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Fresh French Fries

Just the thought alone is enough to trigger a plan on how to get some of those hot, not quite sure how they make it, delicious and salty snack. Your mouth starts to water and you realize it’s been a while since you ate anything.  You’re on your way to the promise of the arches. We all know how unhealthy this is, but still, the siren calls and we bud duh duh duh duh, are lovin’ it. If you were born after 1970, these golden beauties have been a part of your life for the entirety. Remember when you first had them and how that felt? You decided at some point either initially or after going many times; “I like fries!” so your brain will steer you in the direction of getting fries when a craving hits.

Regardless of if we are talking about French fries, phone use, sex, or drugs; addictions happen following the same chemical chain and commonality. Your brain decided it really likes it. Rather, it Needs. This has become just as important for overall functioning as air, water, food and daily hygiene as far as your brain is concerned. You become just as driven to supply the need.

So how does your brain become convinced that something is just as important as air? Conditioning and Context. Think back to your Intro to Psych class and remember the story of Pavlov and his dogs. Ring the bell, reward with food (context); Repeat (conditioning). Consequently, the dog’s brain said “hey, bell rings I get food” – so they started salivating with the bell ring.

Let me introduce your limbic system, commonly called your emotional brain. This addition to your chemical composition causes the reward centers of your brain to light up with pleasure. Think of all the things you enjoy, and probably 50% of you are thinking about You Know Where since the start of this; that’s your limbic system at work. Repeated exposure to whatever it was causes a series of reinforcement to your motivation/reward system, and it doesn’t matter what it is, the “I like this” button has been pushed. You have a new bell. I’d like to tell you that this little system is only activated when something “feel good” happens, but unfortunately this has a wide cast net with hands in every feeling, thought and memory you possess. Every bit of information from the senses goes through this part for cataloging, both positive and negative. This part of your brain determines how you handle things that come up in your life.

So, theoretically let’s say, repeated exposure to something (activity or otherwise) has lit up your pleasure centers. You feel good doing this. Currently, your present situation is stressful, maybe there are family pressures going, you’re in your finals at college, or work is stressing you out. Something is hitting your limbic system, and it doesn’t like it. At this point, your emotional brain takes over and says let’s try …… that makes us feel good.

This is the start of addiction; it can be innocuous like French fries or your cell phone, or it can be detrimental and sudden like opiates or alcohol. Something is going on and the associations that make up who you are, is utilizing coping skills, aka the tips and tricks you learned along the way to deal with life and stress. However, in this day and age of constant stress and deadlines, at what point do we exhaust our ability to deal using only what we have acquired along the way? At that tipping point, when our stress exceeds our ability to cope, we reach for the things we’ve associated really liking. You might reach for your phone at this point, or your favorite, binge worthy Netflix original (or both!), a glass of wine or one of the little tablets left over from your dentist.  Whatever you know makes you feel good and distracts you from whatever stressor you have going on. What calls your pleasure center will be different from someone else’s.

So, if an addiction can form from anything and at any time, why are only some of them so stigmatized? Mostly due to the association of the word. When you hear the term “addiction” it conjures up images. If Regan was your president you would associate it more with marijuana, or if you were raised during the DARE era, your brain probably produced an image of someone with red, bloodshot eyes in dark alleyways or an egg in a frying pan. The younger crowd probably associates it with drinking and vaping, as other forms of what used to be considered ‘illegal’ or ‘illicit’ are now mainstream and legal. Associations are different from generation to generation. Which makes calling out addictions in their most deadly forms a very serious issue as the information must make sense, and remain continuous. Look how long it took to get the word out that smoking was bad for you and it no longer came doctor recommended. If information doesn’t make sense, we have an all new generation of users due to the glamorized nature of drug and alcohol use. Again, if you were raised in the DARE era, you know what I’m talking about.

We all have the potential to develop an addiction, but just as the potential for is there, the potential to beat an addiction is there as well. Understanding and change take time and history shows us it’s possible by increasing our understanding not only of addiction itself, but how it affects all of us who love French fries or anything else that pushes our pleasure button.

Kelly Diehl – Behavioral Health Nurse with Sinnissippi Center, Dixon, IL


 

Relapse Prevention

Chances are, if you’re on this page, you either have done this personally or you know someone who experienced a relapse. This unfortunate aspect goes along with the cycle of addictions: use, dependency, detox, sober living, relapse/ back into dependency, detox, sober living. It is probably the single most complicated aspect of addiction, because it is unique to the individual as to when, how and why it would happen. Logically, you know the consequences of a relapse, but knowledge isn’t always power despite the highly coined phrase. Add in the unfortunate aspect that our brains have a tendency to block out or minimize unpleasant memories, we forget how much something truly affected us or our families when we’re no longer in that situation. When you feel like you have a handle on whatever substance you were using it’s easy to convince ourselves that “just one won’t hurt,” especially when things are out of balance in our personal lives.

So, what starts the possible relapse? Going back to the first article, it basically boils down to why you (or whomever) started using in the first place: Stress exceeds ability to cope. Addiction is not a one track disorder. Again, it is a multitude of small events stressing your emotional health (remember your limbic system processing all these things that are always occurring around you) and the tools you’ve learned to make yourself feel better. Relapse is built in to the treatment cycle because we on the healthcare side, know it will happen. Hence, during detox we focus so much on prevention strategies; but if that’s one of the main focuses of attending a program, why is the rate so high?

If you’ve ever gone through a medical detox facility you are bombarded with attending 12 step meetings or working the program from the moment you walk through, sometimes even before your admission papers are complete, we might give you a day depending, but typically it’s a hard and fast process. Working through with your journal, possibly attending a quick, 3 day trauma introduction group, discovering Cognitive Behavioral Therapy (CBT) skills to help stop thoughts and retrain your brain. We would give worksheets that needed to be handed in to your therapist before discharge. The purpose being to help you identify where your weakness lies with the addiction. That is a lot of information to try and process when you, quite frankly, feel like death warmed over. Nine times out of ten, an addiction disorder goes hand in hand with some other mental health issue, and please don’t assume it has to be a really serious one– the vast majority struggle with anxiety and depression.  I, personally, have never met someone who was addicted to a substance just for the fun of it, there’s always something they are trying to “numb out”. It may start off as a just for fun/relax kind of situation, but continued use implies not wanting to address an issue.  This would be reason number one why relapse happens. Failure to address the underlying cause of the addiction in the first place is a guaranteed set up for relapse.

I cannot stress enough how difficult detox truly is for a person. I would like you to pause for just a moment and imagine the worst flu you ever had, or just imagine being in a position where you feel like you have raging sunburn all over your skin and every time you move all your muscles protest, throwing up hurts, breathing hurts, pretty much everything is on fire, and there is nothing you can do to mitigate that. And every time you try and do the right thing for yourself and get off these substances, you have to go through this. The catch is, the more ingrained a substance is in your body and mind, through repeated use and detox, the worse you feel. It is not a ‘replay the same level again’ situation- the stakes and costs are higher each time. This is why detox has such a high AMA (against medical advice) discharge rate, it sucks. You are sick for what seems an eternity, you hate how you feel, you hate how you are acting or thinking; but going back to whatever brought you in will make it all go away again. Until your next fix is needed. No one can force you to stay in detox (unless you have a court order), but being truthful, most come in on their own accord. Voluntary admissions can make their own decisions about staying in treatment or not, or continuing on to the next step.  Reason number two relapse happens, detox is hard.

After this initial detox where you spend (I’d average) the first three days of seven wanting to die, you have been given the “tools” you need to succeed. But, since you were so sick for half of that time it basically is akin to giving someone an antique tool and saying “ok, go build a house.” Theoretically it’s possible, but it will be so frustrating that you are likely not going to try to build a house with something you have only been given a brief lesson on how to use. And that’s the problem with most acute detox facilities, including the one I worked for. You are given a set of instructions on how to identify where your triggers are, but it’s in another language, or it was thought of so quickly on your part because you are ready to get out of there that your statements are not quite accurate. “Bandwagon” answers, as I call them, which are the expected answers to a question but not necessarily the “true to you” response. My favorite, just to give an example, is “I will call my support person and use my coping skills.” Great, who and what are they? Oh, you don’t know…. Bandwagon.  So now you, the person detoxed, leave with maintenance medication your insurance doesn’t want to cover (or you don’t have insurance, or your copay is ridiculous, or you just don’t go pick it up for a slew of reasons), a set of instructions you sort of understand but not really, and a mess of unresolved issues brought up and only briefly discussed during your initial seven days due to a snowball effect. In a sense, you have opened Pandora’s Box of emotional triggers, without proper follow through because it’s been only seven days. And this is all IF whoever can make it through the actual detox, this is reason number three: Lack of a plan or solid understanding.

This is the weakest point in the cycle for the addict. After detox, if you are not immediately placed in a sober living facility or a partial hospitalization program (PHP) or intensive outpatient program (IOP), you are extremely likely to go back to using your particular drug of choice. A lot of accidental overdose deaths occur at this point as well since the process of detoxing lowers your tolerance.  I have lost count- sadly enough- of my patients who passed away shortly after being discharged from an overdose. Even when doctors/nurses give the explicit instructions to not go back to the same amount you were using previously. Of course, you know what you’ve been told, but you might think, “It wasn’t that much,” and go against your discharge instructions. Oh, those tricky little brains we have that so easily forget, convincing us we have a level of self-mastery and are in control.  Once again, having the knowledge you need does not grant you the power that you need as well.

Enter in the sober living facility, or PHP/IOP, wherever you can be placed or your insurance will cover. Here, acute is over – you feel semi human again. You have had food and showers and restfulsleep. Now, it becomes even more difficult.  Detox is easy compared to the next step, as crappy as you may have felt during it, now you get to learn to LIVE, without the substance you were using to cope. I heard a therapist mention in a group that living without your substance was like telling a child they can’t have their favorite blanket when a thunderstorm rolls in, but not telling them what else they could do if they feel scared or stressed. If you’re following the trajectory of treatment, this is where you learn to address your own personal “why” of substance abuse and help find a new blanket, or better coping skills. Unfortunately, due to the demand of these places, you can’t always get in when you need to, so you’re placed on a waiting list. However, you can’t stay in the acute treatment facility long enough for a bed to open, which would have allowed for a seamless transition through the cycle. This is why the after detox, before sober living phase is a point of relapse for so many.  You are leaving acute, you understand one of the why’s of your addiction, and there are a lot of raw emotions after treatment, but your new coping skills are in their infancy and you still don’t know how to effectively regulate your emotional response to stressors. It is all too easy to become overwhelmed. Add into it, chances are you need a new set of friends as old associations are still using and depending on how long this has gone on, family might be hesitant. Isolation = relapse, which is why it is more common in a PHP/IOP setting as opposed to a sober living home.

After sober living:  *DISCLAIMER* I’ll be fair here and say I have very minimal experience in sober living/after sober living setting. My writing is based on what I’ve seen and stories my patients would tell me about why it didn’t work this time. Remember it’s a cycle, not a personal flaw.

Say you’ve been in sober living and off your substance for six months, which I believe is average, but ranges anywhere from three months to a year. So let’s say that’s six months working on the tangle of experiences and the pitfalls of emotional regulation that are wrapped up in your addiction. I can almost guarantee at this point you’re finding more triggers, more things you never thought of as impacting your addiction, in the center of your therapies.  For the most part, you feel you are making excellent progress. Relationships are improving, maybe you’re holding down work again and you start to feel like maybe you got this. You have a curfew, you have random drug tests, and maybe you’re in drug court, you have accountability. Lot of different scenarios but it’s been almost a year since you started thinking maybe you needed to detox, worked yourself up to going to detox and finished it, and have now started dismantling emotional baggage. You feel good and you are on the upward climb.

You are doing so well that now you have to leave. But I’m not ready, you say to yourself. And the memory of who you were before treatment comes back. It may take a few months, it may take a few years, but if you haven’t learned how to successfully navigate emotions (“feel the feels” as Emily Nagoski, Ph.D. phrases it *) the cycle is going to repeat itself. And this is not solely the fault of the person with the disease. It’s a cycle for a reason.

The nature of the treatment is set up for failure if all the dominoes don’t fall correctly, and often times they just don’t. Either the individual is not ready to really feel the feels that go along with sobriety, or the resources just aren’t there from a treatment perspective to help all the people who really need support in the way they need it. I’m not trying to diminish the impact of following the proper chain by pointing out the weak links, just trying to highlight where the problematic areas show themselves. But this is why relapse happens. I have seen it so many times, detoxed the same individuals so many times, and that is completely O.K. If this is you and you are on the fence about going back in for treatment, don’t feel like we don’t want to see you or like you have failed, this is not true.  Needing treatment over and over is normal, and even when you “get it” you have to keep working at it. If you are in treatment, we know you are still alive so please, call your treatment center of choice for “check ins”; because we do worry when we don’t see you. Or, call your family, a friend, or someone who knows where you are, physically and emotionally. Please do not become ghosts.

The ultimate gist of the cycle is this, repeated each time in succession after relapse:

Step one – You realize you have a substance abuse problem. The pattern of behavior is deeply entrenched in your day to day decision making, this is hard to undo. You attempt to do this on your own, without proper tools or support: Relapse.

Step two – You commit to detox. Commit to the process of voluntarily making yourself feel horrible for a short period of time. It will be worth it in the end, I promise. Unfortunately, removal of this substance causes a panic to form in your brain, especially during the first three days: AMA then relapse.

Step three – Commit to your aftercare. Understand that your addiction did not appear overnight, it was through conditioning and use so it stands to reason it will take longer than seven days to address your “why.” Commit to the therapy, the figuring out who you are without substances. Rediscover yourself, what did you use to like to do before drugs or alcohol stole your joy? This is a long process so above all try and be patient with yourself or your loved one, and try and have a specific to you and your needs plan of action. No bandwagon responses here please.  If you are not honest with yourself here, relapse will most definitely happen. You have managed to stave it off up until this point but again coping skills and different ways of thinking are still new and life happens. Relapse.

Step four –Forgive yourself for failure. I’m not saying don’t try, obviously. But this is such a convoluted disorder and the treatment options just don’t exist yet to have a 100% success rate 100% of the time. Depending on what you personally consider “relapse” you might just be setting yourself up to fail with impossible standards of behavior. Experiencing the “call of the void,” otherwise known as intrusive or wandering thoughts, is completely normal. As long as you do not pull them into reality which takes effort, but you can push through. If you think about using, you HAVE NOT relapsed. It was just a thought. Granted, thoughts can become actions, so it is imperative to follow and continuously work on step three. Redefine what relapse means to you personally, and if you slip up, don’t beat yourself up and just say “well, that’s that. I’ll never succeed.” That’s why the AA/NA model say one day at a time. Tomorrow is a brand new set of 24 hours. Do not let the last 24 hours, or whatever number of hours, you can’t relive or get back ruin your tomorrow. Forgive yourself and move forward; holding on to a sense of self disappointment and or self- hatred will only cause stronger substance abuse issues.

Relapse is inevitable at least once in the treatment cycle, it just depends on what step. Every time the cycle breaks it’s back to square one, and it takes around three to four tries (or more! There is no gold standard) and that’s with the other elements lining up before you make it through the first complete cycle.  It is a hard process correcting a habit that developed over months to years, please commit to yourself or your family member that you will try and show love, don’t enable, but do show support, because it will take months or years to unravel the question of why. Yes, they made mistakes, and in some cases continue to do so, but show me someone who hasn’t. Show me someone who doesn’t have their own inner demons struggling against them in their day to day life, then we can talk 100% success.  In the meantime, just keep trying. That’s all any of us are expected to do, just try for the next 24 hours, and if you need to reach out. I loved getting the “check in” calls, and we don’t mind knowing that at least for right now, you are doing ok. Even if you’re not, calling someone can help stop the slide back.

Kelly Diehl – Behavioral Health Nurse with Sinnissippi Center, Dixon, IL

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