But the missing link is most likely right under our noses. Literally. Take a look at the food on your client’s plate and you can learn a lot about why he can’t get from point A (head knowledge) to point B (heart knowledge/personal belief/action), such that real change happens and is sustained. This link between nutrition – or lack, thereof – and mental health and wellbeing is not necessarily a new one, but somewhere along the line where traditional mental health and addictions training is concerned, its importance dropped off and isn’t adequately addressed (if addressed at all) in most training programs.

Let’s look at a couple examples where this might come into play. An 18-year-old recovering bulimic still struggles with anxiety and irritation, snapping at her parents and feeling jittery, unable to slow down both mentally and emotionally (increasing the likelihood of impulsive behavior – bingeing and purging, substance abuse, casual sex). After addressing all the typical mental-health factors that could come into play and ruling them out, I suggested a major reduction or elimination of caffeine and refined sugars. She comes back two weeks later and reports feeling significantly less anxious and irritable; her parents concur.

Example two: The recovering alcoholic who keeps a daily cocktail of caffeine and nicotine coursing through his veins, and keeps white pasta and bagels on regular rotation in his diet. Not surprisingly, his alcohol cravings are through the roof, and it’s a major challenge every day to not use. In this case, the sugar from the white flour products acts in his body the exact same way alcohol does. And the caffeine is blocking the production of natural serotonin; and he may be on an SSRI to keep that precious serotonin hanging out in the synapses. It boils down to nutritional sabotage.

In her book, The Mood Cure, Julia Ross* talks about the chemical action of sugar and alcohol in an alcoholic’s body: “Alcohol acts just like sugar biochemically, only more so. It contains more calories per gram, and it gets into your bloodstream faster. For people whose blood sugar levels tend to be low [of which research states that 95% of alcoholics are hypoglycemic], this can be irresistible”. This is why those bagels should be verboten to a recovering alcoholic. As Ross says, “You might as well pick up a beer!”

But the nutrition piece is not all about sugar. Ross – a licensed MFT who has practiced for more than 30 years and run Recovery Systems, a clinic in Mill Valley, California, specializing in nutritional therapy for detox, among other mental health issues – reports that anyone suffering from mood issues, such as depression, anxiety, irritability, excessive worry, the inability to concentrate, lethargy, constant, unmanageable stress shares the same issue: a depletion of key amino acids in the brain. When these stores are full, they effectively manage your emotions so you can feel pretty good about life in general. But when one or more of these tanks dips low, your moods suffer, often leading to significant behavioral and mental health issues.

While the mechanisms controlling our brain chemicals are quite complex, the solution is simple: Restore those tanks with the proper food and supplements; avoid certain foods that further deplete them; and engage in healthy lifestyle choices. Doing so, you can ensure a mostly healthy and happy existence. These days, the mind-body connection is no longer the exclusive territory of shaman and “woo-woo” therapists – major science continues to confirm its validity and importance in effectively treating a person for any emotional and physical issue.

Ross reports phenomenal results in typically difficult-to-impossible populations with what she has dubbed nutritional therapy or nutritherapy. Her success stems from a protein-rich diet that provides these essential amino acids to each of the four “mood engines” in your brain responsible for mood-related neurotransmitters: serotonin, GABA, catecholamines and endorphins. This protein, in combination with a healthy range of vitamins and minerals and the right kinds of fats, begins to restore what your brain lacks. And while this deficit may result from several factors – from biological predisposition to prolonged life stressors to poor diet or drug and alcohol abuse – it can all be corrected with the proper nutrients.

In addition to adhering to a “good-mood food diet”, Ross espouses the use of amino acid supplements to steadily refill these empty tanks. All-natural and easily tolerated by most (exceptions exist and are competently addressed in her book), the amino acids would seem to be this elusive missing puzzle piece. While working with nutritionists, doctors and psychiatrists, Ross and her team developed a protocol that they have effectively used for nearly 20 years to great success. When treating alcohol and drug addiction – a field in which relapse rates generally hover around 90% – Ross’s clinic boasts a success rate of about 80-90%, with clients remaining clean and craving-free years later. And, once the tanks have been refilled, typically a six-to-twelve-month process, most clients can stop using them.

Other factors can be at play when basic nutritherapy – diet and supplements – do not work. Checking for adrenal and thyroid issues – as well as something as many as 40% of addicts suffer from, pyroluria, a genetic condition that “blocks the absorption of key nutrients to the brain” – is an essential piece to comprehensively treating your client. Also, many people suffer from parasites, which prevent nutrients from reaching their intended targets, or imbalanced sex hormones. Testing for each of these items helps a clinician effectively hone in on the roadblock to her client’s complete recovery.

Ross recommends “good-mood foods” such as animal proteins; healthy fats (omega-3s and appropriate saturated fats); vegetables, especially the magical dark, leafy greens; “good-mood carbs” – fruits, veggies, legumes and grains, which help achieve the healthy acid/alkaline pH balance essential to good health. Some common-sense recommendations include eating regularly and enough, as well as considering your genetic heritage as a key to understanding what foods your body will function best eating. Also, eating organic and range-fed meat and dairy products as often as possible will help keep a body free of harmful toxins.

Conversely, the “bad-mood foods” are just about everywhere in the typical American diet. Topping the list are refined sugars and white-flour starches. The chemical effects of these two – often in combination with each other – are particularly hazardous to our bodies. Both have been stripped of any original nutrients and refined to cocaine-like potency, in terms of its effects on our neurotransmitters, which are kicked into overdrive and lead to the blood-sugar spike-and-crash cycle that sends us foraging for the next sugar or drug/alcohol fix. Also leading the bad-mood surge is wheat, along with rye, oats and barley. While not everyone is negatively affected by them, the gluten present in each can quietly wreak havoc in the form of digestive issues, depression and diabetes. Bad-mood fats include vegetable oils, such as corn, soy, canola, safflower, sunflower, peanut and sesame oils, to name a few. And we all know the dangers of trans fats – steer clear. Soy rounds out the list due to its hormone-disrupting properties. Some fake foods, such as artificial sweeteners, colors and chemical additives should be a no-brainer in terms of what to avoid, and yet they are regularly consumed on a consistent basis.

Taking a look at the whole person is truly necessary to root out all the factors contributing to his or her emotional and behavioral troubles. Working with complementary clinicians, including psychiatrists, acupuncturists and holistic nutritionists or health counselors, can ensure competent and complete care of our clients, and a potentially relapse-free future.

*Ross, Julia, The Mood Cure, 2002.

Mephedrone is a stimulant, a class of amphetamine. It comes in pill or powder form and can be swallowed, snorted or injected. Methylenedioxypyrovelrone (MDPV) is also a stimulant, and in addition to bath salt, it can go by the street names Blue Silk, Euphoria, Hurricane Charlie, Ivory Dove and numerous others. It can be taken orally, intravenously or in a vaporous form.

Bath salts first appeared in the United States in 2009, according to the U.S. Drug Enforcement Administration (DEA). The drugs mimic the effects of cocaine, LSD, Ecstasy and/or methamphetamine, although most experts say that comparisons to methamphetamine are the most accurate. Law enforcement agents in Mississippi said the problem grew last year in his rural area after a Mississippi law began restricting the sale of pseudoephedrine, a key ingredient in making methamphetamine. According to the DEA, users have reported impaired perception, reduced motor control, disorientation, extreme paranoia and violent episodes. The price can range from $40 to $140 a gram.

According to one estimate by the Minneapolis Star Tribune, bath salts have been confirmed or suspected in more than 15 deaths nationwide. The American Association of Poison Control Centers reported that calls to poison centers about exposures to bath salts skyrocketed from a total of 303 calls during 2010 to 4,720 calls in the first eight months of 2011. The drug appears most popular in the Southeast, with Louisiana experiencing the most poison control calls as a result of overdose, and Florida leading the nation in ER visits.

Recently, there has been a slew of legislative and regulatory activity aimed at curbing the use and abuse of bath salts, mostly at the state level. MDPV is not yet a DEA scheduled drug, but is banned in Louisiana and Florida. Two of the chemicals needed to manufacture MDPV have been banned in seven states. At least 33 states have taken steps to ban at least one of the chemicals needed to manufacture bath salts, but the products remain widely available on the Internet. The chemicals used to make bath salts can also be found in “plant foods” that are sold legally. Again, the name plant food is deceptive: Do not think of Miracle-Gro or something that you put on your lawn. Plant food is the name for another synthetic drug that is sold under a legal name.

As for federal activity, the Office of National Drug Control Policy has taken notice of the growing problem. In September, Gil Kerlikowske, Director of National Drug Control Policy, convened high-level representatives from the Departments of Justice; Health and Human Services; Homeland Security; Transportation; and Defense, as well as the Food and Drug Administration; the National Institute on Drug Abuse; the Centers for Disease Control and Prevention; the DEA; and the Substance Abuse and Mental Health Services Administration, to discuss the threat of synthetic stimulants on public health and safety.

On September 7, 2011, the DEA did take advantage of its emergency scheduling authority to ban three chemicals used in the manufacturing of mephedrone and MDPV, so that the drugs could be deemed illegal to buy or sell for 12 months while it is studied. It is, in all likeliness, the goal of the DEA to classify both as a Schedule 1 narcotic. On Captiol Hill, Sen. Charles Schumer, D-N.Y., has drafted a bill that would add the chemicals to the list of federally controlled substances. The bill, S. 409, is entitled “The Combating Dangerous Synthetic Stimulants Act of 2011.” It has bi-partisan support from 19 co-sponsors.

Bath salts are of particular interest to the military, due in large part to an incident that occurred in April. Army medic David Stewart murdered his wife and then took his own life, following a high-speed chase on Interstate 5 in Washington State. Toxicology reports revealed bath salts in both of their blood. After the murder-suicide, the couple’s five-year-old son was found dead in their home, the cause of death being suffocation. Navy Surgeon General Vice Adm. Adam Robinson wrote on his blog about the legal consequences and health dangers of synthetic drug use. “Consumption of any of these products meets the criteria for drug abuse and is prohibited,” he said.

The drug has caused enough problems to merit an appearance in the CDC’s “Morbidity and Mortality Weekly Report,” first doing so on May 18, 2011. The report focused on a spike in ER admissions due to bath salt use and exposure. According to the CDC’s data, close to 70 percent of those admitted had a history of substance abuse, and almost 50 percent had a history of mental illness. Some experts believe that the 70 percent is indicative of the large number of addicts who are constantly searching for a newer, better high.

Despite all of the recent activity surrounding bath salts, very little is known about the drug. It has not been thoroughly researched, and its effects are unpredictable. Different batches of the drug can vary widely, in terms of chemical composition, price and potency. As regulations banning its sale continue to pile up, the next step in fighting the drug will almost certainly have to be research, in order to make prevention and treatment strategies more effective.

It was the president! Holding his hand over the headset, the ensign at the nursing station turned white. We all gathered around to see what would happen. President Nixon was calling. The sailor turned to his superior officer urgently: “The President is asking to talk to Senator Talmadge. What do I tell him, sir?”

The captain answered with the coolness and calm of any crusader fighting the disease of alcoholism in all its high-class or low-down permutations. “You tell him our patients don’t receive phone calls.”

“Aye, aye sir!” smiled the ensign, reassured that captain Pursch could stick by his guns and said what he meant and meant what he said. He’d take the flack. He’d be strong enough to tell the nation’s chief executive, “No.”

And when the first lady, Betty Ford, came to treatment, it was the same way. Patients were isolated and removed from all their outside stimuli so they had a chance to enter the therapeutic milieu and fall into the loving embrace of AA. They had all semblance of outside ego removed to find a more essential self than the managing, controlling, manipulating and scared-to-death-using addict they had entered treatment as. Betty had to go out to Long Beach to that big meeting on 7^th Street just like all the other patients. She had to make her bed, get along with three (count ’em) three total stranger roommates, and if she didn’t like it, she could speak up in group. There were no special considerations for her status and privilege. We told her, “Alcoholism is an equal-opportunity destroyer.”

This was long before cell phones and texting. The outside world was left at the door. No phone calls, television, only AA literature for reading and limited visiting confined to family groups and outings. As outside stimuli were removed, the patient could fall apart and reconstitute without the drug of busyness that had supported their habits. They were free to be and free to become.

Most of us seasoned professionals refer to that era as “the good old days,” or as my esteemed colleague, Jerry McDonald, for many years, business development specialist for the Betty Ford Center calls them, “the Camelot of treatment.” Having worked in the treatment field since 1968, I’ve had opportunity to observe the erosion of treatment principles giving way to wooing patients and insurance dollars. It is quite rare to find a facility that does not cater to client demands over treatment principles.

My career as an addiction counselor began with developing the first five Phoenix House programs in New York City as part of Mayor John Lindsay’s Addiction Services Agency. These programs were run by recovering addicts who had come from the Synanon model where harsh confrontation was employed each evening in groups which were known as “the game.” Our “residents”, as they were called, quaked in their boots before groups, sometimes dropping “slips” on each other. This meant that if one resident had a beef with another, he’d “drop a slip”, letting staff know he wanted to be assigned to the same group with his named fellow resident because he had something he wanted to bring up with that person. He was ripe for confrontation. These groups went on late into the night, sometimes carried into marathons, which could last a whole weekend. No considerations were given to patient wishes, outside schedules or interests, or any petty, personal preferences. The residents worked all day in their job assignments, and were investigated and confronted in groups at night. Psychological comforting and ego support was a rare commodity, usually only doled out after a person had broken down into some form of confession or insight into their own manipulative processes. Expression of anger was encouraged, but respect for each person’s individual struggle and privacy was required. Each knew “how hard it is” to crack through their own denial systems. These were street heroin addicts. They were people who truly didn’t want to go back out there again.

By initially being denied what they wanted, whether it was a date with a girl, extra food helpings or more time for showering, these residents came up against their own spoiled and demanding natures. They got to see what Harry Tiebout named “the king-baby syndrome,” where the addict rules his family like a wailing baby in a high chair banging his rattle, shouting out orders. They learned in treatment how to endure initial deprivation so they could find out how really strong and enduring they could be. They learned about resilience and waiting and putting up with the intolerable and finding it bearable. They weren’t allowed to complain to family and friends outside the milieu. They were required to jump in fully, invest, take risks, express rage and stay put. They found the fear and deep sadness under the rage and allowed themselves to feel real and vulnerable. They grew. They grew up.

After that Navy hospital experience, I worked developing early alcoholism treatment programs throughout Southern California and eventually opened the nation’s first eating disorders unit in San Pedro, the port of Los Angeles. I carried along the principles I learned in Phoenix House and at the Navy with the First Lady. When I had opportunities to deliver lectures at the Betty Ford Center or to sit on podiums at conferences with her, Betty and I carried those same messages of tough love and laughter.

My first HOPE Units operated on these principles. We took overeaters and anorexics who acted out their frustrations with massive quantities or starvation portions of food, and put them in more challenging situations than they experienced in the outside world. They were all put on the same moderate, low-carbohydrate food plan and encouraged to express their feelings when they would “take it to group.” Again, they were “forced” to enter the treatment milieu, perform necessary job functions on the unit and face themselves and their relationships with food without the distractions of communication technology.

They attended lectures and family groups three nights each week where they encountered other patients further along in aftercare, where they learned about diet saboteurs in their environments and had to face and admit to the destruction the disease had caused to themselves and their loved ones. In psychodrama sessions, they practiced new behaviors, whether it was restaurant ordering, refusing dinner invitations graciously, applying for jobs proudly, fending off taunting and insults, accepting flirtations without returning to bingeing or learning how to relax into what Buddhists prescribe as “an ordinary day.” Their minds were sharpened and focused on issues of recovery. They learned how to stay in the present moment and become fully awake and conscious as discussion of the world out there was kept at a minimum. We all knew they’d be in that soup soon enough.

Most of these patients both loved and hated their treatment experiences. Many still call me three decades later with fond memories of the deprivations they endured, the angry outbursts they made and were accepted for, the fun assignments they grudgingly accepted from the treatment team, whether they were “silence,” “flirting,” “making amends,” “playing tough” or “asking for help.”

Some even joke, “I may have another binge left in me, but I don’t know if I have another recovery.” They feel like survivors and cherish their victory over their own self-destructive tendencies, and aren’t sure if, put to the task again, they could do as well. They really don’t want to go back and redo.

Today things look a lot different from the indoctrinations learned by Betty and others. Early on, I noticed that hospitals were not geared for this kind of treatment. Medical treatment was insistent on making the patient comfortable. Best patients are prone and passive. There were no guidelines or protocols for helping the patient weather discomfort. Medicine was and is still focused on better living through chemistry, and drugs are almost required on most treatment units. I came upon this crisis quite early. Also, nutrition protocols were not geared toward helping patients look at their particular individual lifestyles to find a manner and method and timing of eating that fit for them. I moved my units four different times because we were not allowed to delay breakfast for a later hour of the morning.

Staff convenience always took precedence over patient care. This was especially true for doctors who insisted on patients adapting to their outside busy schedules. As much as we asked the patients to respect their attendance at group therapy as seriously as if it was surgery, we found that doctors insisted on interrupting groups to pull their patients out for their highly reimbursed 15-minute consultations. I developed a policy of keeping patients out of group if their doctor was scheduled to visit that afternoon. Doctors did not like hearing the flak when disgruntled patients complained that they wanted to be in group, not sitting on their bed, waiting for a doctor. They even asked their doctors to conform to treatment protocols.

Then entered “Damaged Care”: the professionals were offered less and less opportunity to develop treatment plans. Extremely capable psychiatrists with special training in addiction were spending their days on the phone arguing with insurance clerks to authorize yet one more day of treatment. We had to verify acuity of care, so instead of truthfully helping the patient see that she ate over an inability to deal with even small realities, like broken fingernails or untied shoelaces, we had to find deeper traumas and delve into past circumstances rather than focus with the patient on present and future functioning. Worst of all, we were required to give the patient drugs, and to disclose more and more chart entries to employers and other outside professionals. It felt awfully sticky and not in the best interest of patients.

At this same time, there was a mad scramble for the insurance dollar, and competing treatment centers all vied to woo the patient. I can’t tell you how many times I was asked to allow our patients to have television in their rooms because, “the hospital down the street allows it.” I guess these administrators never raised teenagers who pleaded, “Johnny’s mom lets him…” And then they wanted freewheeling phone calling, visiting on demand, more carbohydrates in the diet plan and whatever it would take to please the patients and fill the beds. I will never forget one administrator telling me that we had many referral sources visiting the units throughout the day, so “could you please keep your ladies from yelling in group. It doesn’t advertise well.”

I eventually closed our units and focused more on Hope House, a holistic cross between Phoenix House and a Buddhist monastery with family therapy and behavior modification thrown in. It was a noble plan, one I’d still love to develop, but I did not have the business sense to make it fly. I now confine my involvement to individual consultations, retreats and seminars, teleconferences and training others to fight the battles while I write books and travel. All that has offered a great deal of contentment and satisfaction.

But then Betty Ford passed away. And, it made me reflect again on the good old days. As I stared at her flower-draped coffin and meditated on our grand and missed opportunities and her continuing legacy, I mourned deeply for the promises we found back in the middle of the last century and how much treatment has changed. There was a promise to greatly affect the whole tide of spoiled greed and narcissism enveloping the American landscape. The truth and authenticity we found in those early treatment centers, the courage and humility ignited in Betty Ford, came to fruition because of simple people trying to get honest with themselves and others. Privilege, ego and self-aggrandizement were not in the equation. Betty didn’t need them. Recovery and authenticity and honest discipline were most important.

Now, regrettably, Betty Ford and her ideals are no longer leading the way. Now, every patient spends treatment on phone and text. Outside stimuli are allowed and even highlighted in some cases. All focus on the wrong phone call.

The recovering comedian, Russell Brand, recently wrote a touching and impactful letter about the tragic loss of Amy Winehouse. He emphasized the tragic way we pass our addicts in the night, looking through them, not seeing them, and ultimately letting them slip through our fingers. When that happens, we can do nothing but wait. We wait until we get “the call.”

Many of us in treatment centers have allowed our addicts to slip through our fingers. We’ve let them “do time,” focused more on getting out than on “going in.” We’ve taken the easy road of allowing and placating, wooing and rewarding the very behaviors that have kept addiction alive and well. In the interest of being the loved and adored parent figure rather than the respected enforcer who has to say “no,” we’ll rock no boats, make no waves, continue the status quo and discharge the patient when the insurance runs out. Then we wait to get that call.

Sound easy? Absolutely. There is, however, one very important key element missing in all of this and that is action. The law of attraction doesn’t actually state that we have to take action; we just have to think about what we want and the universe will manifest that right back to us. For an addict or alcoholic, this is definitely the softer and easier way to gain sobriety. You don’t have to go to meetings, get a sponsor, read the big book or, for that matter, do any work to become clean and sober. You just think, believe and feel sobriety, and it will just happen. This is similar to the instant gratification mentality of an addict or alcoholic, that if you just have this drink or take this drug, you will suddenly feel better. This was intriguing, but I could not fathom how just thinking something would bring it into existence. However, physicists or law of attraction proponents might disagree.

I became interested in the Law of Attraction and how it might help addicts and alcoholics while working at a famous Malibu treatment center. I noticed after the clients viewed the movie, there was a complete silence in the room; the energy of the environment completely shifted. There was this transformation that permeated the rehab and suddenly clients who had been depressed, unmotivated and detached suddenly became hopeful, inspired and eager to soak up everything their treatment program was providing them. How could this be?

In recovery, the belief is that there must be a complete makeover of your life if sobriety is to be achieved. The law of attraction did not provide these tools. However, what it did offer was the idea that if you live on purpose and if you have meaning in your life, you are aligning yourself with what the universe wants for you. Whether you call it God, universe, source, higher power, Buddha or Jesus, everyone has a calling and a greater purpose. This idea of purpose and meaning in one’s life seemed to be the catalyst that was energizing these clients. It was at this point, I was determined to find a way to integrate the law of attraction into these recovering alcoholics and addicts’ lives, and that is where the Law of Sobriety was incubated.

Addicts and alcoholics in many ways are looking for a transcendent experience when they use and drink to transport them out of the intolerable reality in which they are living. They are already on a spiritual quest of sorts by using mind-altering substances to gain relief and to escape their very existence. Some call it emptiness, a soul sickness, a bottomless pit…but whatever it is, addicts and alcoholics are missing out on any sort of joy and will go to great lengths to find it.

Alcohol and drugs may provide them with a temporary reprieve, but it is certainly not the long-term answer to the pain and emptiness most addicts and alcoholics feel on a daily basis. Happiness is something we seek outside of us, but joy is already within us. If an individual is living a life of purpose and meaningfulness, then joy is possible. Once addicts align their energy with their calling and take certain action steps to get there, then the universe allows them access to a deeper form of satisfaction that is unavailable with the self-destructive behavior that comes from alcoholism and drug addiction. This is when addicts connect with a universal life force, and it is here that space opens up creating a life that is filled with harmony and peace.

This is the serenity for which addicts so desperately search, but always look for in the wrong places. All along, the answers could be found inside their being. They just did not know how to access it because the drugs and alcohol got in the way.

The action steps in creating a joyful life for the addict consists of living on purpose and with intention; living a life of value and authenticity; learning to live in appreciation and compassion for oneself and others; living a life of right action and the power to choose the right path; living with profound awareness and mindfulness; and learning to let go of resistance and attachments.

Living on purpose and with intention is learning to live with focus and clarity, with self-determination and an unstoppable appetite to be the best you can be. It is about getting out of a negative mindset, turning up the positive frequency and going after what it is you most desire – in this case, your sobriety. Just because you have never been able to stop drinking or using before, does not mean you can’t attract the willingness to stop right now.

The first step is stop calling yourself an addict or alcoholic. Although this goes against the 12-step mentality – and I am a huge proponent of the 12 steps – I do believe by continuing to label yourself that, you continue to manifest the baggage that goes along with that marker. I see nothing wrong with calling yourself a recovering alcoholic or recovering addict because that is exactly what you are becoming and is precisely what you want to manifest. This is a positive and optimistic way to address yourself, and at the same time is a deserving title of the work you have put into your sobriety.

I had a client who was continuing to relapse. We explored what it was she was doing in her recovery program to maintain sobriety and instead, we discovered more of what she wasn’t doing. She shared that when the 12-step meetings were over, she would usually bolt out the door, not getting to know any of the other members. Instead, she continued to get together with an old boyfriend who was still drinking and spending time with her siblings who also were not sober. By surrounding herself with active alcoholics and drug addicts, she was taking on their negative vibrations and instead of thinking about recovery, she was caught in the vortex of the using and drinking mentality. When she started to align herself with people who were sober, whether through meetings or other social settings, she began to generate the positive energy required to attract sobriety versus relapsing. When she let go of the environments that were triggers for her, she automatically shifted her negative energy, and the path away from addiction virtually opened up.

From the time you were born, you learned most of your values from your parents and your early environment. As you move into adolescence, you become free to choose your own values and decide if the values you accepted as a child resonate with who you are becoming. As you attempt to gain your own identity, you might rebel against those earlier belief systems. This is when early experimentation with drugs and alcohol may enter the picture, due to peer pressure or the need to self-medicate the pain of living in a dysfunctional family or the growing pains of the teen years. You begin to steer away from your core values because, not only are you not sure what they are, but the external world begins to influence you. You begin to lose sight of your inner being and emit negative energy, only attracting more unhappiness into your life because you are going against your true self. The Law of Sobriety reminds us that to get out any current negativity in your life, you must align yourself with your authentic nature. When you do this, you generate the positive energy required to attract individuals and a life that matches your true vibration.

A distraught mother of a teenager was tearing her hair out because she felt she was losing control of her daughter. Her daughter, once a cheerleader and an A student was suddenly hanging around a questionable group of friends, isolating or acting out when she was home with her family and her grades dropped drastically. She went around telling her friends, the therapist, the school counselor and anyone who would listen how worried she was of her daughter’s changes.

Although seeking advice is important, this mother went to everyone and anyone who would listen, telling them every negative thing she could think of about her daughter. Not once during this time did she talk about the positive attributes her daughter still embodied, such as being sensitive, creative, loving children and being a supportive big sister. Of course, her daughter was in need of direction in pulling up her grades and possibly finding more healthy peers, but she also needed to be encouraged to participate in areas that represented her authentic self, such as her creativity and sensitivity to others. Once her mother enrolled her in an art class and signed her up to volunteer at the local YMCA, her daughter’s positive energy field went off the radar. Once she moved passed her anxiety and fears about her daughter and redirected her into a positive direction, the universe aligned itself to opportunities and events that allowed her daughter to thrive.

Often, when addicts and alcoholics are newly sober, they are dealing with a backlog of shame and guilt. The shame can be from childhood abuse or neglect, lying and stealing in their addiction, an abusive relationship or self-induced shame that is a direct result of their self-destructive behaviors during their addictions.

One woman found herself deeply entrenched in shame and guilt by her promiscuous behavior during her drinking days. By not letting go of the pain she had caused herself, her children and her husband, she continued to relapse. Once she started to concentrate on the positive changes she was making in her relationships with her husband and children, the relapses subsided. She was able to move on by not obsessing over her destructive behavior, but rather by focusing on the newly found intimacy she and her husband were experiencing and how present she had become for her children during sobriety. The Law of Sobriety allowed her to live that spark of divine energy between her children and her husband. By embracing the Law of Sobriety, she was allowing a deep and profound compassion and forgiveness for herself to flow into her being. Her energy of forgiveness and compassion attracted more appreciation and gratitude for the future. By walking through the pain of her past, she was able to transform and gain clarity as to what her new purpose was as a mother and wife. The past was no longer who she was now or who she was becoming, but rather a lesson to be learned.

Heading on the right path is definitely a choice similar to choosing to pick up a drink or smoking a hit of crack. Being conscious is always a choice to bring your awareness and actions to that which is truly who you are and how you are meant to be living. It is a work in progress to continually ask yourself, what is my consciousness creating for me? You decide whether to you align yourself with a negative or a positive choice. As a recovering addict or alcoholic, there is no room for victimhood. You have no one to blame when you know going to the Christmas party will be a trigger and you go anyway. If your time is spent in abusive relationships, causing you to drink or use because of the pain, that is the choice you have made – no one else has made that decision for you. The Law of Sobriety looks at that action, and if it doesn’t resonate personal dignity and self-respect, then you have stepped out of the force of right action. You will only bring more negative relationships back into your life, which is always a slippery slope in sobriety. Often, addicts and alcoholics are suffering from low self-esteem. It is important to realize that until you raise the set point of your sense of worth, it is often much better to make the decision to stay away from new relationships; your perception of a good or bad partner can be way off.

When the founders of the 12-step program discovered “One Day at a Time”, were they not talking about living a mindful and conscious life? Often addicts and alcoholics, who have had a history of trauma, find it quite difficult to stay in the present moment. They disassociate, numb their pain with other addictions or live in the “doing” rather than the “being.” If they are not in the “doing”, then they are most likely projecting into the future or the past and waiting for some momentary, fleeting event to arrive that will take them out of their despair. The moment goes by like a flash, and the sadness that brought them there returns once again.

When this happens, they become irritable, disappointment, frustrated and sometimes go into victim mode. Often clients will ask, “Well, I am sober now, why am I so miserable?” They are discontent because they have dismissed the now and are creating a consciousness of not having something, and they don’t even know what that something is. What I am talking about is this chronic emptiness that only the present moment or a higher power can fulfill. There is nothing to fret about in a moment of time, because in that moment there is no past or future.

Addicts and alcoholics often need more stimulation because of the anhedonia they feel when they are newly sober. The same goes with their using when they build up a tolerance and need more drugs or alcohol to get the same effect. The Law of Sobriety says that when you feel you are lacking, you will only vibrate at that lower frequency. It is through vibrating in a state of abundance for what is at any given moment that you will receive everything sobriety has to offer. When you are in acceptance, you are willing to do whatever it takes to achieve your deepest desire and it is then that you will take the necessary steps to maintain sobriety. Once sobriety is achieved, joy and happiness are no longer blocked, and longing for external gratification will elude you.

The final step of the Law of Sobriety is learning to stop resisting your truth and letting go of outcomes of the way you think your life should be. When you release your perceptions of the way you believe things are supposed to be, you are freeing yourself from negative emotions. When you refuse to let go, you are allowing more of the same back into your life. For example, if you continue believing the next time you use or drink will be different, you are not accepting that part of your true self. You are refusing to integrate that part of you which cannot control your alcohol or drug use, but instead embracing a false self that no longer espouses your authentic nature. The universe only recognizes your true self. As the saying goes, insanity is doing the same thing over and over again and expecting different results. Knowing the reality of your disease is not a jail sentence, but rather a universal truth. Shifting from wanting things to be a particular way to being honest with yourself allows you to take actions that are constructive and energizing, and it is only then you can attract all that you desire in life.

They are emotional anesthetics; they numb pain. The first question — always — is not “Why the addiction?” but “Why the pain?” The answer, ever the same, is scrawled with crude eloquence on the wall of my patient Anna’s room at the Portland Hotel in the heart of Vancouver’s Downtown Eastside: “Any place I went to, I wasn’t wanted. And that bites large.”

The Downtown Eastside is considered to be Canada’s drug capital, with an addict population of 3,000 to 5,000 individuals. I am staff physician at the Portland, a non-profit, harm-reduction facility where most of the clients are addicted to cocaine, to alcohol, to opiates such as heroin, or to tranquilizers — or to any combination of these things. Many also suffer from mental illness.

Like Anna, a 32-year-old poet, many are HIV positive or have full-blown AIDS. The methadone I prescribe for their opiate dependence does little for the emotional anguish compressed in every heartbeat of these driven souls. Methadone staves off the torment of opiate withdrawal, but, unlike heroin, it does not create a “high” for regular users. The essence of that high was best expressed by a 27-year-old sex-trade worker: “The first time I did heroin,” she said, “it felt like a warm, soft hug.” In a phrase, she summed up the psychological and chemical cravings that make some people vulnerable to substance dependence.

No drug is, in itself, addictive. Only about 8 percent to 15 percent of people who try, say alcohol or marijuana, go on to addictive use. What makes them vulnerable? Neither physiological predispositions nor individual moral failures explain drug addictions. Chemical and emotional vulnerability are the products of life experience, according to current brain research and developmental psychology.

Most human-brain growth occurs following birth; physical and emotional interactions determine much of our brain development. Each brain’s circuitry and chemistry reflects individual life experiences as much as inherited tendencies.

For any drug to work in the brain, the nerve cells have to have receptors — sites where the drug can bind. We have opiate receptors because our brain has natural opiate-like substances, called endorphins, chemicals that participate in many functions, including the regulation of pain and mood. Similarly, tranquilizers of the benzodiazepine class, such as Valium, exert their effect at the brain’s natural benzodiazepine receptors.

Infant rats that get less grooming from their mothers have fewer natural benzo receptors in the part of the brain that controls anxiety. Brains of infant monkeys separated from their mothers for only a few days are measurably deficient in the key neurochemical dopamine. It is the same with human beings.

Endorphins are released in the infant’s brain when there are warm, non-stressed, calm interactions with the parenting figures. Endorphins, in turn, promote the growth of receptors and nerve cells, and the discharge of other important brain chemicals. The fewer endorphin-enhancing experiences in infancy and early childhood, the greater the need for external sources. Hence, the greater vulnerability to addictions.

Distinguishing skid row addicts is the extreme degree of stress they had to endure early in life. Almost all women now inhabiting Canada’s addiction capital suffered sexual assaults in childhood, as did many of the males. Childhood memories of serial abandonment or severe physical and psychological abuse are common. The histories of my Portland patients tell of pain upon pain.

Carl, a 36-year-old native, was banished from one foster home after another, had dishwashing liquid poured down his throat for using foul language at age 5, and was tied to a chair in a dark room to control his hyperactivity. When angry at himself — as he was recently, for using cocaine — he gouges his foot with a knife as punishment. His facial expression was that of a terrorized urchin who had just broken some family law and feared draconian retribution. I reassured him I wasn’t his foster parent, and that he didn’t owe it to me not to screw up.

But what of families where there was not abuse, but love, where parents did their best to provide their children with a secure, nurturing home? One also sees addictions arising in such families. The unseen factor here is the stress the parents themselves lived under, even if they did not recognize it. That stress could come from relationship problems, or from outside circumstances such as economic pressure or political disruption. The most frequent source of hidden stress is the parents’ own childhood histories that saddled them with emotional baggage they had never become conscious of. What we are not aware of in ourselves, we pass on to our children.

Stressed, anxious or depressed parents have great difficulty initiating enough of those emotionally rewarding, endorphin-liberating interactions with their children. Later in life such children may experience a hit of heroin as the “warm, soft hug” my patient described: What they didn’t get enough of before, they can now inject.

Feeling alone, believing there has never been anyone with whom to share their deepest emotions, is universal among drug addicts. That is what Anna had lamented on her wall. No matter how much love a parent has, the child does not experience being wanted unless he or she is made absolutely safe to express exactly how unhappy, or angry, or hate-filled he or she may at times feel. The sense of unconditional love, of being fully accepted even when most ornery, is what no addict ever experienced in childhood — often not because the parents did not have it to give, simply because they did not know how to transmit it to the child.

Addicts rarely make the connection between troubled childhood experiences and self-harming habits. They blame themselves — and that is the greatest wound of all: being cut off from their natural self-compassion. “I was hit a lot,” 40-year-old Wayne says, “but I asked for it. Then I made some stupid decisions.” And would he hit a child, no matter how much that child “asked for it”? Would he blame that child for “stupid decisions”? Wayne looks away. “I don’t want to talk about that crap,” says this tough man, who has worked on oil rigs and construction sites and served 15 years in jail for robbery.

He looks away and wipes tears from his eyes.

When it comes to drinking or taking drugs, it is not that simple. Denial is a very cunning and baffling phenomenon that distorts and skews reality. Simply put, denial does not allow the person to really see the problem. The person may really believe there is no problem, or if there is evidence, they excuse it away by means of rationalizing, justifying, blaming, defocusing or just minimizing the whole situation.

This, in turn, becomes a problem for family members or loved ones of the addicted person. They can slip into their own denial by minimizing, covering up and enabling the individual. Or they may try to control the addict’s behavior by nagging, scolding and threatening them. The more they engage in this effort, the more the dependent person seems to rebel and tries to prove everything is fine. Why is this? It is because the dependent person has developed a relationship with alcohol/drugs. Two components of this relationship are trust and love. They like the way it makes them feel when they use or drink and it works every time, so they begin to trust it. Eventually that feeling of “liking it” can turn into “loving it”, and the substance becomes the object of their affection.

When you try to tell dependent people that their interactions with alcohol/drugs are harmful or causing a problem, they use denial in order to protect that relationship – often denying being in denial! The reason for that is because if they could see or understand the reality of the situation, they would have to do something about it. But if the mind can create a state of denial, the relationship can continue. Much like the person you may know who is involved with someone who is not healthy for them – what happens when you try to warn them about this unhealthy person? If the feelings are strong enough, they will deny your reasoning and will just think that you are trying to break them up.

If the denial remains intact and the relationship with the substance continues, main life areas can become negatively impacted. Problems at work or school can increase, as can money troubles, legal problems, conflicts and fights with family members; sometimes physical and mental damages can occur. The addicted person will have difficulty in seeing how these problems are related to his or her usage. If family members protect the addict from the pain of consequences as a result of the addiction, then the denial grows stronger. Many times addicts and alcoholics blame other people or circumstances. Rarely do they blame their woes on the object of their affection: alcohol or drugs.

What can be done about this problem of dependence and the denial that goes with it? The first thing is to understand that the solution is a process that does not happen overnight. Awareness and education are key instruments to start the journey of recovery. Understanding denial and how it works can aid in working through it toward reality. Learning about the disease concept of alcoholism can equip a person with the information needed in order to deal with a person who suffers from it.

Acquiring information from the Internet or talking to professionals or other individuals who have found a solution can be very beneficial. Support groups can be a vital part of the recovery process. What I hear most frequently is, “I really thought I was the only one going through something like this”. It is the silence, lack of knowledge and unwillingness to take action that allows the illness of addiction/alcoholism to flourish. Long-term recovery (which means not using or drinking for a significant length of time or being negatively impacted by someone else’s using) is a very real and a very possible result for family members and addicts.

When you live with chronic pain, it can be very frustrating when you aren’t getting the pain relief you want. I know that when I experience a pain flare-up, my first reaction is I want it to stop — now! Because many pain medications were developed for acute pain conditions, problems can arise when you use them for chronic conditions. When people are in pain, they often have a need for instant gratification (I want it, and I want it now). While acute pain medication can give them the relief they are looking for, it can also lead them down the path to the quick fix.

Being able to tell the difference between appropriate and effective use of pain medication and the beginning of abuse is sometimes difficult to determine. There are progressive stages of problems that include medication dependency, medication abuse, pseudo-addiction and, finally, addiction. The confusion and uncertainty of this progression can be a challenge for both you and your treatment provider.

Some people living with chronic pain are afraid to take their narcotic (opiates, etc.) medication because they have heard horror stories of people getting hooked on pain pills. This leads to a decision to under-medicate, to live in pain and suffer. If you happen to be in recovery for alcoholism or any other drug addiction, the problem is even worse. If you under-medicate, it could trigger a relapse when you try to manage your pain. Or you could overmedicate, which may lead to a rapid tolerance buildup and, finally, reactivation of your addiction.

Understanding Addiction

In this section, I will use the terms addictive disorders and addiction to discuss what the DSM-IV-TR™ (Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition, Text Revision) classifies as substance use disorders and is also referred to as chemical dependency, or psychological dependence.

I define an addictive disorder as: A collection of symptoms (i.e., a syndrome) that is caused by a pathological response to the ingestion of mood-altering substances and has 10 major characteristics that I have listed below.

Common Addictive Disorder Symptoms

1. Euphoria
2. Craving
3. Tolerance
4. Loss of Control
5. Withdrawal
6. Inability to Abstain
7. Addiction-Centered Lifestyle
8. Addictive Lifestyle Losses
9. Continued Use Despite Problems
10. Substance-Induced Organic Mental Disorders

Differentiating Between Addiction and Pseudo-Addiction

No one who is in treatment for chronic pain starts out with the goal of becoming addicted to their pain medication; nevertheless it happens at least 10 percent of the time. If someone has a family member with addiction or mental health conditions, or if they have a personal history of addiction or mental health problems, they are at high risk for racing through the progression of addiction.

People at risk for addiction react differently from the very first experience of taking pain medication. With ongoing exposure, they experience the seeking/reaching stage, at which time they begin to doctor shop. There are many questions to be addressed when treating someone who has chronic pain and coexisting substance use disorders. The three most important ones I talk about at my Addiction-Free Pain Management® trainings are these:

1.    Are we managing pain but fueling the addiction?
2.    Are we treating the addiction but sabotaging the pain management?
3.    Is it addiction or pseudo-addiction?

The term pseudo-addiction is fairly new to the addiction treatment field, but has been used in pain management for quite a while now. The point to remember is that even though pseudo-addiction looks like addiction, it is actually caused by an undertreated or mistreated chronic pain condition. However, the treatment plan for pseudo-addiction and addiction is identical. The major danger of pseudoaddiction is that if it is not adequately addressed, it can turn into full-blown addiction — sometimes quickly, sometimes slowly.

I have worked with many patients over the years who were labeled “prescription drug addicts”, but who were actually suffering with pseudo-addiction. A client, Sharon, was an example of how damaging a misdiagnosis can be. Sharon was in her early forties and came from a fairly normal and religious upbringing. She had never used alcohol or any other drugs, including nicotine, and, up until her chronic pain condition, had never used psychoactive prescription medications either.

Sharon began having infrequent migraine headaches and went to her general practitioner who gave her Vicodin, which worked for a time. As the Vicodin began losing its effectiveness, her doctor prescribed OxyContin, but she also used Vicodin for breakthrough pain. Sharon later found out that she would have been better off using migraine-specific medication from the start.

Although barbiturates and opioids are sometimes considered effective for short-term migraine relief, many doctors are now recommending against prescribing this type of medication for long-term use. The risks for potential dependence and abuse are too high, and there is a real danger of developing medication overuse headaches (sometimes called pain rebound or transformed migraines).

Because transformed migraines are difficult to diagnose, many people are not being treated appropriately. Treatment is further complicated by the chronic nature of migraine headaches. People with transformed migraines may overuse pain relievers, both prescription and over-the-counter, on a daily basis with or without having a headache. This puts them at risk for building a tolerance to the drugs. Additionally, taking too many pain relievers containing caffeine can also lead to rebound headaches.
As Sharon’s migraines became more frequent, she began taking more and more medication to get any relief. As the dose increased, her family and then her doctor became concerned that she had become addicted to the OxyContin and Vicodin. Sharon’s doctor told her he couldn’t help her anymore unless she went into an addiction treatment program.

Sharon’s family found an addiction treatment program that said they treated pain and prescription drug addiction, which is when her nightmare began. While undergoing detoxification from the OxyContin and Vicodin, Sharon was forced to stand up in front of groups and identify herself as a drug addict. She was not even allowed to say she was a prescription drug addict, which was humiliating for this very conservative woman.

After Sharon stopped all of her medications, the migraines kept coming back. To add insult to injury, when she asked for help with the migraines, the program staff said she was “drug seeking” and all she needed to do was “turn it over” and work the steps. Even though I’m a big advocate of a 12-Step approach for people with addictive disorders, it can be dangerous to label or advise chronic pain patients in this manner.

Sharon was discharged from this program with a letter to her doctor stating she was an addict and should not be given opiates anymore. She became depressed and attempted suicide. Sharon’s family finally sent Sharon to the pain clinic where I was consulting. I met with her several times, assessed her case and discovered that her diagnosis was not addiction, but pseudo-addiction.

Addressing Pseudo-Addiction

As mentioned above, pseudo-addiction describes patient behaviors that may occur when pain is under-treated. People with unrelieved pain may become focused on obtaining medications, clock watch or otherwise seem to be inappropriately drug-seeking. Even such behaviors as illicit drug use and deception can occur in the person’s efforts to obtain relief. Pseudo-addiction can be distinguished from true addiction in that the behaviors will resolve once the pain is effectively treated.

• Pseudo-addiction looks a lot like addiction
• Patients may appear to be “drug-seeking”
• Patients may need frequent early refills
• Behaviors are caused by under-treatment
• Problematic behaviors resolve when the patient’s pain is adequately treated

As this was the case for Sharon, the pain clinic prescribed migraine-specific medications, since opiates are contra-indicated for ongoing migraine treatment. There are seven triptans (Imitrex, Maxalt, Zomig, Amerge, Axert, Frova and Relpax) that were developed for and FDA approved as migraine abortive (management) medications. These medications work to stop the migrainous process in the brain and stop an attack with its associated symptoms.

Sharon responded well to Maxalt, but she also was put on a preventative medication called Migranal. Ergotamine medications, such as DHE and Migranal, are used as vasoconstrictors for migraine prevention and sometimes mixed with caffeine. They are also FDA approved for migraine treatment, as is Midrin (a combination of acetaminophen, dichloralphenazone, and isometheptene). Because of these two medications, her migraines were now effectively managed.

Sharon was also prescribed an SSRI antidepressant as we began to implement a cognitive behavioral therapy treatment plan for the depression and pain-focused psychotherapy for pain management. Today Sharon is experiencing a great quality of life, but still has nightmares about her time at the treatment program. Getting back to my original three questions: Sharon’s general practitioner risked fueling an addiction, and the addiction treatment program definitely sabotaged her pain management.
It is important to work with a multidisciplinary team and get assessments to determine if you are experiencing addiction or pseudo-addiction when you have chronic pain and coexisting addictive disorders. Sharon experienced pseudo-addiction — not addiction as everyone thought. Once she was placed on an appropriate migraine medication management plan, along with cognitive behavioral therapy to address the psychological pain symptoms, Sharon’s quality of life improved dramatically and her migraine episodes lessened both in frequency and intensity.

Understanding and Addressing Chronic Pain and Addiction

Pain is the reason many people start using potentially addictive substances. Jeanie is an excellent example of what can happen when a pain condition is not managed appropriately and treatment depends only on medication.

We know that regular use of psychoactive medication, plus a genetic or environmental susceptibility can lead from pain relief to increased tolerance. Both of Jeanie’s parents were alcoholics, and she was in an abusive marriage. She developed a chronic pain condition and was prescribed opiate medication to treat her pain. Jeanie soon discovered that her pain medication also helped her escape from painful childhood memories and the trauma of an abusive relationship.

Eventually Jeanie’s medication no longer helped with the physical pain symptoms or her emotional distress, so she started taking much more than was prescribed. She eventually went to several different doctors to get the amount she believed she needed, but her pain continued to get worse. In fact, Jeanie’s medication started to increase or amplify her pain signals — this is called the pain-rebound effect.

Physical pain is the reason many people like Jeanie start using potentially addictive substances. Chronic medication use, plus genetic or environmental susceptibility can lead to increased tolerance as a result of searching for pain relief. Eventually, the addictive substance no longer manages the pain symptoms. Not only will it increase or amplify the pain signals, it can also cause an extreme sensitivity to pain, a condition called hyperalgesia. The end result is severe biopsychosocial pain and problems.

Jeanie did become addicted to her medication, which increased her pain and created problems in every area of her life: physically, psychologically and socially (biopsychosocial). Because Jeanie was experiencing both chronic pain and substance dependency problems, she needed a specialized, concurrent treatment plan for both conditions.

An effective synergistic treatment protocol for Jeanie’s chronic pain and substance addiction condition included the three following components:

• Appropriate Medication Management
• Core Clinical Processes
• Nonpharmacological Interventions

Appropriate Medication Management: Jeanie’s medication management plan included collaborating with an addiction medicine practitioner/specialist. This person made sure that her medication was needed, was recovery-friendly and was the right type, as well as the appropriate quantity and frequency, so it would not trigger relapse.
Core Clinical Processes: Jeanie also needed to deal with her irrational thinking, uncomfortable emotions and self-defeating urges and behaviors, as well as the isolation tendencies that can develop with co-existing pain and addiction. I used a cognitive behavioral therapy approach using the eight clinical processes in the Addiction-Free Pain Management® Workbook as a starting point, which worked well since her health care provider was experienced in the concurrent treatment of chronic pain and substance dependency.

Nonpharmacological (Holistic) Interventions: I supported Jeanie to search out alternative non-pharmacological/holistic pain management modalities such as hydrotherapy, physical therapy, acupuncture, chiropractic, prayer, meditation, hypnosis, self-hypnosis and so on. I also suggested she read Managing Pain Before It Manages You (2001), a book by Margaret Caudill, which was very helpful for her. Jeanie also used both a 12-Step group and a chronic pain support group, which greatly enhanced her recovery.

Knowledge Is Power

Developing an effective treatment plan also required that Jeanie understand which stage of the addiction process she was in. It was also important for her to know how much damage had been done by her inappropriate use of pain medication. As Jeanie progressed, she learned how to identify which stage of the developmental recovery process she was in, and then implemented appropriate treatment interventions.

As you can see, the road to recovery can be a difficult one for someone with both chronic pain and a coexisting addictive disorder. However, most of the chronic pain research I have reviewed over the past two decades has been very clear about treatment outcomes. The best prognosis is when people are proactive in their own treatment and recovery process. One way they can do this is to learn as much about their pain and effective pain management as they can.

As the title of this section stated, knowledge is power. Once people understand what is really going on with their body and mind, they can take action to effectively manage their pain. In fact, the most important shift they can make is to stop believing that pain is their enemy and accept it as their friend.

Jeanie looked at me like I was crazy when I suggested that she make peace with her pain and that pain is her friend; she had a very difficult time accepting that. Even so, it is true. It was very important for Jeanie to stop seeing herself a victim of her pain condition and empower herself by developing a pain management and chemical dependency recovery program. Fortunately, Jeanie adhered to her treatment plan and remains clean and sober, as well as effectively managing her chronic pain.

The Relapse Intervention Plan

While walking the tightrope of pain management and addiction, it’s important to make sure patients have a safety net in case they fall. I call this the relapse intervention plan, which must be developed with the patient before moving into the three-part treatment process explained above.
This is their insurance policy. People don’t buy auto insurance because they plan to crash into other vehicles. They have it just in case. The relapse intervention plan should be a mandatory component of a treatment plan for anyone with chronic pain and coexisting disorders; especially addiction.

In its simplest form, developing a relapse intervention plan consists of writing out a specific plan for the following three questions.

1. What is your healthcare provider supposed to do if you relapse, stop coming to sessions or fail to honor your treatment or medication management contract?
2. What are you going to do to get back in recovery if you start inappropriately using pain medication (including alcohol) or other drugs or other ineffective pain management so that you can stop using before you hit bottom?
3. Who are three significant others who have an investment in your recovery? What is each of them supposed to do if relapse occurs? Make sure you have their day and night phone numbers accessible and they have a copy of this plan.

The premise here is simple: Those who fail to plan, plan to fail. I believe that positive treatment outcomes are possible if people have a three-part, multidisciplinary treatment plan, are committed to being active participants in their treatment process, and they develop a relapse intervention insurance policy — especially when walking the tightrope of pain management and addiction.

Terence Gorski, a pioneer in relapse prevention, defines a trigger event as “any internal or external occurrence that activates a craving (obsession, compulsion, physical craving, and drug-seeking behavior)” (Gorski, 1988). In breaking down this definition, internal occurrences are thoughts or feelings, and external occurrences involve the five senses: sight, sound, smell, taste and touch. In order for something to be a trigger, such an event must be connected in some way to the person’s using. The event must also happen just before, or simultaneous to, the actual use (Gorski, 1988). The most important thing to know about what makes a trigger a trigger is its connection to the use.

A simple way of explaining this is by relating it to classical (or Pavlovian) conditioning. Ivan Pavlov was a Russian scientist who won the Nobel Peace Prize in 1904 for his research in digestive processes. While studying the relationship between salivation and digestive processes in dogs, he would show a dog meat powder and measure the resulting salivation level of the dog; they did this repeatedly. One day, Dr. Pavlov noticed that when he walked into the lab, the dog started to salivate even before showing it the meat powder. There appeared to be some connection made for the dog between Dr. Pavlov and the meat powder, which caused it to salivate. To study this phenomenon, he added a third variable (a bell) and rang it just prior to showing the dog meat powder and measured the resulting salivation level. He did this repeatedly: bell -> meat powder -> salivation, bell -> meat powder -> salivation. He eventually found that he could ring the bell, not present the meat powder, and the dog would still salivate. Thus, there was a connection made for the dog between the bell and the meat powder that prompted the salivation (PageWise, 2002). For our purposes, the bell is the trigger for the dog’s drug of choice – meat powder – which caused the dog to salivate for, or crave, the meat powder. The challenge for the addicted is to identify the bells (triggers) that cause them to salivate (crave) their drug of choice. This will allow them to avoid or manage such triggers until the time in their recovery comes to start recovering from them.

Recovering from Triggers

According to Gorski, there are three phases in the trigger recovery process: avoidance, gradual re-introduction and extinction. Phase I is to “eliminate as many of them as you can, for a limited period of time, until stable” (Gorski, 1988). As stated previously, in very early sobriety, you do not go to bars or other using places; you avoid people who use and drink; and you avoid any other triggers you identify.

“The second phase is a gradual reintroduction of the triggers so that the person can learn how to cope with them” (Gorski, 1988). This does not mean to gradually re-introduce the addict into the crack house or their favorite watering hole, but there are some trigger situations that you should be able to eventually participate in. As stated earlier, alcohol permeates our society and you would have to live a very sheltered life in order to avoid it over the long term. Therefore, in order to lead any kind of a normal life, gradual re-introduction to some trigger situations is necessary. This re-introduction process is best done with the addict’s sponsor or with a therapist or group if he or she has one. The following is an example of this process in my own sobriety.

When I was about 90 days sober and still involved in the aftercare portion of my treatment program, we were invited to the wedding of my wife’s cousin in Chandler, Arizona. I thought: “I’d really like to go!” However, I had learned from past experience that decisions I made on my own in relation to my sobriety were typically bad ones. So I decided to leave it completely up to my group and put it out to them. The consensus was that since I was still working a very strong sobriety program, going to daily meetings and going with my supportive wife, I could probably stay sober if I created a sobriety plan. The group then proceeded to help me put this plan together.

First, they suggested that I carry a Big Book (Alcoholics Anonymous) onto the plane. The thinking was that since flying on an airplane was a trigger for me to drink, it would be difficult to order a drink while holding a Big Book in my hand. The book has an embossed cover so nobody would know what it was and, if they recognized it, they probably have one and I might meet someone in the program.

The next suggestion was to go to 12-Step meetings each day I was in Arizona. They had me call the downtown Los Angeles Central Office of Alcoholics Anonymous (AA) to get the number of the central office in Chandler, Arizona. I was to get a meeting scheduled for each day I was there and, if possible, schedule a meeting for the time of the reception so if I got into trouble, I could simply leave the reception and go to a meeting. In fact, this actually happened – here’s a funny little story:

At the reception, I found myself talking to my wife’s uncle next to the wet bar at his home. Suddenly, someone plopped down a bottle of my favorite whiskey onto the bar right in front of me. After recovering from my slight panic, I excused myself and informed my wife that I was going to a meeting. Fortunately, and I suggest this highly, I got the address and directions from AA’s Central Office, which made it easy for me to go.

I went to the meeting and took a 90-day chip in celebration of my sobriety time. After the meeting, I ended up going back to the reception where everyone was having a great time dancing. This really looked fun to me, but I had never danced sober before. I always had to have at least a few drinks in me first because I was not a very good dancer and cared too much about what other people thought of me. When I had a few drinks, I felt like I danced like John Travolta. So, I concocted a plan to wait for a fast song that I liked, run and slide onto the dance floor while playing air guitar and, hopefully, begin dancing. So a Van Halen song came on and I was off and running. Little did I know that just after I left for my meeting, the bride and groom arrived, walked across the portable dance floor, and everyone followed tradition by throwing rice at them. You can imagine what happened next. As I attempted to slide onto the dance floor, my feet hit the rice and came right out from under me. I hit the floor, followed by two of my wife’s female cousins (one of them the bride!) who I managed to take down with me – one of them right onto my lap. I rose to my feet with my beet-red face and, as I looked around the dance floor, I could see my wife’s family’s reaction, which I perceived as, “There he goes, he’s drunk again” And I was probably the only sober person there.

Anyway, other elements of my sobriety plan consisted of calling my sponsor each day I was there, reading the Big Book for a half-hour each evening and not going anywhere alone. Upon returning, my group and I processed what worked, and what additional program tools I might have used so I could use them the next time I might have to expose myself to triggers.

Through this process of gradual re-introduction, I was able to participate in increasingly more activities in my recovery to the point that now I can do almost anything without being triggered. This is due to the third phase of the recovery process called the “extinction process” (Gorski, 1988). As mentioned earlier, triggers become extinguished when repeated exposure to them is connected with not using, rather than using.

In closing, I believe that we as addiction professionals have a responsibility to prepare our patients for living in a society where alcohol and drug use is prominent. Now that we know how triggers are created and, thanks to the brilliant work of our colleague, Terence Gorski, we also know about the trigger recovery process so we can enhance our patients’ chances at long-term recovery.

References:
Gorski, Terence T. (Speaker). (1988). Cocaine craving and relapse: A comparison between alcohol and cocaine (Cassette Recording Number 17 – 0157).
Independence, Mo: Herald House/Independent Press.

Pagewise, Inc. (2002). This study in classical conditioning is one of the most renown for its incredible results. Learn about Pav-dogs! [Online]. Available Internet:

http://ks.essortment.com/pavlovdogs_oif.htm.

Tyler, Bob. (2005) Enough Already: A Guide to Recovery from Alcohol and Drug Addiction. Long Beach, Ca: Humble House Publishing.

But today’s New Age Addict is no longer a member of this subset of criminal types, living outside the realm of society. Today’s addict is your mother, or your sister’s kid, the guy in the next cubicle, the neighborhood postman or the checkout girl at Wal-Mart. They don’t score their drugs on the street. They procure them from New Age Drug Pushers. This pusher isn’t a pimp or the creep that hangs out in schoolyards. The New Age Addict gets his fix from the pharmaceutical companies that manufacture his medication, from the pharmacies that distribute these drugs, the doctors that prescribe the painkillers, and the Internet that delivers it conveniently to your doorstep. The Culture of Addiction has been transformed. The paradigm has shifted from use by a marginal societal sub-culture of old-school drug addicts to an uber-culture of mainstream American Soccer Moms and high-functioning professionals.

The medicine cabinet in the master bath comes up empty. She pushes aside prescription bottles for sleep, acid reflux, anxiety and an assortment of minor aches and pains. The cap on her husband’s Rogaine is loose. As she dislodges bromides and Benzos from their rightful place on the shelf, several bottles tumble into the sink below, shattering.

Her eyes dart to the clock on the nightstand. Ten minutes. Her purse lays open on the bed as she crosses to it, her hand now digging deep into its abundant gathering of make-up accessories and miscellanea. But the object of the young woman’s inquiry still evades her as she dumps the full contents of the small sack across the comforter. Still nothing.

The steady tattoo of the clock’s digital pulse is dialed up. Time. Time.

Her mother turns, a broad smile plastered across her face. But the smile is frozen and empty, overshadowed by a glassy, distant stare in her eyes, a stare that seems to look right through her child, not seeing her at all.

— excerpted from The New Age Addict