I have been interested to see the difference in approach to vaping between America and the UK right now.

Last week the British medical research journal ‘The Lancet’ published a review of the evidence around vaping and declared vaping to be “the most disruptive influence on smoking in decades”. They found the harms to be 1/20th of smoking, that the success of giving up cigarettes was approximately twice as effective vs other NRTs, and that it isn’t proving to be a gateway drug into smoking for youngsters. ( http://bit.ly/2kdjGEJ ) I’m sure it can’t be great to be breathing in any smoke from any source but given that our treatment industry has spectacularly failed to come up with another effective solution, we need to work with and support what does work since cigarettes kill far more alcoholics than alcohol does:

“….. the death rate for alcoholics who seek treatment is 48.1% within 20 years compared with an 18.5% death rate for the general population. Of those deaths, more than half (50.9%) are attributed to smoking, and only 34.1% attributed to alcohol.” ( http://bit.ly/2mespY3 )

Putting the current fears of vaping risks into context. The CDC estimate that in the USA cigarettes cause “1,300 deaths every day”. ( http://bit.ly/2kIbcpj ) whilst there are now 6 in total attributed to vaping ( http://bit.ly/2kgEI5x ) Surely we should really be panicking about 1300 deaths a day?

Vaping isn’t the end game for recovery from smoking but it seems the evidence around it isn’t being accurately reported and I feel we might do more to set the record straight.

People often wonder this, or it’s opposite, how much is ‘abnormal’ to drink. Sometimes this is quite hard to explain, especially the relationship between hard-drinking, alcoholic drinking and normal drinking.

In America, they broke drinking behaviour down by each 10 % of the population and the resulting graph is very revealing.

It is interesting to note how little most people drink but even more interesting to see how much is drunk by those who are alcoholic. If the drinks industry is making this much of it’s money out of those who are ill, they should have considerably more responsibility for the cost of their care in the NHS.

If we want to change any behaviour, it helps to know as much as possible about it, understanding the complex functions and roles it plays in our lives. The more we can understand about it, the easier it will be to pull away from it.

You could apply this analysis to any behaviour you want to change, gambling, drinking, taking drugs. It is known as a “Functional Analysis”. 

We can ask ourselves:

The Behaviour

What do you usually do?

How much do you usually do it?

Over how long a period of time do you usually do it?

Then we look at the ‘triggers’ for doing it:

External Triggers

Who are you usually with when you do this?

Where do you usually do this?

When do you usually do this?

Internal Triggers

What are you usually thinking about right before you do this?

What are you usually feeling physically right before you do this?

What are you usually feeling emotionally right before you do this?

Then the consequences, positive and negative:

Short-Term Positive Consequences

What do you like about doing this with (your buddies)?

What do you like about this where you most often do it?

What do you like about this when you most often do it?

What are the pleasant thoughts you have while you do it?

What are the pleasant physical feelings you have while doing it?

What are the pleasant emotions you have while doing it?

Long-Term Negative Consequences

What are the negative results of doing this in each of these areas:

Interpersonal:

Physical: 

Emotional: 

Legal:

Job:

Financial:

Other:

Going carefully through these answers we can pretty quickly see situations we might want to avoid or replace, and where we might need extra support and other resources. 

Having a greater awareness of the complex roles that behaviours perform in our lives gives us a much better chance to successfully move away from them. 

I first learned about PROMIS clinics in the summer of 2015 when I first decided to seek professional help and rehabilitation for my ongoing struggles with substance abuse combined with a lifelong battle with bulimia nervosa. At 27, I had been combatting my illnesses (on-and-off) for over a decade and had tried everything I possibly could to ‘get better’ on my own. Overwrought with feelings of shame and fear, I was living in a deep state of denial for some time before I finally hit rock bottom and had no other choice but to face the reality and severity of my problems. So, at 27 I began my journey of recovery with expert help and individualised care of the PROMIS team at Hay Farm and now, four years later, under the care of the team in London (Kendrick Mews). 

It is impossible to describe how my experience at PROMIS has changed and saved my life, so I wrote to the teams to thank them:

As most of you know, I am not often lost for words or short of things to say, especially amongst you all! However, as it were, I find myself struggling to find the words that could possibly convey my appreciation for all your efforts and constant encouragement during my time at Hay Farm. A mere “thank you” somehow seems futile; it is used so frequently and often casually as a common expression of gratitude, however lacking sincerity. “Thank you”, in my opinion, does not verbalise how much of an impact you all had on me, my recovery and my life in general. I remember so clearly how terrified I was at the notion of staying in treatment for 28 days, an entire month to face my disease however painful it would be. I had been brought to my knees for the last time but was reluctant to commit.

Then something happened. I surrendered. I put all my faith and trust in your hands. You challenged me, and I cried. You challenged me some more, and I listened. You challenged me when I needed it most, and I began to change. Over the course of six weeks, I poured my heart and soul into my recovery, and in return, you gave me the support and the tools I needed to rebuild myself and my self-worth. I can honestly say that no one could have ever prepared me for the emotional, physical and spiritual challenges that I faced every minute of every day. No one said it would be easy, but then again, no one can possibly say just how hard the journey of recovery would be either. Through it all, you were there to reassure me that I was on the right path. 

I will forever be indebted to the teams at Hay Farm and Kendrick Mews for helping me to surrender completely to my disease, and to accept my powerlessness. I handed you all my control and in return, I unknowingly began to forgive myself and regain respect and love for my mind, body and spirit. With your help, I finally put down my mask and have since become acquainted with my true self (and it turns out, she’s not so bad!). 

You are a fantastic team of people, more like a family, and I wouldn’t be where or who I am today without you. 

We are seeing a terrible surge in drug deaths in Scotland right now and it’s time to take urgent action.

There is a clear case study that gives us a great example of exactly what needs to be done.

In the lead up to the new millennium, Portugal was also seeing a horrible rise in drug deaths. This was when a physician, Dr Joao Goulao, introduced a new government drugs policy where drugs offences were no longer treated as criminal acts but instead were managed by the health authorities and seen as a health problem.

The results of this have been really clear. From a long period of increasing drug deaths.

Immediately after applying this new policy in 2001 drugs deaths directly turned around and headed down.

Other associated deaths were also reversed

Since then, whilst drugs deaths in other European countries trended higher, Portugal continued to trend lower.

If you look to see where Portugal now sits in comparison to Scotland or the USA ( the two worst cases for drugs deaths ) you can see clear evidence of Portugal’s success:

In case you are concerned that because of this lack of ‘punishment’, addiction problems amongst the young are increasing? It simply isn’t the case. In the immediate aftermath of this change in policy, there was a slight increase in people ‘admitting’ to having used drugs but over the longer term, the trend has been lower.

(Source https://transformdrugs.org/the-success-of-portugals-decriminalisation-policy-in-seven-charts/ )

Dr Goulao has explained the success of a health approach to addiction it isn’t simply a matter that Portugal ‘decriminalising’ drug problems but “the biggest effect is caused by allowing the stigma of addiction to fall, allowing people to speak clearly and pursue professional help without fear”.

We have been stuck in a failing ‘drug war’ paradigm for decades and it has continually made the problem worse. It is urgently time we abandon this failed policy and adopt a purely health-based approach to addiction.

Whether you are concerned about someone you love, or if you are in a group therapy based recovery process yourself, one of the most challenging but important skills you will benefit from developing is that of being able to give people constructive feedback. 

There are many reasons to avoid telling each other the truth, it risks upsetting people, we are unlikely to be appreciated for it, and so it becomes the social norm for us to all ‘mind our own business’ and keep quiet. It then falls down to very close friends or family to give honest feedback but this is very limiting and, even close friends and family may find it easily backfires and so helpful feedback is avoided by most people. 

Brene Brown became world famous after a Ted Talk she gave describing her research into vulnerability. In her book, daring greatly, she came up with a beautiful metaphor for giving constructive feedback. She calls it “Sitting on the same side of the table.” She lists a checklist she uses to identify if she is ready to give feedback. She considers if:

1. I’m ready to sit next to you rather than across from you.
2. I’m willing to put the problem in front of us rather than between us (or sliding it toward you).
3. I’m ready to listen, ask questions, and accept that I may not fully understand the issue.
4. I want to acknowledge what you do well instead of picking apart your mistakes.
5. I recognize your strengths and how you can use them to address your challenges.
6. I can hold you accountable without shaming or blaming you.
7. I’m willing to own my part.
8. I can genuinely thank you for your efforts rather than criticize you for your failings.
9. I can talk about how resolving these challenges will lead to your growth and opportunity.
10. I can model the vulnerability and openness that I expect to see from you.

You can see that the feedback process can be taken from something that easily offends to something that encourages people to grow and learn, something we all want to do.

If you are negotiating your own early recovery or you are trying to help someone you love, there will be lots of times when you will want to give people helpful feedback, this checklist is a lovely way to ensure this is a constructive and kindly process.

You can see Brene Brown’s groundbreaking TED talk here: 

And see “Daring Greatly” at Amazon here:

In this short clip from an interview with the American comedian and podcaster, Theo Von, the Canadian Professor of Psychology, Jordan Peterson, argues that alcohol acts as a replacement for excitement and adventure in peoples lives and if they are to succeed in stopping it is important to find another way to express this.

Clinics like ours incorporate an aspect of adventure and new experiences into the treatment programme so that people can find a new passion and drive in their lives. We also like other organisations like Resurface, who are combining the experience of surfing with recovery and we fully endorse these sorts of recovery activities.

Simply stopping doing something, in and of itself, is really hard to maintain. Instead, it is more fulfilling to move towards a new and exciting life filled with opportunity.

How do you or would you like to express excitement and adventure in your recovery?

Last year, Prof John Read and Dr James Davies published a paper in the scientific journal ‘Addiction’ reviewing the withdrawal effects of antidepressants and suggesting these are worse than most people have been informed.

They raise concerns that symptoms of withdrawal are both more common, affecting nearly half of people trying to come off them, and last much longer, up to 4-6 weeks ( rather than the one or two suggested in the government guidelines ). They are also concerned that the symptoms of withdrawal people experience when trying to stop taking the medication may be mistaken for a relapse of their illness, causing them to go back onto the medication without good reason. Finally, they argue that the withdrawal symptoms are so severe that the clinical guidelines around their use should be revised.

Antidepressant medications are being used more and more, rising by 170% since 2000. As many as 16% of the UK population were prescribed antidepressants last year and half of all users have been taking them for more than 2 years. Looking further, 36% have been on antidepressants for more than 5 years and 26% expect to stay on them for life. Alarmingly, 65% had never had a discussion with the person who prescribed them about coming off and, perhaps in a connected way, 45% of those who had stopped the drugs had done so without consulting their doctor. Indeed, about 1 / 3 people taking antidepressants for more than 2 years have no clinical indications for taking them.

Depression is a horrible problem to have to suffer with and, if antidepressants are providing effective treatment, it may well be worth tolerating some side effects and withdrawal symptoms. The main problem is that it seems as though these downsides and side effects are being understated and people may not be being given full and accurate information about them. Nearly half of people experiencing withdrawal effects describe them as ‘severe’, and it is not uncommon for people to continue experiencing withdrawals for several months. This is quite different from the current guidelines which describe ‘discontinuation symptoms’ as ‘mild and self-limiting, resolving over 1-2 weeks’.

All of this is not to say that people should stop medications they are finding helpful or that others shouldn’t explore medications as a good treatment option but it does sound like the advice and management around medication needs a lot more care and attention. Firstly, people need more detailed advice about the difficulties they might experience when they try and stop their medication and secondly their cases need regularly reviewing to see if, when and how they might consider stopping.

Finally, it should be emphasised that although we are discussing some of the side effects of medications, many still find them extremely helpful. Also, there are a number of new medications for depression showing great promise so the outlook for sufferers will only improve in the coming years and maybe even months. We shall report on some of these new treatments in articles very soon.

References:

“A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based?”:

https://www.sciencedirect.com/science/article/pii/S0306460318308347

The CAGE alcohol questionnaire takes just four questions to diagnose alcohol problems:

1. Have you ever felt that you should cut down on your drinking?

2. Have people annoyed you by criticizing your drinking?

3. Have you ever felt bad or guilty about your drinking?

4. Have you ever had a drink first thing in the morning to calm your nerves or get rid of a hangover?

9/10 people answering yes to two or more questions have been found to have an alcohol problem and 9/10 people who answer yes to all four are diagnosed to have alcoholism. 

Research has shown the CAGE questionnaire is both reliable and valid as a tool to screen for alcohol problems. ( https://en.wikipedia.org/wiki/CAGE_questionnaire )

The great value of the CAGE questionnaire is that people in front line health positions can use it as a quick and reliable screen to include amongst other health questions and allow earlier identification of problems and hachance to get help sooner. 

Whether you have an addiction problem, care about someone with an addiction problem or even if you work with people who have addiction problems, I think it helps to step back for a minute and understand how this problem and it’s recovery unfolds. It’s too easy to get blinkered, judgemental of ourselves and others, and not see the overall patterns of what we are looking at.

Professor John Kelly, addiction professor at Harvard Medical has produced a slide which really neatly summarises how these problems evolve and how recovery ensues. Please bear in mind that we are talking about averages here and we are talking about severe addiction problems. When you have an average, of course, there are going to be people who have very different experiences but this shouldn’t stop us from looking at averages to get an understanding of the course of recovery.

Addiction Onset

The first period that Professor Kelly described was the ‘onset’ of the problem. From the point at which it could be said that the addiction was first recognisably a problem, there was an average of a 4-5 year period where people have tried a series of self-initiated cessation attempts before they ask for outside assistance or help.

Help-Seeking

The next period could be described as an average of 8 years of Help-Seeking after which they are able to achieve full sustained recovery for more than one year. When I first heard Professor Kelly describe this he was very quick to point out that this period had a lot of recovery time in it, it’s just that it was taking this time to achieve an average of one full sustained year abstinent. On average people may have 4 or 5 treatment episodes and engagements with Mutual Help organisations ( AA, SMART etc.. ) during this stage.

5 Continuous Years of Abstinence.

During the first 5 years of abstinence, there is a need for continued care and mutual help. At the end of this first 5 years, the risk of relapse drops below 15%. This is significant because 15% of the population will develop an addiction problem so Professor Kelly has argued this is like saying that after 5 years of recovery, people return to having the same risk of addiction that the rest of the population have.

Conclusions and lessons to be learned

So, standing back and looking at this data, what conclusions can we draw?

It takes time

From the point of view of having an addiction problem, I think it is helpful to see that it takes time to get into recovery. There is this frightening saying that ‘relapse is part of the process of recovery’ and it can be disappointing to hear this. Of course, there are many people who achieve sustained recovery ‘first time’ but equally, there are many who struggle longer. I don’t think this should be very surprising. Addiction problems are the tip of the iceberg, underneath and around are many other social and psychological issues that interplay and so it really can’t be any surprise that it takes practice to get all these elements into the right alignment for recovery. If you reflect on any other skill you have developed, I bet there were times when you felt your learning was going backwards instead of forwards. The important thing here is not to feel like you just can’t get it if you have a slip or a relapse.
Overwhelmingly in this research data you can see a pathway that people with severe addiction problems are taking to come into recovery and long term remission from their problems. It’s important for everyone involved to keep the faith that this is where you are all heading.

Early intervention

You can see from the first period that there is this long stretch of 5 years after addiction becomes a problem but before someone seeks outside assistance. If it is apparent to the sufferer then it must also be apparent to those around them. Why is it taking so long to start asking for help? Perhaps there is still some embarrassment and shame? Perhaps friends and families think it’s none of their business. Somehow we need to make asking for help an easier thing and we should also encourage friends and families to bring this subject up. The sooner someone can get started with this, the sooner they will recover.

Family and friends

Addiction brings with it a series of crisis and during these episodes, it is very easy for any and all of us to lose hope. Looking at this outcome data you can see the evidence that the long term prognosis is in fact very good. The period that everyone must find very stressful is that middle period, averaging 8 years, where people are trying to find that first year of continuous abstinence. This is the time when there can be such tremendous recovery and hope and then, terrible setbacks. It is understandable to lose hope and feel very frustrated during this phase but it is such a shame if people can’t see what lies beyond. Ultimately, people could have any number of possible medical or psychiatric problems, addiction is just one of these, but the recovery rates for addiction are very similar for nearly any other chronic problems, medical or psychiatric. One of the statistics that Professor Kelly quotes is an outcome study ( White 2013 ) which calculated that 60% of individuals with addiction will achieve full sustained remission. Perhaps it’s the continued shame and judgement that surrounds addiction as so many still consider it a moral or character problem rather than understanding it’s medical and psychiatric dimensions. This is the time to set our sights on the long term outcome and outlook.

Carers and professionals.

From the perspective of someone who helps people with addiction problems, there are quite a few lessons here. One is the importance to try and find ways of helping people access help at earlier points. There is that beginning 5 year period where people are attempting to stop on their own before asking for help. Why aren’t they asking for outside assistance when this will so massively increase their success? I have another article about this very point so I won’t elaborate on it now but it’s worth us all reflecting on this. I would also ask people to consider how the expectation of recovery is phrased. It’s clearly important to study and discover what was working for them vs what wasn’t, but I do hear people being highly critical of treatments/people or methods as if there was ‘one’ other simple key which this new person/clinic/treatment centre can now offer. I see this in self-help groups, I see it amongst professionals and I see it between clinics. I suggest it’s important that we help people see this as a process of coming into recovery rather than one singular. To this point, it is most important that we be sure to offer the widest range of evidenced treatments rather than just one based on ‘opinions’. Let’s focus on the research evidence and share a range of skills and let’s help sufferers be less punishing of themselves and let’s help others be less punishing of them also.

It will be the focus of another article I am writing to look at how to minimise relapse.

In summary, let’s help people by sharing with them the bigger picture of this process of the recovery ‘Lifecycle’.