis when one can remain superficially claiming 'genetics made me do it" the way the superstitious once said ' the devil made me do it."
Genetics is important scientifically and practically. Many diseases can be avoided with genetic testing in infancy which then allow environmental alterations which will protect a child at risk. PKU is a classic disease of that kind. The key here is 'risk'. It's a probability assessment. Genetics is clearly implicated in the colour of one's skin or the eye colour but at the level of complex human behaviour the contribution of genetics is usually s at most 50%. That means that 1/2 of the outcome was determined by genetics and one half determined by environment. The interface between the brain and environment has commonly been called the 'mind' and some social scientists, more out of cowardice and laziness than science, have excluded 'free will' or 'mind' from equations because quite frankly it's human and humans mess up reductionist science. The study of mice and now computer generated programs is much more satisfying than introducing the human factor with it's almost god like potential for throwing monkey wrenches at monkeys.
I watched Devil's Advocate, last night with Keeanu and Al Puccino and was delighted that the writers and actors really did have a scientifically sound understanding of modern genetics when they made this challengingly brilliant movie.
The genome experiment was so exciting before humanity with it's vanity, lawyers and copywrights got ahold of the thing. Just as the secrets of the papal library are religiously kept so the secrets of the genome will be politically kept. The words changes but in the end so much remains the same. The final question is to ask whether the body or mind is represented by free will or fate. For now there's a lot of probability in reform and change much to the chagrin of some. My own thought is that we are genetically programmed for Love and Space Travel.

Quintin Jardine

Quintin Jardine is Scotland's primo Crime Writer. Ian Rankin and he seem to rank at the top of that genre as far as can be told from across the pond. They're both a bit more old world than American crime writers. Their characters have more depth and the plots seem just a bit more twisted in more ways than one. W.E.B. Griffith's Badge of Honor series is an interesting constrast in police procedure to Quintin Jardine's Edinborough police chief Bob Skinner series Reading both one gets a feel for the hierarchies and obligations of duty and relationships on different forces. Jardine's characters are endearingly warm and neighbourly and more reminiscient of the real life Canadian police I've known than the slick or tough or para military police often portrayed in American TV crime fiction.
In Skinner's Round, Bob Skinner is almost grandfatherly, married to Sarah, the coroner doctor with their new baby, Jazz and a difficult talented young woman daughter from his former marriage. Skinner's Round starts with the murder of golf course owner Michael White, found with his throat slit in a jacuzzi at the opening of the Witch's Hill golf course. An ancient curse appearing in the newspaper sends Detective Rose off on a fascinating historical investigation that shadows the grizzly plot that unfolds during the Golf pro series. I couldn't help but think this would be the best gift for any golfer who likes crime fiction as the suspense built up in the golf game parallels the murder investigation. I found it an intriguing read and very much enjoyed that I never saw the ending coming. Truly a grand who dunnit as well as everything else!

What the detective story is about is not murder but the restoration of order. P.D. James 1920 -

Pharmaceutical Therapy Post Addiction

Pharmaceutical Therapy Post Addiction

Just because you once were a toxic wasteland doesn't mean you won't ever again need a pharmaceutical agent. If your alcoholism caused you pancreatitis and you need surgery it's only smart to accept it, plus anesthesia, plus opiates post surgery. That doesn't mean you can pack a pistol to put up the nurses nose demanding more 'till it feels good' and still claim to be in recovery. The key to proper pharmaceutical prescribing is that you let a competent professional, not yourself, do the prescribing and follow their directions. A competent professional is not a drug addicted physician who offers you a shot of whiskey from the lower drawer mid morning. Ideally, the person prescribing is a bit more competent.

Drugs which you can't use are those which are commonly known as "illicit", that is, any thing that there's a law against possessing. Further, if a pharmaceutical agent 'sells' on the street, then it's likely that it's a drug of abuse and should be avoided. Hence the so called "downers", such as the benzodiazepine class of drugs, barbituates and the "upper's", such as the dexedrines and the ritalins.

Claiming to have a diagnosis, doesn't necessarily mean that you should have the drug that goes with that diagnosis. For instance a rabid coke addict humping your leg may claim his doctor said he had ADD (attention deficit disorder) but that doesn't mean more amphetamines are going to make him mellow. Many an acid head insisted they were too 'mellow' for this world and had to 'trip' out to get real. Sometimes a walk -in clinic doctor will say whatever you want to hear just to get you out of their office, especially if you smell or alternatively are seductive and faster if you are both.

Hazelton's research suggests that those who avoid using any pharmaceutical outside of the first week or two of detox when benzos and barbituates,antipsychotics, and anti seizure drugs are normal tend to do better at staying clean and sober for a year. This suggests that you try non pharmaceutical means for addressing negative emotions in the first year of recovery if at all possible. Addicts and alcoholics are routinely called "bipolar' because they are emotionally unstable in the first year or even two of recovery, often called the long hang over. It's typified by irritability, emotional lability, anger episodes, feeling good without cause, feeling sorrow without immediate reason and the general adolescent range of emotional experience. That's not to say everyone has to feel this much, some do 'unthaw' more slowly and not all do it in spurts and starts.

That said, if you are weeping uncontrollably, going to 12 step meetings, exercising, praying, meditating, volunteering at the local community centre, and still feeling suicidal and sitting for long periods of time in the garage in the car with the motor running, you probably do need medication. If you are beating up your loved ones and getting arrested for kicking policeman maybe you too would benefit from seeing a psychiatrist. If you can't sleep for weeks at a time and are down everyone elses throat you too might need medication. Of course if you have heart disease, diabetes, a thyroid condition or any other purely medical condition you'd be unwise to have stopped your medications when you decided to clean up that marijunia and red wine habit.

Antidepressants are the most common medication prescribed in the first year or two of recovery. Mirtazepine has the advantage of being an anti anxiety and sleep inducing antidepresant that causes the least sexual side effects. It tends to improve the appetite which for some is also beneficial. In contrast buproprion is an energizing antidepressant that improves concentration, has been marketted as zyban to reduce smoking, and has the fewest sexual side effects. If you don't want to have to think about sex so much in the first year of recovery, paroxetine is the best antidepressant with a major antianxiety component. The SSRI's such as prozac, celexa and cipralex are themselves very good indeed especially if there are any other complicating medical factors. Because addicts and alcoholics have usually altered their brain chemistry the rule of thumb is to start slow and increase slow without expecting the medication to make you feel like you did when you were 'high'.

It's also not that useful to discuss what you remember you were like before you went on your binge and orgy of self abuse. Your memory is usually impaired and tells you what you want to hear and further your exciting chemistry experiments have thoroughly altered your previous neurochemistry conditons.

Antipsychotic medications or atypicals are commonly used for anxiety. These are used at high dosage in schizophrenia whereas for alcoholics and addicts in recovery they tend to be beneficial in the lowest dosage. The most favoured is quitiapine (seroquel) usually used 25 to 100 mg for anxiety or sleep. It has the least tendency to cause extra pyrimidal side effects therefore there's little fear that your eyes will roll back in your head and stay there till you stop the medication. Also rispiridone .5 mg to 2 mg range per day is commonly used. Olanzepine can also be used but has a greater likelihood of causing metabolic syndrome with weight gain and risk of diabetes. Ziprasidone (Zeldox) is the newest in this class and a real breakthrough medication.

Mood stabilizers are medications which are used in high dosage for seizures but were found in lower dosage to have benefit with migraines, sleep disorders, mood instability or pain disorders. Gabapentin is commonly used in the 100 to 1200 mg range safely. Topiramate has the advantage for some of causing weight loss as well and is commonly used in the 50 to 150 mg range. Valproic Acid has been used but has been associated with spontaneous death from liver collapse, most commonly causes elevated liver enzymes and generally speaking there are better and safer alternatives for those in recovery, especially alcoholics. Carbamezapine is an old stand by which had the benefit of being the drug of choice for the anger associated with temporal lobe epilepsy so is commonly used for those with anger problems, again starting with the lowest dosage.

It is important to note that most 'side effect' profiles especially those appearing on the internet are from 'medical disclaimer' sources and often for very high dosage in very sick people often having taken them for many years. . Dr. Anderson out of San Diego did the key research on what the actual drug side effects are when they're really being used by real doctors for real patients. It's a wholly different story than the one put out by the pharmaceutic industry either to avoid law suit or to get FDA approval. In any case no one is generally enlisting former alcoholics and addicts for brain chemistry research or new general pharmaceutical trials. The data on what works comes mostly empirically from practitioners in the field.

Trazadone is an antidepressant medication that is commonly used as sleep medication sometimes along with gabapentin. Most of the other sleep medications are potentially drugs of abuse. It is common to have sleep disturbances in the first year of recovery and it is one of the joys of recovery that the sleep eventually returns to normal by the second year. Sleep loss for one night at a time isn't a terrible hardship as any on call doctor can testify to but night after night of sleeplessness requires journalling and possible referral to a sleep lab rather than more and more medication.

All these medications can be used individually or in combination if the prescribing physician has experience with multiple prescribing or a nifty little palm pilot device that helps him review the side effects of overlapping medications. The rule should always be 'low and slow' which is the exact opposite of the gut feeling most addicts have about medication usage, ie 'lots and fast".

Recovery is not an overnight process. The brain of an addict or alcoholic is a changed brain. The restoration to some sort of normal takes at least 2 years if not more. The risk of use is increased with mood altering drugs because they can incite a craving or can give one false confidence which distracts one from the normal nonpharmacological approaches to recovery. Medication is an adjunct to the process of restoration of physical health, relationships and community.

That said, it's a good idea to tell your doctor you're in recovery and what you used to use. This is really important if you're going for surgery because commonly addicts and alcoholics in recovery need more rather than less pain killer. It's the exception to the general rule. It may be a really good idea therefore to tell the anesthetist you used to be a cocaine addict or drank excessively rather than waking up in the middle of a heart operation and causing unnecessary fuss about the man with the mask and bloody knife cutting into you.

Toys and Tools

I’m positively exhausted. Yesterday, Harley wanted more fuel. Not an unreasonable request from a hard working motorcycle. I thoughtlessly didn’t turn on the reserve tank before he passive aggressively stalled. Then the battery didn’t have juice to turn over the pouting engine . My friend got off the bike and walked over the bridge acting like she didn’t know me. I pushed Harley over and down to First and Clark, while car drivers played their favourite game, let’s brush a biker. When I called a taxi, my friend returned. We got my truck with the tools, the reserve gas tank and the new Harley battery. On the side of the road I installed this and let her drive the truck to my sailboat while I drove Harley over Second Narrows. I thought of a friend who told me he’d love to have my ‘toys’. He has no idea how much learning and maintaining go into tools. His idea of life is a limousine and room service.
The sailboat is 30 years old. It’s crossed oceans and is forever a work in progress. Right now it’s more work than progress. I also lived on it for many years. After sailing back from Hawaii last summer it begged me to put it out of it’s misery. With tender loving care I ground and epoxied superficial steel wounds while continuing the process of ‘laying on hands’, something machines truly respond to.
Last night I thought I’d get the Dickinson Diesel Stove working again. Not surprisingly, I had no need for this in the tropics so didn’t care that it didn't work. Last night, I installed a new 3 psi fuel pump. That got diesel fuel to the stove. However whenever I lit the stove it merely smoked excessively and would not flame. With eyes watering and no visibility onboard despite all hatches now being open, I considered the chimney. On top, I found it half closed, opened it fully and went back to lighting the stove. Aha, a happy little flame. Eyes red, she returned to the boat.
The little flame then burst into a forest fire flame which had me thanking Tim McGiveney, my surveyor, for insisting I install new fire extinguishers. “It’s supposed to do that?” she asked. I nodded noncomittally while turning off the fuel and crowding her for the exit. Without fuel the stove eventually went out. After that amazing pyrotechnic exhibition it refused to flame. After dismantling and cleaning carburetors and pumps the only explanation could be a clogged fuel line deep in the bowels of the boat.. It was 1 am and electric heater and candles would have to provide sufficient warmth for a night at sea. So far, instead of a boat trip, we’d not left the dock.
Today I got a warmer and heavier duvet. This was after I made my way through the propane stove system till I got flames for the essential morning coffee. Admittedly I was highly motivated. The boat has been kind as the head continues to work. The hot water system proved beyond my comprehension this time and while I ensured I had electricity to the depthsounder I concluded the fault was with the computer component. I have a hammer, drill and wrenches but the computer components require a little more delicacy. Without a depthsounder , we’d not be going off yet to anchor in some cozy cove.
I also finally found a 2009 Tide and Current chart at Martin’s Marine off Lonsdale the third marine store I’d gone to before finding this essential. To get back out to sea I will have to go under Lion’s Gate and that necessitates knowing the currents if I don’t want my boat to become a whirling dervish.
I was rather thankful later to fill my tanks from the broken dock water system I repaired so I could have another cup of coffee. It only required me soaking myself quite thoroughly. After that I surprised myself by finding where the navigation light wiring had rusted, replacing it and adding a new bulb to the port system in case I have to run at night . She’d remembered how to use the propane stove and had hot dogs prepared for lunch. “It’s so peaceful. It’s just like camping,” she said insisting she didn’t mind that we were still at dock beside tugboats and not anchored in some cozy cove watching eagles. She went back to reading her book bundled under the new duvet while I continued to ‘mess with the boat’ .
I’ve often thought it would be great to be rich. I imagine sitting about being fed grapes and having beautiful young people working those long fans they had before air conditioning. In my fantasy, as politically incorrect and appalling as it is, I’m smoking a big Cuban cigar. The very rich people I’ve known haven’t done things like that. For one they already have air conditioning. Further, knowing them I’ve learned that keeping one’s money is hard work. Poorer people are forever wanting to take it. Worse governments,lawyers and accountants are always scheming . Even the rich dictators in foreign countries with American backing have to watch their backs for other rich dictators with American backing who want to take their money. They both have to watch out for the Americans who now want them to be democratic despite how bad this is for their dictatorships. Maybe if my mother wasn’t forever darning socks and Dad wasn’t forever fixing old cars to save on buying new I’d have taken up a life of limousines and room service too.