Chronic Pain implies a
dysfunctional central nervous system (brain, spinal cord, and autonomic nervous
system). With acute pain the central
nervous system is doing its job to help protect the individual from further
harm and/or to help the individual obtain help for the underlying tissue
damage. With chronic pain there becomes
little or no functional value in having pain.
As a consequence, with chronic pain the central nervous system is no longer
providing a useful service and so by definition is dysfunctional.
The central nervous system is
extremely complex and its dysfunction can stem from many factors. Indeed, our experience is that it is rarely
just one factor and most often a combination of several factors which
contribute to ongoing chronic pain. Our
job is to help you explore what factors may be interfering with your proper
central nervous system function while helping you find ways to promote a
healthier central nervous system function.
There is
clearly a role for medicines in patients with chronic pain but if one limits
the interventions to medications the likelihood of success is greatly
limited. We will provide you with
opportunities to learn more about what you can do to help your central nervous
system perform in a healthy fashion. As
a result, if you hold fast to a belief that the cure or answer to your pain
problems lie simply in another surgery or structural intervention, we are unlikely to be of much help. For us to help you, you must be willing to
explore and experiment with those suggestions we provide to improve your
central nervous system function. Yes,
you need to be willing to experiment because what helps one individual with
chronic pain might not be the best for another.
Also, if your current beliefs and approaches were getting you the
results you wanted, you wouldn’t be seeking our services.
Our physicians are well trained to
help you place good bets with regard to what might be of help. Many of the patients who come to us have been
clearly made worse by surgery or medications.
We hope to provide you with the opportunity to try a number of options
that have clearly helped others with little or no side effects. While our approaches are based on
evidence-based medicine, a number of our suggestions will possibly not have
been formally tested. This is because
with the number of combinations of approaches, formal testing is not formally
available. Nonetheless, all the best
current evidence supports that patients who receive a combination of
interventions do best.
In summary,
we are here to help you explore your chronic pain and in so doing to help you
find ways to improve your overall health.
July
19, 2005
Addiction implies a dysfunctional
central nervous system (brain, spinal cord, and autonomic nervous system). The central nervous system is extremely
complex and its dysfunction can stem from many factors. Indeed, our experience is that it is rarely
just one factor and most often is a combination of several factors which
contribute to ongoing chemical dependency/addiction. Our job is to help you explore what factors
may be interfering with your proper central nervous system function while
helping you find ways to promote a healthier central nervous system. The first step is always to stop self
administering drugs. Addiction
virtually can’t exist outside of the setting of self management of a drug. Everyone’s brain/life experiences are unique
so we can’t say with certainty how one individual will respond to a chemical or
other intervention. We can, however,
help you place “good bets” through our experience and scientific study of what
has helped or hurt others. We can always
help you learn from mistakes and continue to take steps to recover.
We believe that everyone was
made/designed to feel good. Amazingly
enough there is no pain center in the brain.
In contrast, there are areas of the brain that, when stimulated, result
in one feeling “blissful”. This is
fairly strong supporting evidence that the brain is designed to help us feel
good. In this model pain/suffering is
only a by-product of something interfering with or threatening the brain’s
ability to help us feel good. Using
this model, addiction reflects a “hijacking” of the brain’s ability to help us
feel good. With addiction what once may
have helped us feel good actually starts to interfere with proper brain
function and in some cases even results in the destruction of brain tissue. Since the brain is the most important organ
involved in our ability to meet our full potential as human beings, to destroy
or hamper its proper function clearly reflects a disease process. Yes, chemical dependency is a disease of the
brain and all evidence supports the idea that approaching it as a disease is
what works best.
Our culture teaches us that the
brain’s main function is to think, help us solve problems, etc. Well, in fact only a small percentage of what
the brain does is involved in what one might call thinking. It oversees a lot that we normally don’t
“think” about. It controls a lot of
unconscious behavior that we are normally totally unaware of. It also is the seat of emotions, which
clearly effect how we behave and respond.
If addiction is to improve the
brain needs to heal. Fortunately, we
know more and more about what can help the brain heal. The brain doesn’t just respond to drugs and
surgery. We know that contextual issues
such as perceived safety and thoughts can clearly help or hurt the brain. What and how you think and behave affects
your brain and its function. Persistent
thoughts and behavior can actually change the observable function/structure of
the brain. That is why it is essential
to help addicts with their thoughts and behavior. As an addict becomes more aware of how their
thinking and behavior affects their brain they have the opportunity to make the
changes necessary to return to normal brain functioning. Recognizing the behavior, thoughts, and
contexts that are toxic to your brain’s healing is an important step in
recovery. The real work lies,
however, in breaking out of one’s
conditioning and in getting the support
necessary to alter the behavior, thoughts, and contexts long enough that the
brain can heal and that cravings and other addictive behavior can cease. Patients will often hear me talk about the
“rat brain” within us. It is caring for
this part of our brain that is essential if addiction is to cease. It is an unconscious part of our brain and
it controls emotions, feelings, bodily functions, the fight or flight response,
etc. Fortunately, by avoiding toxic
drugs, thoughts, and behaviors, a reprogramming, often one that occurs
unconsciously, allows the rat brain to heal.
Why is spiritual growth so
important to recovery? We think it is
because we are made or, if you like, our brains are designed to desire
“God”. To define “God” is of course
problematic. When the nucleus accumbens,
a part of the brain that is involved in our natural reward system, is
stimulated with an electrode, patients will report a great sense of well being,
a peace, and a sense of unity with what is.
It feels similar to what mystics of all religious traditions relate when
they experience “God” or in some eastern traditions “enlightenment”. We hope to help you find ways, other than
using chemicals, to feel good, at peace, and fully human. If these ways are sustainable and natural, it
makes sense that these approaches would be helpful in someone struggling with
an addiction. Established methods/steps
for spiritual growth are sure to help.
There is
clearly a role for medicines in patients with chemical dependencies. We know there are many problems with the
central nervous system that interfere with people feeling good and that are
associated with addiction. For example,
depression, so common in patients with addiction, clearly interferes with
people feeling good and experiencing the feeling of God’s grace. There are ways besides medicines to help
with depression but nonetheless medications can be essential. Attention Deficit Disorder and Post
Traumatic Stress Disorder are other brain disorders commonly associated with
addiction. Often patients with Bipolar
disorder do much better with their addictions once their condition is medically
supervised. What’s more, in opiate and
nicotine dependencies there is clear evidence that replacement therapy helps
stabilize the brain and allow patients to start to develop healthier
lifestyles, ways of thinking, and, consequently, healthier brains.
For us to help you, you must be
willing to learn; to explore and experiment with those suggestions we provide
to improve your central nervous system function. Yes, you need to be willing to experiment
because what helps one individual with addiction might not be the best option
for everyone. Also, if your current
thinking, beliefs, and approaches were getting you the results you wanted, you
wouldn’t be seeking our services.
Our staff is well trained to help
you place good bets with regard to what might be of help dealing with your chemical
dependencies. We hope to provide you
with the opportunity to try a number of options that have clearly helped others
with little or no side effects. While
our approaches are based on evidence-based medicine, a number of our
suggestions will possibly not have been formally tested. This is because with the number of
combinations of approaches, formal testing is not formally available. Nonetheless, all the best current evidence
supports that patients who receive a combination of interventions do best.
In summary,
we are here to help you explore your chemical dependency and in so doing to
help you find ways to improve your overall health.
July
19, 2005
By James K. Rotchford, MD
Those of you who are patients of Dr. Rotchford have perhaps
heard him talk about different types of pain using the terms Type 1, 2, and
3. This handout reviews this terminology
and intends to make it easier for you to appreciate that different types of
pain exist despite the fact that they may all “feel” the same.
We will be discussing conditions for which the primary
problem is pain. Many people have
serious underlying structural problems, including bulging disks, advanced
arthritis, scar tissue, degenerative disc disease, etc., and yet have no pain
or significant disability. In these
cases, the “software” component of the central nervous system is taking care of
any “hardware” weaknesses the patient may have.
This analogy is based on the computer model where “hardware” is what one
can actually touch or see, that is the machine, the monitor, the hard drive,
etc. whereas “software” is what actually makes the computer work.
The following
discussion emphasizes the software component as being essential to how we
understand and approach chronic pain.
Most people who visit a pain specialist have already had their
“hardware” thoroughly evaluated and/or treated.
As a result of this evaluation, it becomes increasingly clear that the
pain associated with their condition is what is most disabling and causes the
most suffering.
In this “neuro-anatomical” software model, pain generally
has three origins; but regardless of its genesis, it often “feels” the same.
The first is “Type 1,” and comes from the standard mechanisms we all learned
about in grade school. For example, if
you touch something hot or injure yourself in some other way, a signal
originating from the “hurt” area of the body travels to the spinal cord and up
to the brain to the alarm, and is then processed into what we feel as
pain. Pain medications and
mechanical/surgical interventions are often quite helpful in alleviating this
first type of pain. Other terms more or
less synonymous with Type 1 pain are acute pain, nociceptive pain (pain
originating from tissue damage), or standard somatic pain. The neural pathways
for this first type of pain are the best known, and are continuing to be
further clarified by research in the neurological sciences.
The next two types of pain generally fall into the realm
of “chronic” pain. A good description of chronic pain is that
which is present and often feels very similar to the first type of pain, but
persists longer than expected. This type
of pain originates either at the spinal level or from dysfunction in the brain.
We refer to pain at the spinal level as neurogenic, neuropathic, sympathetic,
or “Type 2” pain. Although these terms
imply slightly different problems, they essentially reflect pathology at the
spinal cord level in the nerves themselves.
One might describe this kind of pain as spinal “short-circuiting.” Repeated inflammation, injury, or surgery to
the area involved are likely to be part of the patient’s history. I believe some patients, based on their
inherited “wiring,” are more susceptible to this type of pain. Although we know less about this type of
pain, progress is being made all the time.
At present, treatment options generally include medications that try to
stabilize neural membranes. These
medications are most often classified as anti-depressants or anti-seizure
drugs. Other options include acupuncture
and/or Lidocaine injections to help quiet down this “neurogenic” pain. More recently, Lidocaine patches have been
tried with some success.
The third type of pain, or “Type 3,” is the pain that is the
most complicated. One also calls this
pain “central” or “limbic” mediated pain.
The limbic system is deep in the center of the brain and deals with emotions
and other basic regulatory functions such as sleep, appetite, thirst, sexual
drive, etc. In animal experiments, it
has been established that there are neural pathways descending from the
hypothalamic-limbic system that, if stimulated appropriately, can block all
painful signals from getting to the brain.
Likewise, if the pathways are interrupted or are not working correctly,
there is objective evidence that the brain receives signals identical to those
received when tissue damage is actually occurring. This descending pathway from our limbic
centers is so critical that it can totally block out pain or even create pain
depending on how well it’s functioning.
We suppose that sleep disturbances or emotional stressors contribute to
the functioning of the descending pathway and, as a result, modulate pain
levels. Although the exact mechanisms
are not entirely known, it is well accepted that sleep disturbances and
emotional stress are clearly aggravating factors in pain management. Based on clinical experience, acupuncture, in
conjunction with appropriate counseling, may assist patients by helping the
descending pathway from their limbic system work better. It is likely that this pathway and its
corresponding brain centers are also involved in pain of suppressed
(psychological) origin.
A different approach to this often overlooked Type 3 pain is
described in depth by physiatrist and university professor John Sarno, MD. Although one doesn’t need to agree with all
his explanations for why his more “educational” approach works, one can give it
a try because it’s safe, cheap, and likely to help. A word of caution is in order, however,
because Dr. Sarno knows little about alternative forms of medicine; he stays
strictly within “Western” paradigms of thought and health. Nevertheless, his book “The Mind-Body
Prescription” is essential reading for anyone with a persistent painful
condition.
In a typical pain management practice, one generally cares
for patients for whom the pain is predominantly Types 2 and/or 3. If the pain were primarily Type 1, it would
most likely have already been addressed and taken care of by standard Western
approaches. If Type 3 pain is correctly
dealt with, the self-healing process that occurs invariably helps Types 1 and 2
pain as well. Most patients with chronic pain suffer from a combination of the
different types of pain.
Although certain medications such as anti-depressants have
achieved some success, they are generally of limited benefit unless the problem
is primarily that of depression.
Depression is often associated with chronic pain, but rarely is it the
only cause. Unfortunately, there is yet little objective evidence with regard
to how best to manage this third type of pain.
Often, a very eclectic approach is what is needed, and some patients
clearly benefit from seeing a variety of clinicians who specialize in pain
management.
Unfortunately, at this point in time, our culture wants to
deny the importance and prevalence of Type 3 pain. This becomes evident in Workers’ Compensation
cases where the insurance carrier denies any disability associated with pain
that can’t be ascribed to “objective” evidence, such as something obviously
structural (hardware) in nature. Since
the causes of persistent pain in these cases are invariably Types 2 or 3, the
basis for this type of pain is not readily identifiable (it doesn’t show up on
x-rays, exams, or lab work). As a result, it tends to be discounted or outright
denied.
In the future we can expect better “imaging” capabilities
that will allow us to better “objectify” Types 2 and 3 pain. Meanwhile, our culture and even medical
professionals reject or minimize the importance of these latter types of pain.
It is human nature, I suspect, to tend to deny or diminish that which we don’t
readily understand. Regardless, we all
know that much of what makes life so worth living is the “mystery” begging to
be explored and revealed.
GENERAL HEALING/HEALTH PRINCIPLES:
Suggestion: Take one or two of the following principles
and focus on them at least for a week or
so. To help you do this make a
commitment before you go to sleep to think back on the day and ask yourself how
well you integrated one of these principles.
If you didn’t do so well that day remember: “Progress not
Perfection.” Also don’t hesitate to ask
for help/support.
“Progress Not Perfection”
Patience
Explore “What does it mean to be human?”
Complete healing comes from within
Open-mindedness and a willingness to
listen
Acceptance of what is
Willingness to ask for help/support.
Let go of simple “rational”
explanations.
Willingness to question previous
assumptions and beliefs.
Practice/focus on gratitude
Focus on the things which bring joy into
your life.
Explore and maintain one’s values.
Embrace the mystery of life.
Being ready to get into the solution,
even if the problem hasn’t been solved.
Be willing to explore your symptoms
rather than just have symptoms treated
Practice being in the “Now”
Eradicate Resentments/Don’t let the sun
set on your anger
Recite regularly the “Serenity prayer”
(Of
course this is just a partial list)
Top
of the List:
Proper nutrition/supplementation
Regular
meals with cooked entrees, a good multi-vitamin, consider Max-EPA fish oil 2000-4000 mg a day.
Have you had your Vit D levels checked? Some patients with inflammation in their
systems respond to low inflammation diets.
If you can afford some herbal supplements we can tailor some just for
you.
Good sleep hygiene.
If
you are having trouble getting to sleep or staying asleep be sure to ask for
help. Start with standard behavioral
changes. Try and get to bed and awake at
the same time each day.
Regular schedules.
Each
of you have been given forms and instructed in your syllabus as to the importance
of keeping a regular schedule.
Regular aerobic exercise to 80% of
maximum heart rate
If
all my patients could exercise for 40minutes a day at 80% of the max heart
rate, I suspect at least 50% would no
longer need professional help with their pain.
Exercise is also important to counter the stresses of chemical
dependency and for symptoms of ADHD.
Education.
The
more you learn about what might help the better!
VERY
IMPORTANT:
Comprehensive health care.
If
someone is ill their CNS just doesn’t like it!
Regular medical visits help assure that standard bases are being
covered.
Taking
proper medications as prescribed.
It
is very important that patients with pain and chemical dependency take their
medications as prescribed. It is very
important to keep your self-medicating to a minimum.
Spiritual direction & growth.
The
CNS likes to experience direction. A sense
of meaning is helpful as well. If you
are experiencing more joy in your life as a result of spiritual growth, it follows you will experience less pain and
be less inclined to use drugs/alcohol inappropriately.
Supportive group activities.
Well
this one is easy because if you are a patient of OPAS then it already is
happening. Consider 12 step meetings or
church, charitable, sporting, hobby groups.
Consider volunteering.
MAY WELL BE IMPORTANT:
Supportive/Motivational Counseling.
Professional
counseling that helps you recognize what might help is often essential in
patients with chronic pain and/or CD.
Present moment exercises.
Remember
that you are breathing, focus on your
feet touching the ground, present sounds,
smells, and feelings throughout your body. There’s no end what can help here. These exercises are natural anti-stressors.
Meditation
If
you haven’t learned how it’s about time!
Educational opportunities.
Keep
reading/learning and asking questions!
Perhaps it’s time to take some classes for work or fun.
Cognitive/Behavioral Support
For
patients who have had significant traumas in their lives cognitive/behavioral
therapy can be essential to help the CNS forget about the trauma.
Healthy Family/Social Support.
Is
your family loving, supportive, understanding, and think you are the
greatest? If so, there’s something wrong with this picture and
it’s important to realize that the whole family is affected by chronic
illnesses and they may need more help than you. Ask/look into family members getting support
as well.
OPAS
decided to have this handout as part of its basic handouts. Fortunately it is a minority of patients with
chronic pain who commit suicide.
Nonetheless, suicide is a significant risk in patients with chronic pain
so we felt it essential to discuss it right up front with all patients.
What follows is a modification of
some ideas on suicide by Jonathan Marsh, a counselor for addictions.
I think it is helpful for patients dealing with chronic painful
conditions as well because there are so many similarities between addictions,
compulsions, and chronic pain. Some of these similarities include:
- A
sense of being out of control
- Shame
from behavior: patients with chronic pain are often disabled,
frequently unable to fulfill normal responsibilities/duties just like
individuals who have significant addictive or compulsive disorders
- Associated
Stressors:
- Family
stress
- Legal
stress
- Associated
complicating medical conditions
i. Recovery from surgery
ii.
Side effects of medicines
iii.
Depression, anxiety, post-traumatic stress disorder
iv.
Hepatitis or other medical conditions associated with underlying disorder
- Financial
Stressors
- Often
lack of effective and available help/understanding from the medical
community
- Neuro-anatomical
correlates
a. The
areas of the brain involved in addictions, compulsions, and pain thresholds
have many overlaps.
b. Associated sleep disorders are common
Quick-fixes are the exception
a.
Comprehensive care which includes contextual and
individualized care are necessary
b.
Behavior and habits need to be changed gradually and
require persistent and ongoing attention.
c.
They generally can be looked at as chronic illnesses
such as diabetes or psoriasis. No cure is available only
appropriate management tools to minimize long term disability and suffering.
I hope the above list is adequate
to convince you of some benefit in understanding and treating chronic pain as one
would an addictive disorder. What’s more, patients dealing with
chronic pain often have a history of addictions to alcohol or other mind
altering substances. If not
personally part of their history then family members regularly have had some
problems. Finally, chronic pain is
statistically at least as high a risk factor for suicide as having an addiction
problem is.
Suicide is an often considered option in early addiction/pain
recovery. It is for the same reason that
addiction itself exists: suicide offers immediate relief to what is perceived
as an overwhelming amount of stress/pain. Rather than to face the emotional
pain that comes with the guilt, shame, consequences, failures and/or other
destructive consequences of their condition, compulsive and chronic pain
patients may well turn to thoughts that only death will keep them from
suffering overwhelming emotional and physical pain.
During recovery, when the addictive behaviors (their only
remaining stress management technique) are taken away, and the ability to use
other potential behaviors to replace that addiction is eliminated, a
significant void is created in the person's emotional life. In chronic
pain patients we often see this happening when we eliminate the possibility of
a patient taking pain medication on an as needed basis. This void
is quickly filled by an increasing amount of stress which comes from facing the
reality of what their life has become. This usually means having to face
a reality that is filled with guilt, shame, regret, remorse... These feelings,
coupled with the “all of nothing” principle that most compulsive people live
by, create a classic prescription for thoughts of suicide. An addict's dream:
the ability to permanently balance everything in their life with one act.
When someone begins to contemplate suicide as a means of
stress management, he/she has created a self-perception that nothing can rescue
them from the hole that they have fallen into. No amount of sincerity, no
amount of effort, no amount of “recovery” will ever be enough to fill the
emptiness and pain that they feel inside or in their bodies. This is
almost inevitable, as addictions and chronic pain interfere with so many
different aspects of one’s life that taking an honest inventory of the damages
can be overwhelming. In the past, this feeling could be managed with fantasy
and acting out, but in recovery, that option is removed. The
realization of how much time and resources have been lost to the addiction and
chronic pain can, in and of itself, lead to feelings of hopelessness and
despair. What’s worse, a person in such an emotional state most often does not
have the necessary skills to effectively deal with such a burden. The
foundation of values has not yet been built and so suicide, the permanent
ending of one’s own life, offers this person the control that he/she so
desperately needs. Even the simple thought of being dead, without actually
acting on it, often triggers feelings of relief in such a person’s mind.
Progressively, the suicidal thoughts and gestures may assume roles in the
chronic pain behavior, offering the pain patient a method for artificially
relieving stress.
The permanency of suicide, although intellectually
comprehended, is not applicable to the struggling person's reality, as the pain
patient is incapable of visualizing a viable future separate from the pain
& its inevitable consequences. In other words, the pain patient may
perceive suicide as an acceptable option because he is incapable of perceiving
other options as realistic. Intellectually, he may understand there are options
for improvement/ recovery, but emotionally, he lacks the ability to commit
himself to such an unknown future. Suicide, at the very least, comforts him by
offering an immediate illusion of control.
It is important to correct this misperception, and it can be
done with the simplest of logic:
Death, eventually, will strike us all. When it does, it will
take with it everything that we have associated with our life. That includes
not only the negative associations–the pain, the shame, the embarrassment, the
sorrow; but the positive ones as well–the accomplishments, the friendships, the
pride in how we lived our lives. There is nothing that you have lost as a
result of your pain that you would not have eventually lost anyway. There are
no legal consequences that are too great; no legacy and no morality judgments
by others that will affect you more than death. No matter where your religious
beliefs may lie with regard to the afterlife–be it Heaven/Hell,
Reincarnation/Karma or even in the belief that there is no afterlife–suicide is
an illusionary option of control which undermines each of these beliefs.
At best, suicide accelerates the inevitable, denying you the
chance to challenge yourself–both with the pain and in life. At best, suicide
denies those around you, both known and those who you have yet to cross paths
with, the opportunity of experiencing the person that you know you are inside.
At best, suicide allows others to always remember you for who you are now, a
“chronic pain patient” that will forever be your legacy. But at worst, suicide
reinforces the option for others who might have gained strength in your
recovery. Your success may very well trigger the confidence in others to
recover as well. To shatter the misperception that such “recovery” is
impossible. At worst, you will continue the painful and destructive cycles that
are usually passed down from generation to generation. Rather than becoming a
part of a loved one's value system from this moment forward, you become part of
their stress. Also, at worst, you will be dead–not just until the pain goes
away, but forever. There will be no honor, no proof of sorrow or remorse. There
will only be death.
If you have thought about, or are currently thinking about
suicide as an option, make a commitment to remove that option from your life.
Know that you will get past these current struggles, and will continue moving
forward until you have. Why eliminate suicide as an option? Because when you
allow such an option, you also allow yourself to fail to get better. You
allow yourself to continue falling deeper and deeper into your compulsive hole
because you know that, deep down, if things get too bad, or if you ever get
"stuck"...there is always suicide. With such an option available,
there is little motivation to see the immediate need for change. In such
a situation, Survival becomes a value that you must develop to maintain balance
in your life. If it helps, imagine that you went through with it. Consider your
past as “dead”, and that you are now reborn to live the life that you desire.
After all, that is what recovery is all about–beginning anew. When you base
your life on a foundation of values–self-respect, spirituality, meaning–there
is nothing that anyone can take from you, not even your freedom. Eliminate
suicide as an option and you will have eliminated your doubts about getting
better. You decide: are you more likely to recover with the attitude that if
things get too rough, there is always the option of killing yourself; or with
the option that things can never get too tough. That even in the worst possible
scenario, can be seen the opportunity to challenge yourself. To continue
growing? What a difference it is to believe that death is all that can stop you
from recovering, rather than death being the ultimate recovery tool.
6/2/2003
Some of these points are taken from the textbook: Principles
of Addiction Medicine- Third edition
The main
point to understand is that stopping the use of alcohol or a drug doesn’t seem
to alter much the natural course of chemical dependency. It’s like someone going on a diet every
once in awhile. There is a temporary
reprieve and improvement in some symptoms but inevitably the weight and
associated problems return. So
detoxification, while often life-saving and useful in providing an opportunity
for education, in itself rarely alters the natural history of
addiction/chemical dependency.
Once
dependence is established, the reinforcing properties of drug
self-administration serve are limited in large part to avoid the discomfort of
real or imagined withdrawal. Ingestion
of the drug can even be associated with unpleasant physical symptoms as well as
a host of very negative feelings such as shame, guilt, and depression. Nonetheless, the dependent individual often
continues to use or relapse. It is clear
that the major sources for relapse are situational triggers that unconsciously
stimulate relapse.
It is by
creating a context in which these triggers are recognized, minimized, or dealt
with in a new way that alters the natural course of addiction. Most data suggest that it takes nearly five
years of abstinence to assure that the natural course of addiction has been
altered. So what are the known
“contextual” issues associated with prolonged abstinence and recovery.
- the
abstinence occurs in the community and lasts for years rather than months.
- is the
product of compulsory supervision or experiencing a consistently aversive
experience related to alcohol or drug use
- involves
finding a substitute activity to compete with substance use
- requires
developing a new drug-free social network
- includes
membership in a self-help group (through which one may discover a
sustained source of hope, inspiration, and self-esteem in religion or
Alcoholics Anonymous).
These same factors tend to be identified in remission from
abuse of tobacco, food, opiates, and alcohol.
So as noted,
the control that a drug exerts over an individual’s behavior depends only
modestly on its pharmacologic properties.
Second, to a remarkable degree, relapse to drugs is independent of
conscious free will and motivation.
Also note that
in some studies, the short-term death rate among abstinent alcoholics was
similar to that among progressive alcoholics.
Newly abstinent alcoholics were “less normal” on several measures of
psychological functioning than were alcoholics who had been abstinent for more
than four years. Thus, abstinence should
not be considered in isolation but within a context of over-all social,
physical, psychological, and spiritual rehabilitation that may require years to
achieve.
Revised 7/2004
