Highlights of recently published NIDA-supported studies

Studies Focus on Acculturation and Hispanic Youth

U.S.-Born Hispanic Women Have More Drug Problems Than Immigrants: Among 19- to 21-year-old Hispanic women in South Florida, those born in the United States face a higher risk of drug addiction than immigrants, according to a recent study by Dr. R. Jay Turner and colleagues. The U.S.-born women reported more acculturation, measured as preference for English over Spanish, and greater exposure to stressful events, both of which were associated with increased risk for addiction. The gap in acculturation between the two groups accounted for 40 percent of the risk difference; a high score on either acculturation or stress exposure was associated with a nearly three-fold increase in the odds of addiction, compared with low scores on those measures (evaluated at one standard deviation above and below average). The investigators speculate that cultural influences help protect foreign-born Hispanic young women from stress. Native-born and immigrant young men reported similar levels of stress exposure and had similar rates of addiction.
Drug and Alcohol Dependence 83(1):79-89, 2006. [Abstract]

Latino Parent Training: Men and women who completed a parent-training program adapted for Latino culture reported improvements in effective parenting practices and their children’s (aged 13 years, on average) behavior compared with those who did not receive the intervention. Children whose parents received the program also reported that they were less likely to abuse tobacco, marijuana, and other drugs in the future. The parents also said their children’s behavior improved.

Drs. Charles R. Martinez and J. Mark Eddy of the Oregon Social Learning Center randomly assigned 73 Spanish-speaking Latino parents (90 percent were of Mexican heritage) to participate in Nuestras Familias: Andando Entre Culturas (Our Families: Moving Between Cultures) or to receive no intervention. During each of 12 weekly 2.5-hour sessions, participants in the intervention group discussed developing effective family communication, bridging cultures, being positive, and encouraging success using appropriate discipline and limit setting, and practiced parenting techniques in role-play.
Journal of Consulting and Clinical Psychology 73(5):841-851, 2005. [Abstract]

Medical Care During Addiction Treatment Reduces Hospital Use

On-site delivery of primary care reduces emergency department (ED) visits and inpatient hospital stays over the next 12 months among adult patients in methadone maintenance or in long-term residential treatment programs, according to a recent article by Dr. Peter D. Friedmann and colleagues. Their longitudinal analysis showed that offsite referrals reduced hospitalizations, but not ED visits, among those in long-term residential programs. Neither on-site care nor offsite referral curbed health service use by outpatients in nonmethadone treatment programs. In all three types of programs, health care use declined after substance abuse treatment. Overall, ED visits decreased from 47 percent to 23 percent, and hospitalizations from 42 percent to 13 percent; the greatest reductions were observed among patients with the longest stays in treatment. The National Treatment Improvement Evaluation Study included six methadone maintenance programs, 14 long-term residential programs, and 24 outpatient nonmethadone programs with over 2,000 patients. The investigators advocate future studies of the cost-effectiveness of integrating primary care into addiction treatment.
Medical Care 44(1):8-15, 2006. [Abstract]

Brain Changes Accompany Cocaine Withdrawal

Rats repeatedly exposed to cocaine and then withdrawn from it exhibit neural changes in the lateral amygdala, a part of the brain involved in responding to pleasurable and aversive stimuli. Such changes may mediate the negative emotional effects that accompany drug withdrawal, say the researchers who documented the effect in a recent study. Dr. Vadim Bolshakov and colleagues at Harvard Medical School have shown that longterm potentiation (LTP), a process underlying learning and memory, occurs in the lateral amygdala when cocaine-exposed rats no longer have access to the drug. They found a clear link between LTP and enhanced levels of the neurotransmitter glutamate in the lateral amygdala and signs of withdrawal in the rats. The findings suggest that amygdala circuits might contribute to drug modulation of motivational states and influence addictive behaviors.
European Journal of Neuroscience 23(1):239-250, 2006. [Abstract]

Posted September 1, 2009

From:

http://www.nida.nih.gov/NIDA_notes/NNvol21N2/RIB.html#medical

A NIDA-funded study has demonstrated that the relapse rate for heroin addicts increases with time and that the probability of long-run abstinence depends on the age of first drug use. Those who start daily heroin use at a younger age are more likely to relapse than those who start later.

The study, conducted by Dr. Marnik G. Dekimpe of the Catholic University Leuven in Belgium and his colleagues in Belgium and at the University of California, Los Angeles, examined the treatment histories of 846 patients at methadone clinics in central and southern California. The researchers looked at males and females, whites and Chicanos, most of whom started using heroin between the ages of 17 and 25. Subjects were interviewed over a 4-year period during and after treatment to determine the probability of their relapse to heroin use.

The finding that relapse is connected to time suggests the need for long-term periodic monitoring of a former heroin user’s abstinence, Dr. Dekimpe says. The researchers also found drug relapse odds were significantly different across the sociodemographic groups studied, suggesting that prevention resources could be directed to groups at higher risk. No significant differences in relapse probability were associated with either gender or education.

Posted August 25, 2009

From:

http://www.nida.nih.gov/NIDA_Notes/NNVol14N6/BBoard.html

EzineArticles.com Bill Urell Platinum AuthorThere is an old adage that states quitting drug and alcohol use is easy, staying quit is the hard part. I’m not sure if I agree with the easy part, but it is a fact that many people have difficulty maintaining abstinence from drug and alcohol use and suffer a relapse. There are certain attitudes and behaviors that can be developed that will decrease the likelihood of returning to drug and alcohol use.

Here is a list of the top five sobriety tools:

1. Motivation level – maintaining abstinence from mood altering drugs is definitely doable, but in most cases difficult. In order to achieve difficult goals it makes sense that the motivation has to be very high. People who rank their sobriety as a number one priority often have better results than those who put maintaining recovery on their ‘to do’ list. There should be an absolute commitment not to drinker drug ‘no matter what’.

2. Handling cravings – as sure as the sun will rise tomorrow, thoughts and cravings of using drugs or alcohol will occur to anyone in recovery. The skill that needs to be developed is to stop these thoughts and cravings from becoming an actual using incident. The good news here is that cravings generally decrease in frequency and intensity over time. It helps to have a concrete plan of action in place prior to the occurrence of the craving for using thought.

3. Coping skills – often people in early recovery rely on coping skills that were developed to protect their drug and alcohol abuse. This might include becoming isolated and pushing people away, becoming dishonest in cheating, or becoming self-centered in the extreme. In other cases coping skills are either undeveloped, or underutilized. Some examples of life skills that may need some work are the ability to communicate, basic social skills, knowing how to develop and maintain interpersonal or intimate relationships.

4. Identifying, owning, and processing emotions – there is often stated rule in relapse prevention that advises people in recovery to avoid “people, places, and things” that could be dangerous to the recovery. In reality, is may not be the situations or triggers that are more dangerous, but our rather our inability to handle the emotions that these things generate. Our actions are often generated by our feelings.

5. Self-esteem and self-confidence – if a person does not have the self-confidence in their ability to remain abstinent, certainly undercuts the motivation to keep working at it. If a person does not start feeling better about themselves in recovery and gain self-esteem, then the idea of returning to drug and alcohol use can become very attractive. There needs to be some internal reward for going through all the effort of maintaining sobriety.

Relapse back into drug and alcohol use happens with alarming frequency for great number of people. It is therefore only prudent to develop plans that decrease the possibility of relapse. However, relapse not a part of the recovery process, many people stopped using drugs in our overall never to return to it. In my experience, however, these people have put a great deal of proactive planning into use. They have made recovery their number one priority and have been ferocious in their commitment.

by Bill Urell

Posted August 18, 2009

From:

http://addictionrecoverybasics.com/2009/05/13/drug-and-alcohol-relapse-prevention-neglecting-these-five-key-issues-can-lead-to-relapse/#more-980

Researchers in Chicago apply an old medical maxim: “Chronic diseases require chronic cures.”

Supplementing regular recovery checkups with motivational interviewing and active linking to treatment can get relapsing patients back into treatment sooner and help them stay longer, report NIDA-funded researchers. In the 2 years following treatment, patients who received the additional interventions were three times as likely to reenter treatment as others who received assessments only.

Lead investigator Dr. Christy Scott and coinvestigator Dr. Michael Dennis developed the effective intervention, which they call the Recovery Management Checkup (RMC) system, to expedite the recovery of people who had attended treatment and were now living in the community and experiencing substance abuse problems. They say the findings suggest that their approach to treating substance abuse as a chronic condition may help patients shake off the shame of relapse. “By the time patients had participated in checkups for 2 years, many who were initially reluctant to reenter treatment would call a peer to link them with help after a slip,” says Dr. Scott, of Lighthouse Institute in Chicago, a Division of Chestnut Health Systems, Inc.
INTERVENTION MATCHES RELAPSE PATTERNS

In developing the RMC system, the researchers built on previous studies in which they had identified patterns of chronic substance abuse, relapse, and recovery. They found that, during the first 3 years after treatment, people frequently transitioned between recovery, substance abuse, and treatment—a cyclic pattern suggesting that periodic checkups, with intervention when necessary, might help shorten relapse episodes. They also researched approaches used to manage other chronic health conditions and found that monitoring for relapse and reducing the time from relapse to treatment reentry improved long-term outcomes.

To implement the RMC system, Drs. Scott and Dennis hired and trained a cadre of research assistants and linkage managers, many of whom were local recovering individuals. Chestnut staff and clinical colleagues at Haymarket Center, the largest addiction treatment provider in Illinois, interviewed 448 men and women who had met the standard criteria for a substance abuse diagnosis at some time in their lives, had abused alcohol or other drugs in the past 90 days, were not in protective custody, and intended to live in Chicago for the next year. Cocaine, alcohol, opiates, and marijuana were the most commonly abused drugs. Immediately following the interview, patients received a referral to Haymarket Center for treatment—60 percent as residents and 40 percent as outpatients—for 27 days, on average; 11 percent remained in treatment for 90 days or more. Upon leaving treatment, each patient scheduled eight quarterly followup appointments. Before the first checkup, researchers randomly assigned the patients to either the RMC intervention or an assessment-only control group.

At each checkup appointment, patients met with a research assistant. The assistant administered a 45-minute version of the Global Appraisal of Individual Needs assessment and ascertained information about the patient’s living situation and substance involvement. If the patient had not abused any substance during the past 90 days, the assistant encouraged continued abstinence and scheduled the next appointment. Patients who reported slips were merely advised to reenter therapy if they were in the control group, but met with a linkage manager if they were in the intervention group and living in the community.

The linkage manager conducted motivational interviews, usually lasting less than 30 minutes, in which he or she provided feedback on patients’ substance abuse and related problems, discussed ways to work through barriers to treatment reentry, and considered motivations to return to therapy. If a patient was willing to reenter treatment (even with low motivation), the linkage manager scheduled an appointment, telephoned with a reminder, and arranged transportation. The linkage manager provided assistance for 2 weeks, but afterward, responsibility for continuing therapy fell to the patient. Between RMC appointments, the patient received cards and calls from the research office; these served as a reminder of the next visit and carried a message of support from the research team.
CHECKUPS BOOST CHECK-INS

The researchers were able to interview patients at both the beginning and end of a quarter in 87.5 percent of cases. They categorized each patient’s current status as in the community abusing substances, in treatment, in recovery (no substance abuse, problems, or treatment while living in the community), or incarcerated. Between the beginning and end of each quarter, about one-third of the patients, on average, transitioned from one status to another. Most (82 percent) transitioned at least once during the study, with 62 percent moving between points several times (see chart).

Among patients who relapsed, 67 percent of RMC patients reentered treatment within 90 days after the checkup, compared with 51 percent of assessment-only patients. RMC patients returned to treatment sooner (27 versus 45 days) and stayed in treatment longer (7.75 versus 4.68 days), on average, than the control group. Length of treatment predicted transition to recovery at the next quarterly assessment—for every 10.5 days in treatment, a patient was 1.2 times more likely to be abstinent at the next quarterly checkup.

“The checkups help a patient evaluate his or her behavior and recovery-related issues—much as a person with diabetes would report on blood sugar levels and diet and exercise patterns,” says Dr. Thomas Hilton of NIDA’s Division of Epidemiology, Services and Prevention Research. “By employing individuals in recovery as linkage managers, the program also offered an opportunity for the patient to return to treatment or at least receive support from someone who has been there.”

Drs. Scott and Dennis plan to tailor the checkups for specific populations—for example, women involved in the criminal justice system. Treatment providers who want to implement the checkups can contact Dr. Scott (cscott@chestnut.org).

SOURCE

Scott, C.K.; Dennis, M.L.; and Foss, M.A. Utilizing recovery management checkups to shorten the cycle of relapse, treatment reentry, and recovery. Drug and Alcohol Dependence 78(3):325-338, 2005. [Abstract]

Posted July 30, 2009

By Lori Whitten, NIDA NOTES Staff Writer

From:

http://www.nida.nih.gov/NIDA_notes/NNvol20N6/Checkup.html

By Lori Whitten, NIDA NOTES Staff Writer

Telephone-based continuing care, in which an addiction counselor supports patient recovery with 15-minute calls once a week, can be as good as or better than face-to-face care at helping most patients maintain abstinence after intensive outpatient treatment (IOP). In a recent NIDA-funded study, the benefits of a telephone support protocol were evident nearly 2 years after the last call for all but the 20 percent of patients with severe addiction problems that did not resolve during IOP.

“Telephone-based continuing care does not require transportation or interfere much with work or childcare responsibilities, and this flexibility may help patients stay engaged in recovery and maintain the gains achieved during initial inpatient or outpatient treatment,” says Dr. James McKay, lead researcher of the study.

Dr. McKay and colleagues at the University of Pennsylvania, the Treatment Research Institute in Philadelphia, and Brandeis University worked with two Philadelphia-area outpatient addiction programs. Patients seeking treatment in these programs received about 9 hours of outpatient group therapy each week for 1 month, on average. The therapy concentrated on overcoming denial of substance abuse, learning about the addiction process and cues to relapse, and beginning self-help participation. Dr. McKay and colleagues recruited patients who “graduated” from therapy—that is, continued in the IOP and achieved abstinence in the last week—to receive 12 weeks of continuing care and followup for 2 years.

The patients, 359 men and women aged 18 to 65, were typical, in terms of demographics and problem severity, of individuals seeking treatment at publicly funded outpatient addiction programs. Half met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria for co-occurring cocaine and alcohol dependence, 87 were dependent on cocaine only, and 91 were alcoholic. Thirty percent had met the criteria for a diagnosis of major depression at some time in their lives. When they began treatment, they reported 8 years of cocaine and 18 years of alcohol abuse, on average, and multiple attempts to quit.

Telephone Counseling Helps Outpatient Treatment
Graduates Stay Abstinent
Graph – Months after graduation     Two years after graduating from intensive outpatient treatment, more patients who participated in telephone-based continuing care (TELE) had maintained abstinence during the previous 3 months than those receiving standard group counseling (STND). The percentage of abstinent patients did not differ between TELE and relapse prevention (RP) continuing care.
Graph – Number of High-Risk Characteristics     Throughout the study, patients with four or more characteristics reflecting severe addiction were better able to maintain abstinence if they participated in STND compared with TELE.
Graph – Months after graduation     The percentage of cocaine-positive urine samples did not increase as quickly during the followup for TELE patients as it did for those who participated in RP, with a similar trend for TELE compared with STND.

All patients participated in 12 weeks of continuing care after completing a month of intensive outpatient treatment, and reported outcomes every 3 months during the 2-year followup.
Regular Contact With a Therapist Is Crucial

The investigators randomly assigned each patient to one of three continuing care therapies: a face-to-face therapy, either standard group (STND) or relapse prevention (RP); or telephone-based (TELE) counseling. In STND care, the most common approach to continuing care for addiction, 122 patients attended twice-weekly counseling sessions that emphasized overcoming denial and engaging in mutual and self-help activities. In RP therapy, 135 patients attended an individual session of cognitive-behavioral therapy and then group sessions once a week. In this approach, patients identify situations that prompt substance abuse and work to improve coping responses using structured activities and homework exercises.

In TELE care, 102 patients met with counselors in person the week before beginning the telephone phase to discuss the therapy and receive a workbook with exercises that structured subsequent calls. At a scheduled time each week, they telephoned counselors and talked for 15 to 20 minutes about progress during the previous week, any episodes of substance abuse, participation in self-help and other pro-recovery activities, plans for achieving the next week’s goals, and any concerns. Counselors contacted patients who did not call and discussed in a supportive way their reasons for not doing so. To ease the transition from outpatient to continuing care, therapists offered the TELE patients group counseling once a week for a month. Patients struggling with relapse at that point could continue with group sessions; more than a third (35 percent) exercised this option.

The researchers followed up with patients every 3 months throughout the study and contacted 86 percent 2 years after graduation from IOP. At this point, about two-thirds of TELE patients reported abstinence during the previous 3 months, compared with about half of those who had participated in STND. An analysis of urine samples from the cocaine-addicted patients showed an overall increase in the percentage of cocaine-positive samples during the followup period, but the increase was more rapid among RP participants than TELE participants. The TELE group had higher abstinence rates than STND throughout followup. Patients who participated in TELE maintained the gains of IOP even though they received about half as much therapeutic contact (428 minutes) as those receiving STND or RP (845 and 861 minutes, respectively).

“Continuing care benefits people in recovery in several ways, but regular contact with a therapist is crucial for patients with a chronic condition, and especially helps patients who have relapsed get back into treatment,” says Dr. Dorynne Czechowicz of NIDA’s Division of Clinical Neurosciences, Development and Behavioral Treatments. Although larger studies with more diverse patients are needed, Dr. McKay and his colleagues laid important groundwork, she says.
Face-to-Face Care for Severe Problems

Some patients need more contact with a counselor than telephone-based continuing care affords to maintain recovery. To identify these patients, Dr. McKay and his colleagues examined the link between outcomes and seven patient characteristics: co-occurring addiction to alcohol and cocaine at the beginning of IOP; any alcohol use, any abuse of cocaine, minimal attendance at self-help meetings, below-average social support during IOP; and a lack of commitment to complete abstinence, and low self-efficacy for recovery at the end of IOP.

Patients who demonstrated three or fewer of the characteristics—about 80 percent of the study population—did at least as well with TELE continuing care as with the other two approaches. But the remaining patients, those who met the criteria for co-occurring addiction at the beginning of treatment and did not achieve the main goals of IOP—abstinence from cocaine and alcohol during treatment, commitment to abstinence, and participation in self-help programs—were at high risk for relapse and showed better outcomes with STND continuing care, relative to TELE, during most of the followup. The findings suggest that TELE may be inappropriate for patients with more severe addiction problems until they demonstrate stable abstinence from drugs and alcohol, says Dr. McKay.
Flexible Continuing Care

“Some practitioners are developing flexible arrangements to engage and retain more patients in continuing care,” says Dr. McKay. Flexibility in the practical sense—the ability to call one’s counselor from any location—extends participation in continuing care, not only to busy people, but also to those living in rural areas or who have lost driver’s licenses.

Telephone-based care is one way that a treatment intervention can respond to each patient’s progress during recovery; it gives counselors the flexibility to intensify care if the patient is struggling to maintain abstinence. “Clinicians managing other chronic disorders—for example, hypertension and cancer—are using progress during initial treatment to determine subsequent care. It’s not a new therapeutic approach, but it is novel to addiction treatment,” Dr. McKay says.

Sources

* McKay, J.R.; Lynch, K.G.; Shepard, D.S.; and Pettinati, H.M. The effectiveness of telephone-based continuing care for alcohol and cocaine dependence. Archives of General Psychiatry 62(2):199-207, 2005. [Abstract]
* McKay, J.R., et al. Do patient characteristics and initial progress in treatment moderate the effectiveness of telephone-based continuing care for substance use disorders? Addiction 100(2):216-226, 2005. [Abstract]

By Lori Whitten

Posted July 21, 2009

From

http://www.nida.nih.gov/NIDA_notes/NNvol20N3/Telephone.html

Volume 20, Number 3 (October 2005)

While each family member is responsible for his or her own recovery and no one can recover for another, the symptoms of addiction and co-addiction each impact upon the relapse potential of the other. Even if the alcoholic/addict is no longer drinking or using and no longer experiencing the alcohol/drug-related symptoms of the disease, the post acute withdrawal symptoms affect and are affected by co-addiction. Both the symptoms of post acute withdrawal and the symptoms of co-addiction are stress sensitive. Stress intensifies the symptoms and the symptoms intensify stress. As a result, the recovering addict and the co-addict can become a stress-generating team that unknowingly and unconsciously complicates each other’s recovery and create a high risk of relapse.
What can family members do to reduce the risk of their own relapse and the risk of relapse in the recovering addict? They can become informed about the addictive disease, recovery, and the symptoms that accompany recovery. They must recognize that the symptoms of post acute withdrawal are sobriety-based symptoms of addiction rather than character defects, emotional disturbances, or mental illness. At the same time they must accept and recognize the symptoms of co-addiction and become involved in Al-Anon and/or personal therapy as they develop plans for their own recovery.
Clinical experience with relapse prevention planning in a variety of treatment programs has indicated that the family can be a powerful ally in preventing relapse in the addict. In 1980, relapse prevention planning was modified to include the involvement of significant others including family members. This significantly increased effectiveness. With further clinical experience, however, other problems became apparent. Many family members refused to participate in relapse prevention planning. Other family members participated in a manner that was counterproductive.

In 1983 relapse prevention planning was expanded to include relapse prevention in both the addicted person and the co-addict. The newly designed relapse prevention planning protocol utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in family relapse. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is presented as a family disease that affects all family members requiring them to get treatment.

All members of an addicted family are prone to return to self-defeating behaviors that can cause them to become out of control. An acute relapse episode can occur with an addict or a co-addict family member. Like addicts who develop serious problems even though they never use alcohol or drugs, the co-addict often becomes dysfunctional even though the addict is sober and working an active recovery program.

It is important to protect the family from the stress that may be generated by the symptoms of post acute withdrawal experiences by the recovering person and to cooperate in plans to protect the recovering person from stress created by symptoms of co-addiction. Remember that none of you became ill overnight. Recovery will, likewise, take place over a long period of time. Develop a plan to prevent personal relapse and support relapse prevention plans for the recovering addict.

Family Relapse Prevention Planning is intended to help prevent acute relapse episodes in the recovering addict, to prevent crisis in the co-addict, to develop a relapse prevention plan for both the addict and co-addict and to develop an early intervention plan to interrupt acute relapse episodes in both the recovering addict and the co-addict. For the addict this involves interrupting problems that are caused both by Post Acute Withdrawal (PAW) Syndrome in the sober addict and by alcohol or drug use in the addict who has returned to drinking or using. For the co-addict this involves interrupting the co-addiction crisis. The family needs to work with a counselor to establish a formal relapse prevention plan that will allow them to support each other’s recovery and to help intervene if the relapse warning symptoms get out of control.

The family relapse prevention planning protocol consists of twelve basic procedures. These are:

1.Stabilization: The first step in relapse prevention planning is to stabilize both the addict and the co-addict. The addict is stabilized through the process of detoxification or treatment of post-acute withdrawal symptoms. The spouse is stabilized by treating the co-addict crisis, through detachment from the addicts crisis, by regaining a reality-based perspective, and the development of some basic personal strengths. This often requires attendance at Al-Anon and professional counseling.

2.Assessment: Prior to developing a relapse prevention plan it is necessary to evaluate the addict, the co-addicts, and the family system.The evaluation should assess the current problems of each family member, their willingness and ability to initiate a personal recovery program, and their willingness to become involved in a program of family recovery.

3.Education about Alcoholism, Co-addiction, and Relapse: Accurate information is the most powerful of all recovery tools. The addict and the family must learn about the disease of addiction, the condition of co-addiction, treatment, and relapse prevention planning. This education is best provided to the family as a unit in multiple family classes. It is helpful if separate group therapy programs accompany the education for each family member. The addict should enter an addict group, the adult co-addict should enter a spouse’s group, and the co-addict children should enter a children’s group. It is in these group treatment sessions that individual recovery of all family members is initiated.

4.Warning Sign Identification: Both the addict and the co-addict need to identify the personal warning signs that indicate that they are becoming dysfunctional. Again, this is best done in a group setting. The addict is better able to identify relapse-warning signs when working with other addicts. Co-addicts are best able to initially identify relapse-warning signs when working with other co-addicts. Relapse warning sign lists for addiction and co-addiction are useful guides for personal warning sign identification.

5.Family Validation of Warning Signs: After each family member has developed a personal list of warning signs and reviewed these in his or her group, a series of family sessions is scheduled. During these sessions all family members present their personal lists of warning signs and ask for feedback. Other family members discuss the warning signs, help assess fi they are specific and observable. New warning signs may be added to the list based upon the feedback of others. Since each family member has a list of warning signs that precede acute relapse episodes there is no identified patient. All participate from a position of equality. They essentially say to each other, “We have all been equally affected, in various ways, by addictive disease.”

6.The Family Relapse Prevention Plan: Family members discuss each of their warning signs, how the family has dealt with those warning signs in the past, and what strategies could be effectively used in the future. Future situations in which the warning signs are likely to be encountered are identified. Strategies for more effective management of the warning signs for each family member are discussed. During this process a great deal of role playing and problem solving occurs. Problems are often identified that are taken back to the separate therapy groups for further work.

7.Inventory Training: All member of the family receive training in how to complete a morning planning inventory and an evening review inventory. These focus heavily upon time structuring, realistic goal setting, and problem solving.

8.Communication Training: The family members must learn to communicate effectively in order for a Relapse Prevention Plan to work. The family is trained in the process of giving and receiving feedback in a constructive and caring manner.

9.Review of the Recovery Program: All family members will report to the family the recovery program that they have established for themselves. This focus here is, “How will you and I know that I am doing well in my recovery?” All are invited to express their recovery needs and point out their progress in treatment.

10.Denial Interruption Plan: Both addiction and co-addiction are diseases of denial. Most of the denial is unconscious. Neither the addict nor the co-addict realizes that they are in denial when it is happening. It is important to take the reality of denial into account early. Each family member should be asked the question, “What are other people in your family supposed to do if they give you feedback about concrete warning signs and you deny it, ignore the feedback, or become angry and upset?” Each family member should recommend specific plans for dealing with their own denial. This open discussion sets the stage for intervention should denial become a problem in the future.

11.The Relapse Early Intervention Plan: Addiction and co-addiction are prone to relapse. Relapse means becoming dysfunctional in recovery. For the recovering addict relapse may ultimately lead to alcohol and drug use, or it may simply mean that the person becomes so depressed, anxious, angry, or upset that he is dysfunctional in sobriety. For the co-addict relapse means the return to a state of co-addict crisis that interferes with normal functioning. Once family members enter an acute relapse episode they are out of control of their thoughts, emotions, judgements, and behavior. They often need the direct help of other family members to interrupt the crisis. Many times they resist this help. They act as if they do not want help even though they desperately need it. The family is instructed in the process of intervention. Intervention is a method of helping people who refuse to be helped. This intervention training has resulted in a radical decrease in the duration and severity of relapse episodes in family members.

12.Follow-up and Reinforcement: Addiction and co-addiction are life-long conditions. The symptoms can go into remission but they never totally disappear. They rest quietly, waiting for a lapse in the recovery program to become active again. It is important that the family maintain an ongoing recovery program including AA/NA, Al-Anon, and periodic relapse prevention checkups with a professional addiction counselor.

This Article is exerpted from “Staying Sober” By: Terence T. Gorski

Posted July16, 2009

From

http://www.recoverycrossroads.com/community/showthread.php?t=3912
Copies of the book can be obtained from CENAPS® Corp.
Copyright© 2000, All Rights Reserved to Author

In many cases the addict is the first family member to seek treatment. Other family members become involved in order to help the alcoholic get sober. Many family members refuse to consider the fact that they also have a problem that requires specialized treatment. These family members tend to deny their role in their addicted family and scapegoat personal and family problems upon the addicted person. They develop unrealistic expectations of how family life will improve with their loved one getting abstinent. When these expectations are not met, they blame the addict for the failure, even though he or she may be successfully following a recovery program. Their attitudes and behaviors can become such complicating factors in the addict’s recovery that they can contribute to the process of relapse and even “set-up” the addict’s next “episode of use.”

On the other hand family members can be powerful allies in helping the addict prevent fully engaging the relapse process. Relapse Prevention Planning utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in the family relapse process. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is a family disease that affects all family members, requiring everyone to get involved in treatment. The addict needs treatment for addiction. Other family members need treatment for co-addiction.
The term “co-addiction” is sometimes used to refer only to the spouse of an addict and other terms are used to refer to other family members. We are using the term “co-addict” to refer to ANYONE WHOSE LIFE HAS BECOME UNMANAGEABLE AS A RESULT OF LIVING IN A COMMITTED RELATIONSHIP WITH AN ADDICTED PERSON.

Co-addiction is a definable syndrome that is chronic and follows a predictable progression. When persons in a committed relationship with an addicted person attempt to control drinking, drug use, or addictive behavior (over which they are powerless), they lose control over their own behavior (over which they can have power) and their lives become unmanageable.

The person suffering from co-addiction develops physical, psychological, and social symptoms as a result of attempting to adapt to and compensate for the debilitating effects of the stress of living with someone who is addicted. As the co-addiction progresses, the stress-related symptoms become habitual. The symptoms also become self-reinforcing; that is, the presence of one symptom of co-addiction will automatically trigger other co-addiction symptoms. The co-addiction eventually becomes independent of the addiction that originally caused it. The symptoms of co-addiction will continue even if the addicted person in the family becomes sober or joins AA/NA, or the co-addict ends the relationship.

The condition of co-addiction manifests itself in three stages of progression.

Early Stage: Normal Problem Solving and Attempts to Adjust
The normal reaction within any family to pain, to crisis, and to the dysfunction of one member of the family is to do what they can to reduce the pain, ease the crisis, and to assist the dysfunctional member however possible in order to protect the family. These responses do not make things better when the problem is addiction, because these measures deprive the addicted person of the painful learning experiences that bring an awareness that his/her addiction is creating problems. At this stage, co-addiction is simply a reaction to the symptoms of addictive disease. It is a normal response to an abnormal situation.

Middle Stage: Habitual Self-Defeating Responses
When the culturally prescribed responses to stress and crisis do no bring relief from the pain created by the addiction in the family, the family members TRY HARDER. They do the same things, only more often, more intensely, mores desperately. They try to be more supportive, more helpful, more protective. They take on the responsibilities of the addicted person, not realizing that this causes the addict to become more irresponsible.
Things get worse instead of better and the sense of failure intensifies the response. Family members experience frustration, anxiety, and guilt. There is growing self-blame, lowering of self-concept, and self-defeating behaviors. They become isolated. They focus on the addict’s addictive behavior and their attempt to control it. They have little time to focus on anything else. As a result they often lose touch with the normal world outside of their family.

Chronic Stage: Family Collapse and Stress Degeneration
The continued habitual response to addiction in the family results in specific repetitive, circular patterns of self-defeating behavior. These behavior patterns are independent and self-reinforcing and will persist even in the absence of the symptoms of addictive disease.
The things the family members have done in a sincere effort to help have failed. The resulting despair and guilt bring about confusion and chaos and the inability to interrupt dysfunctional behavior even when they are aware that what they are doing is not helping. The thinking and behavior of the co-addict is OUT OF CONTROL, and these thinking and behavior patterns will continue independent of the addiction.
Co-addict degeneration is bio-psycho-social. The ineffective attempts to control drinking and drugging behavior elevate chronic stress to the point of producing stress-related physical illnesses such as migraine headaches, ulcers, and hypertension. This chronic stress may also result in a nervous breakdown or other emotional illnesses. Out-of-control behavior itself is an addiction-centered lifestyle that pervades all life activity, even that which seems unrelated to the addiction. Social degeneration occurs as the addiction focus interferes with relationships and social activity. Spiritual degeneration results, as the focus on the problem becomes so pervasive that there is no interest in anything beyond it, particularly concerns and need related to a higher meaning of life.
Recovery from co-addiction means learning to accept and detach from the symptoms of addiction. It means learning to manage and control the symptoms of co-addiction. It means learning to focus on personal needs and personal growth, learning to respect and like oneself. It means learning to choose appropriate behavior. It means learning to be in control of one’s own life.
Because it is a chronic condition, co-addiction, like addiction, is subject to relapse. But a condition of co-addict relapse may be more difficult to identify. Without an ongoing recovery program and proper care of oneself, old feelings and behaviors thought to be under control may surface and become out of control. Life again becomes unmanageable; the co-addict is in relapse mode.

RELAPSE WARNING SIGNS FOR CO-ADDICTION
From the observation of counselors who have worked with recovering family members, relapse warning signs for the co-addicted significant other have emerged. The following list has been compiled from these observations.

1.Situational Loss of Daily Structure. The family member’s daily routine is interrupted by a temporary situation such as illness, the children’s schedule, the holidays, vacation, etc. After the event or illness, the significant other does not return to all of the activities of his or her recovery program.

2.Lack of Personal Care. The significant other becomes careless about personal appearance and may stop doing and enjoying small things that are “just for own personal enjoyment.” The person returns to taking care of others first and self second or third.

3.Inability to Effectively Set and Maintain Limits. The significant other begins to experience behavioral problems with the children or roommates. Limits that are being set tend to be too lenient or too rigid and result in more discipline problems.

4.Loss of Constructive Planning. The significant other begins to feel confused and overwhelmed by personal responsibilities. Instead of deciding what is most important and doing that, he or she begins to react by doing the first thing that presents itself, while more important jobs go undone.

5.Indecision. The significant other becomes more and more unable to make decisions related to daily life.

6.Compulsive Behavior. The significant other experiences episodes during which he or she feels driven to do more. Whatever has already been done does not seem to be enough.

7.Fatigue or Lack of Rest. He or she becomes unable to sleep the number of hours necessary to feel rested. When sleep does occur, it is fitful.

8.Return of Unreasonable Resentments. The significant other finds himself or herself mentally reviewing persons or events that have hurt, angered, or been generally upsetting. As these are reviewed, the significant other relives the old emotions and feels resentments about them.

9.Return of the Tendency to Control People, Situations, and Things. As the co-addicted significant other feels less control over life, he or she begins openly to try to control and manipulate other people or situations. The addicted person may be the prime target, but does not necessarily have to be.

10.Defensiveness. The co-addicted person may not totally approve of some of his or her own actions, but when challenged about them will openly justify the actions in a sharp or angry way.

11.Self-Pity. The co-addict begins to dwell on problems from the present or the past and in turn begins to magnify them. The significant other person may ask, “Why does everything always happen to me?”

12.Overspending/Worrying about Money. The significant other may be very concerned about the family finances, yet impulsively spends money in order to “feel better.” He or she becomes convinced that what was purchased was deserved, but ends up feeling guilty and even more trapped.

13.Eating Disorder. The significant other “loses” his or her appetite to the point that even favorite foods are not appealing. Or the significant other may begin to overeat, regardless of appetite, in order to feel better. The overeating satisfies for only a very short time, or not at all.

14.Scapegoating. There is an increasing tendency to place the blame on other people, places, and things. The co-addict looks outside of self for the reasons why he or she is feeling bad.

15.Return of Fear and General Anxiety. The significant other begins to experience periods of time when he or she is nervous. Situations that previously did not cause fear or anxiety are now causing those emotions. The significant other may not even know the source of the nervousness.

16.Loss of Belief in a Higher Power. The significant other begins to lose belief in a higher power, whatever it may be. There is a tendency to rely more on self-alone, or to turn to the addict for strength and the solutions.

17.Attendance at Al-Anon Becomes Sporadic. The significant other changes the pattern of Al-Anon meeting attendance. He or she may go to fewer meetings, thinking there isn’t time, the meetings aren’t helping, or are not needed.

18.Mind Racing. The significant other feels as though he or she is on a treadmill that is going too fast. In spite of attempts to slow down, the mind continues to race with the many things that are undone or the problems that are unsolved.

19.Inability to Construct a Logical Chain of Thought. The significant other tries to solve problems and gets stuck on something that would normally be simple. It seems that his or her mind does not work anymore, that it is impossible to figure out the world. As a result, he or she feels powerless and frustrated with life.

20.Confusion. The significant other knows they are feeling out-of-sorts, but don’t know what is actually wrong.

21.Sleep Disturbance. Sleeplessness or fitful nights become more regular. The more the person tries to sleep, the less he or she is able to. Sleep may come, but it is not restful. The significant other looks tired in the morning instead of rested.

22.Artificial Emotion. The co-addict significant other begins to exhibit feelings without a conscious knowledge of why. He or she may become emotional for no reason at all.

23.Behavioral Loss of Control. The co-addict begins to lose control of his or her temper especially around the addict and/or the children or roommates. Loss of behavioral control is exhibited in such ways as over-punishing the children, hitting and yelling at the addict, or throwing things and tantrums.

24.Uncontrollable Mood Swings. Changes in the co-addict’s moods happen without any warning. The shifts are dramatic. He or she no longer feels somewhat down or somewhat happy, but instead goes from feeling extremely happy to extremely low.

25.Failure to Maintain Interpersonal (Informal) Support Systems. The co-addict stops reaching out to friends and family. This may happen very gradually. He or she turns down invitations for coffee, misses’ family gatherings, and no longer makes or returns phone calls.

26.Feelings of Loneliness and Isolation. The co-addict begins to spend more time alone. He or she usually rationalizes this behavior – too busy, the children, school, job, etc. Instead of dealing with the loneliness, the co-addict becomes more compulsive and impulsive. The isolation may be justified by convincing him or herself that no one understands or really cares.

27.Tunnel Vision. No matter what the issue or situation might be, the co-addict focuses in on his or her opinion or decision and is unable to see other points of view. He or she may become close-minded.

28.Return of Periods of Free Floating Anxiety and/or Panic Attacks. The co-addict may begin to re-experience, or experience for the first time, waves of anxiety that seem to occur for no specific reason. He or she may feel afraid and not know why. These uncontrollable feelings may snowballto the point that he or she is living in fear of fear.

29.Health Problems. Physical problems begin to occur such as headaches, migraines, stomach aches, chest pains, rashes, or allergies.

30.Use of Medication or Alcohol as a Means to Cope. Desperate to gain some kind of relief from the physical and/or emotional pain, the co-addict may begin to drink, use drugs, or take prescription medications. The alcohol or drug use provides temporary relief from the growing problems.

31.Total Abandonment of Support Meetings and Therapy Sessions. Due to a variety of reasons (belief that he or she no longer needs the meetings, immobilizing fear, resentment, etc.), the co-addict completely stops going to support meetings or to therapy or both.

32.Inability to change self-defeating behaviors. While there is recognition by the co-addict that what is being done is not good for himself or herself, there is still the compulsion to continue the behavior in spite of that knowledge.

33.Development of an “I Don’t Care” Attitude. It is easier to believe that “I don’t care” than it is to believe that “I am out of control.” In order to defend self-esteem, the co-addict rationalizes, “I don’t care.” As a result, a shift in value system occurs. Things that were once important now seem to be ignored.

34.Complete Loss of Daily Structure. The co-addict loses the belief that an orderly life is possible. He or she begins missing (forgetting) appointments or meetings, is unable to have scheduled meals, to go to bed or get up on time. The co-addict is unable to perform simple acts of daily function.

35.Despair and Suicidal Ideation. The co-addict begins to believe that the situation is hopeless. He or she feels that options are reduced to two or three choices: going insane, committing suicide, or numbing out with medication, and/or alcohol, drugs or maladaptive, perhaps compulsive behavior.

36.Major Physical Collapse. The physical symptoms become so severe that medical attention is required. These can be any of a number of symptoms that become so severe that they render the co-addict dysfunctional (e.g., an ulcer, migraines, heart pains, or heart palpitations).

37.Major Emotional Collapse. Having seemingly tried everything to cope, the co-addict can conceive no way to deal with his or her unmanageable life. At this point the co-addict may be so depressed, hostile, or anxious that he or she is completely out of control.

Relapse is so common in the alcohol and drug recovery process that it is estimated more than 90 percent of those trying to remain abstinent have at least one relapse before they achieve lasting sobriety. But a relapse, sometimes called a “slip,” doesn’t begin when you pick up a drink or a drug. It is a slow process that begins long before you actually use.

The steps to a relapse are actually changes in attitudes, feelings and behaviors that gradually lead to the final step, picking up a drink or a drug.

Attitudes, Feelings and Behaviors

In 1982, researchers Terence T. Gorski and Merlene Miller identified a set of warning signs or steps that typically lead up to a relapse. Over the years, additional research has confirmed that the steps described in the Gorski and Miller study are “reliable and valid” predictors of alcohol and drug relapses.

If you are trying to obtain long-term sobriety and avoid having a relapse along the way, it is important to recognize the following warning signs and take action to keep them from progressing into a full-blown relapse.

11 Steps to a Relapse

Change in Attitude – For some reason you decide that participating in your recovery program is just not as important as it was. You may begin to return to what some call “stinking thinking” or unhealthy or addictive thinking. Basically, you are not working your program as you did previously. You feel something is wrong, but can’t identify exactly what it is.

Elevated Stress – An increase in stress in your life can be due to a major change in circumstances or just little things building up. Returning to the “real world” after a stint in residential treatment can present many stressful situations. The danger is if you begin over-reacting to those situations. Be careful if you begin to have mood swings and exaggerated positive or negative feelings.

Reactivation of Denial – This is not denial that you have a drug or alcohol problem, it’s denial that the stress is getting to you. You try to convince yourself that everything is OK, but it’s not. You may be scared or worried, but you dismiss those feelings and you stop sharing those feelings with others. This is dangerous because this denial is very similar to denial of drug addiction or abuse.

Recurrence of Postacute Withdrawal Symptoms – Anxiety, depression, sleeplessness and memory loss can continue long after you quit drinking or doing drugs. Known as postacute withdrawal symptoms these symptoms can return during times of stress. They are dangerous because you may be tempted to self-medicate them with alcohol or drugs.

Behavior Change – You may begin to change the daily routine that you developed in early sobriety that helped you replace your compulsive behaviors with healthy alternatives. You might begin to practice avoidance or become defensive in situations that call for an honest evaluation of your behavior. You could begin using poor judgment and causing yourself problems due to impulsive behavior without thinking things through.

Social Breakdown – You may begin feeling uncomfortable around others and making excuses not to socialize. You stop hanging around sober friends or you withdraw from family members. You stop going to your support group meetings or you cut way back on the number of meetings you attend. You begin to isolate yourself.

Loss of Structure – You begin to completely abandon the daily routine or schedule that you developed in early sobriety. You may begin sleeping late, or ignoring personal hygiene or skipping meals. You stop making constructive plans and when the plans you do make don’t work out, you overreact. You begin focusing on one small part of life to the exclusion of everything else.

Loss of Judgment – You begin to have trouble making decisions or you make unhealthy decisions. You may experience difficulty in managing your feelings and emotions. It may be hard to think clearly and you become confused easily. You may feel overwhelmed for no apparent reason or not being able to relax. You may become annoyed or angry easily.

Loss of Control – You make irrational choices and are unable to interrupt or alter those choices. You begin to actively cut off people who can help you. You begin to think that you can return to social drinking and recreational drug use and you can control it. You may begin to believe there is no hope. You lose confidence in your ability to manage your life.

Loss of Options – You begin to limit your options. You stop attending all meetings with counselors and your support groups and discontinue any pharmacotherapy treatments. You may feel loneliness, frustration, anger, resentment and tension. You might feel helpless and desperate. You come to believe that there are only three ways out: insanity, suicide, or self-medication with alcohol or drugs.

Relapse – You attempt controlled, “social” or short-term alcohol or drug use, but you are disappointed at the results and immediately experience shame and guilt. You quickly lose control and your alcohol and drug use spirals further out of control. This causes you increasing problems with relationships, jobs, money, mental and physical health. You need help getting sober again.

Relapse Is Preventable

Relapse following treatment for drug and alcohol addiction is common and predictable, but it is also preventable. Knowing the warning signs and steps that lead up to a relapse can help you make healthy choices and take alternative action.

If a relapse does happen, it is not the end of the world. If it happens, it is important that you get back up, dust yourself off and get back on the path to recovery.

_Sources:

_{National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research Based Guide.” Revised 2007.}

_{National Institute on Drug Abuse. “An Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model.” Accessed May 2009.}

_{Miller, WR, et al. “A Simple Scale of Gorski’s Warning Signs for Relapse.” Journal of Studies on Alcohol. 1 September 2000.}