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This post is a comprehensive post on relapse prevention ending with an exercise that will help you to start the development of a relapse prevention plan.
For our purposes we’re going to look at 3 stages of relapse prevention:
1. Recognizing early relapse warning signs.
2. Identifying and avoiding relapse triggers and cues.
3. Preparing our own customized Relapse Prevention Plan
In the last post, Relapse Prevention Part 1, we thoroughly defined early relapse warning signs as changes in thoughts, attitudes, and behavior patterns. These signs for an indicator of stagnation or lack of growth, and a gradual return to our using patterns. To borrow a phrase from 12 step groups, we became “restless irritable and discontent”.
The seed of susceptibility had been sown.
Now we are moving on to identifying the relapse triggers and cues. If we are showing early relapse warning signs we’re very susceptible to a relapse. Triggers and cues are simply the stimulus that can have us reaching for drink or drug. Our susceptibility is like sticks of dynamite, the triggers and cues are simply the match that lights the fuse.
Metaphorically, we are like a gun powder keg ready to go off.
Let’s take all look at some of those flames that can light the fuse:
Clinical observation and research tell us that 3 types of stimulus can trigger intense drug craving, leading to renewed abuse:
1. Priming: “Just one” exposure to the formerly abused substance be it a cigarette, a drink, or an illegal drug can precipitate rapid resumption of abuse at previously established levels or greater. Examples of combating this are to remove alcohol from your house, not going near drug dealers or hanging out with people who use. Even though you may be able to handle exposure 99 out of a 100 times it just takes “that once” when you are not quite ready for it.
Here is a personal example of how this happened to me. I was in a large store notorious for long lines at checkout, and those really annoy me. There was a cashier who was either new or struggling that day. I was becoming angry. The woman in front of me turned around to me and said “I can’t believe it, I hate this place.” She had been drinking and blasted me with alcohol breath. She caught me by surprise and I was not ready for it. The result of exposure to this, was that I was actively thinking about drinking all the way home, and well into the night.
2. Environmental cues: This is the classic “people, places, or things” that the 12 step programs warn so vehemently against. Any association that reminds you of past use can be a cue to use. One vivid illustration of the power of such cues is a negative one: A small percentage of American service personnel became addicted to heroin while overseas during the Vietnam War. When they were removed from that environment, the great majority, after detoxification, reported no further problems with opiates.
Here is an example of an environmental cue. I was walking in the mall one day just people watching and strolling leisurely. All of a sudden I was stopped dead in my tracks and was spinning around searching for a girlfriend of 30 years ago. What happened is that somebody had walked by me wearing a particular perfume that happened to be the same as my ex used to wear. That stirred memories and images of 30 years prior. I really expected to see my ex-girlfriend. This happened so fast my head was turning before realized who and what I was looking for.
3. Stress: Both acute and chronic stress can contribute to the establishment, maintenance, and resumption of drug or alcohol abuse. Some patients and treatment providers point to stress as the most common cause of relapse. The impact of stress recently was highlighted when researchers documented increased rates of smoking and alcohol consumption by New Yorkers after the September 11, 2001, attacks.
Stress and anxiety are such critical components that their relapse prevention plans that focus almost exclusively on methods to reduce stress and anxiety. I like to think of stress and anxiety as a focus on the future, of what may or may not happen. That seems like a bit of a waste to me, because three-quarters of the things that we worry about don’t happen, and the other quarter we couldn’t do anything about anyway. Not surprisingly, the 12 Steps have a slogan to deal with a tendency to fixate on the future. That is “ a day at a time”, or ”stay in the present moment.”
A More Science Based Discussion of Relapse Prevention
Our knowledge of relapse is incorporated in science-based drug treatments.In cognitive-behavioral therapy, for example, patients learn to confront the consequences of their drug use, recognize the environmental cues and potentially stressful situations that trigger strong drug cravings, and develop strategies to steer clear or respond without relapsing.
This is essentially what we are trying to accomplish in these three sections we are spending on relapse prevention. We are looking at:
1. Early relapse warning signs.
2. Triggers and environmental cues
3. Strategies to deal with them
In having a discussion on relapse triggers and cues, what we are really talking about are those inputs or actions that can trigger cravings. Much of the scientific study on triggers and cues has come as a result of the study of cravings.
The general relapse prevention strategy of “recognize, avoid, and cope” is particularly applicable to craving. After identifying your most problematic cues, we should explore the degree to which some of these can be avoided.
There is, an exercise at the end of this document to help you identify those problematic cues. I have also separated this PDF into an individual file so you can print it out and work on it on its own.
New research findings appear to shed light on one of the deepest mysteries involving drug relapse:We know that former abusers of addictive drugs remain vulnerable to powerful drug cravings for months or years after establishing abstinence.
Scientists have known for some time that addictive drugs hyper-activate key brain circuits that provide pleasure and are closely linked to motivation and memory. Research also has shown that drugs change brain cells in these circuits in numerous ways, some of which might be linked to craving.
However, these changes generally last only as long as a drug is actually present, or a little longer. To explain how craving can recur after long abstinence, researchers need to show that the drugs change the cells in ways that change back slowly or not at all.During the past 3 years, research teams at Yale and Texas Southwestern Universities demonstrated that repeated exposure to cocaine produces alterations in gene activity in the nucleus accumbens that can persist for weeks.Last year, researchers at the University of Michigan showed that cocaine self-administration changes the actual shape of these neurons — a change that is long-lasting or even permanent.
Further research will tell whether these changes are critically important to long-term vulnerability to drug craving, or whether they play a relatively minor role. The studies were conducted with laboratory animals and cocaine, and we need to find out whether they also apply in humans and with other drugs.
What accounts for the extraordinary persistence of drug cravings?
It is important to recognize that experiencing some craving is normal and quite common. Craving does not mean something is wrong or that the patient really wants to resume drug use.Science-based medical treatments buffer patients against the craving that leads to relapse. There are some drugs that have been proven in some instances, to help with craving. It should be pointed out that these aids, in and of themselves, are not a sufficient basis to build an entire recovery or relapse prevention strategy on.
1. Methadone and other opioid agonist agents block the euphoric effects of opioids and stabilize brain processes whose disruption is linked to craving.
2. Naltrexone, an opioid antagonist, blocks opioid-induced euphoria and counters opioid craving with an aversive effect.
3. Disulfiram (Antabuse) is used to treat alcohol abuse, and it is currently being tested to determine whether it also can offset cocaine craving. Anti-anxiety agents are prescribed to moderate stress.
Explaining Drug and Alcohol Craving:
To explain the ideas of craving and conditioned cues, we can look at a couple of examples. In scientific studies they have found that’s when cocaine addict start to chop the cocaine and lay it out in lines, that action itself releases naturally occurring euphoric stimulants into the brain.
A more traditional and generalized example might be of the conditioning experiments of Pavlov and his dogs. He conditioned the dogs in his experiments to salivate with the ringing of a bell. The bell became a trigger to the expectation that the dog would be rewarded by food, therefore, in anticipation of the food he started salivating. I have heard a lot of people describe “the hunt” as just as important for enjoyment as acquiring or imbibing in the substance.
A very important point is that cravings are traditionally time limited. In other words, if you can buy some time, and take some appropriate action, the craving will dissipate. I have also heard anecdotally that the farther along you are in treatment and recovery the less intense and less frequent cravings are. We are trying to extinguish those cravings.
How bothered are you by craving?
There is tremendous a variety in the frequency, level and intensity of craving that people experience. For some, achieving and maintaining some control over the effects of craving will be an important relapse prevention strategy. This may take some time to achieve. Other people deny they experience any craving at all.
Strategies To Cope With Drug Cravings:
Let’s take all look 5 strategies to help cope with craving:
1. Distraction
2. Talking about craving
3. Rolling with the craving
4. Recalling negative consequences
5. Changing Self talk
1. Distraction:
In a lot of instances a strategy that really works for handling cravings, and those triggers and cues is distraction. A very effective form of distraction is doing something physical, take a walk or jog, go swimming, or mow the lawn. How about taking a bath, or hot shower? another illustration of the concept of distraction is to change your environment, it just get out of there, and go somewhere safe . Again, there’s a 12 Step slogan that illustrates this point and that is “move a muscle changes thought.”
2. Talking About Craving.
If you have created a support network, then use it. Using supportive, abstinent friends and family members, talking to them about craving when it occurs, is a very effective strategy. Talk therapy is the basis of much of psychology. This can help reduce the feelings of anxiety and vulnerability that often accompany cravings. The trick here is that you have paid attention and found willing and appropriate listeners. If you are isolated and cannot get hold of anybody, get creative. There are 800 number hotlines to call, emergency crisis centers, you can go online to chat rooms and online forums.
3. Rolling With The Craving.
The concept of this technique is to let cravings come on, peak, and pass; in other words, to experience them without either fighting, fearing or giving into them. You can use imagery of a wave rolling up on the beach, or what other scenario grabs you. In the science-fiction book Dune, I remember reading the tool used for overcoming fear. I have to paraphrase it, but it went something like this “Fear is the mind killer, I will allow it to pass over me and through me and when it is gone, I will remain, but stronger”. This is a similar idea to rolling with the craving
4. Recalling Negative Consequences.
When experiencing craving, many people have a tendency to remember only the good effects, their euphoria of using. This called euphoric recall. As part of this, they often forget or under play the negative consequences the negative consequences. A strategy to combat this I what I call “playing the movie foreword”. What has really happened in the past when you picked up one drink or one drug? Chances are it never stopped there, it got worse and worse. Play that scene out to the logical conclusion.
This strategy can be a double-edged sword. I have had people base their entire relapse prevention strategy on remembering the negative consequences, recalling the pain. While this is a useful tool, the knowledge that bad things may occur doesn’t stop that many people from actually using.
5. Changing Negative Self-Talk Into Positive Self-Talk.
Let’s face it, we all talk to ourselves. There is an internal dialogue that accompanies us throughout the day. This strategy essentially means taking the “automatic thoughts” that accompany a craving, and consciously reframing them.
An example might be an automatic thought of “I really want to use that would make me feel great”, running around in your head over and over. Well, you can counter that by saying “Wait a minute, what would really happen if I used? Eventually my money or the drugs would run out, I might go into withdrawal. I would get the shakes and have a massive hang over. That doesn’t sound like much fun.” Hey, they are your thoughts you can change them, if you want to.
Identifying Relapse Triggers
Let’s work to develop a comprehensive list of our own triggers. It may be helpful to concentrate on identifying the craving and cues that have been problematic in the past.
Are You Ready?
I have provided a large list of potential relapse triggers. the object of this exercise is to narrow the list down to the five potentially most troublesome for you. Start with quickly scanning the list, and marking any triggers that you think may apply to you. Now go back over the triggers you have marked and select the top five that you believe could be most troublesome. Take those five and arrange them in order from the most worrisome on down. Here we go:
1. Complacency
2. Isolation
3. Dishonesty
4. Depression
5. Argumentativeness
6. Self pity
7. Cockiness
8. Expecting too much from others
9. Letting up on daily disciplines
10. Forgetting gratitude
11. Omnipotence
12. Selfishness
13. Not attending 12 meetings
14. Obsessive and compulsive thinking
15. Boredom
16. Maintaining resentments
17. Old “people, places and things”
18. Keeping drugs and/or alcohol in the house
19. Grandiosity
20. Major or sudden “life” changes
21. Exhaustion
22. Anger
23. Anxiety
24. Boredom
25. Stopping medications against your doctor’s advice
26. Shame
27. Self pity, dwelling on unresolved conflicts or past hurts
28. Loneliness and isolation
29. Fear
30. Frustration
My Top 5 Relapse Triggers, and some solutions for them:
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