The Lifecycle of Addiction and Recovery

Addiction problems seem to be something that comes to everyone’s attention because of the crises that it causes. Possibly the first few crisis situations pass by and are excused to circumstances but soon enough of a series of crisis shows there is a deeper problem. At the time that people first become aware that addiction could be an underlying cause of these crises, it is really important to understand as quickly as possible how recovery works. Failing to understand this in a comprehensive way early will allow the problem to persist for much longer than it needs to with devastating and debilitating consequences. Unfortunately, getting friends and family to agree on what needs to be done can be quite a challenge, which we will reference in another article. Let’s focus here on what the ‘lifecycle’ of addiction looks like and what we can learn from that in terms of the correct interventions we should make.

At the point when someone first develops a problem with addiction, there is a phase where they encounter problems from the addiction and make a series of attempts to stop on their own. On average this period lasts about 5 years. These first few crises could be things like being caught drunk driving, being caught in possession of drugs, being repeatedly late for work etc. Any one of these on their own could just be bad luck, but a succession shows there is a deeper problem. After an average of 5 years of these ‘self-initiated cessation attempts’, the person asks for outside assistance

At the point where someone first accepts the need for outside help, they may have a number of treatment episodes, residential treatment, day-care and self-help support. From here it takes on average about 8 years before someone can successfully achieve one continual year of sustained abstinence. That may sound a bit dispiriting but it must be emphasised that the overwhelming majority of this period of time is spent abstinent, it’s just that getting to the point where that lasts consistently for more than one year takes time. 

Finally, once one year of abstinence has been achieved, it takes a further 5 years until the risk of relapse drops below 15%. The reason this figure is so significant is that 15% is that this is the same risk percentage that the general population have of ever developing an addiction problem in the first place, so if our group have gotten down to a risk of 15%, then at this point in their recovery they are at no more risk than the general population.

So what can we learn from understanding this Lifecycle of Recovery?

1. In the first phase, there is a good opportunity for outside agencies such as doctors surgeries, lawyers offices, A&E departments and even friends and families to help bring the problem into someone’s consciousness earlier. The earlier that they can be helped to see it is a problem, the sooner they can get to the next stage and ask for help.
2. During the second ‘treatment’ phase ( the 8 years of early recovery ) it is important not to become to dispirited or to be dragged up and down by the relapses. Don’t distract the process by looking for miracle treatments. This is a process, it will take time and lessons can be learned as they progress but rather than feeling that it isn’t working or something completely new has to be tried, it is more helpful to congratulate them for the progress made so far and to move back to recovery as quickly as possible. The sufferer may feel shame and the family may feel angry and frightened. These are times for cool heads and kind hearts.
3. Even once a year of recovery has been achieved, the first five years are still a risky period. It is important to maintain recovery during this time and for everyone to be aware of the risks. After 5 years continued abstinence, it is also important to acknowledge that the sufferer can be trusted to be in remission from their problem and trusted to behave as responsibly as any other member of society. Constantly monitoring or treating with suspicion will have a negative consequence. We must all embrace this new life.

References: This chart and data is taken from a talk given by Professor John F Kelly of Harvard Medical School

 https://scholar.harvard.edu/johnfkelly/home

It’s good to hear that the Middlesborough health service, alongside the police, is trying a new way to help people with severe heroin addiction. In a groundbreaking move, 15 people with heroin addictions are going to be provided with free Diamorphine ( medical heroin ) twice a day. Once they are stabilised, they will also be given help to manage other mental health issues, and help to find work and housing. 

People working in rehabs are often horrified at the prospect of sufferers being given ‘free’ drugs, or even being provided safe places to use ( shooting galleries, as they are sometimes known ) in case this encourages or prolonging the course of addiction. 

Even though abstinence is the best outcome, we need to be able to interact with sufferers before they come to that realisation for themselves and, even more essentially, we need to keep them alive. 

Critics might think that this approach is putting the cart before the horse. Most clinics work on the good principle of getting people abstinent first before working on all the other areas needing attention but for people at the extremes of society, extreme poverty and even extreme wealth, it can prove to be more effective to stabilise their use, build up their other resources ( sometimes referred to as ‘recovery capital’), and then move on to work on the detox further down the line. It’s also crucial to keep them alive! About 10% of the population took a recreational drug last year, 5% took cocaine for example. Only 0.5% took opiates but 75% of drug misuse deaths were due to opiates ( 2,208 deaths last year ). This is why we should look at this specific drug with a slightly different perspective. 

If we look at the experience of America during its recent opioid addiction epidemic, it has been painful to witness resistance to harm minimisation approaches which could have saved many lives. In comparison, Portugal has led the world with its practice, taking opiate addiction problems away from the criminal justice system and putting it clearly in the health arena, where they belong. 

The overarching lesson has to be that we should be careful to avoid dogma when it comes to helping people with mental health problems. We naturally have to have good guiding principles to the way we work but there are also many nuanced cases where we must be more flexible. The most important measure we should always be using to judge how we operate is whether an approach moves a specific individual towards better health and wellness, or away from it.

This will be an interesting project to follow.

References:

https://www.bbc.co.uk/news/uk-england-tees-49988727

How many people use drugs?

http://www.emcdda.europa.eu/countries/drug-reports/2019/united-kingdom_en

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. ( The Lancet )

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.” ( https://www.verywellmind.com )

Putting the current fears of vaping risks into context. The CDC estimate that in the USA cigarettes cause “1,300 deaths every day”. ( https://www.cdc.gov/tobacco/data_statistics ) whilst there are now 6 in total attributed to vaping ( https://eu.usatoday.com ) 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 could do more to set the record straight and keep encouraging people to move away from tobacco.

If you are trying to give up tobacco then you are doing the one thing that will have the greatest positive impact on your health and we salute you for your efforts and we owe you better reporting about this.

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