Addiction Recovery: Define Terms and End Conflation

People with addiction are at risk of premature death. Defining terms and making sure we know what we’re talking about is an imperative.

Illogic and misinformation can kill people with addiction.

Do no harm. 

Discussion of addiction is plagued with conflation, i.e. thinking things are the same when they are different. Discussion is also compromised by confusing correlation with causation, i.e. assuming that if things happen at the same time, one caused the other.

Definition of conflationFollowing is a list of terms and basic definitions used in this guide. Terms are in narrative order, not in alphabetical order. Terms explicitly not used are listed at the foot of this post.

Addiction is the generally-used, non-clinical term for substance use disorder.

A substance use disorder is a medical condition involving the organ of the brain. The primary symptom of the disorder is persistence in behavior despite negative consequences. (For brevity and the general audience intended for this guide, “addiction” is the term used most often, but interchangeably with “substance use disorder.”)

Dependence is conflated with addiction. The difference between addiction and dependence can mean life or death. Dependence exists when a substance is needed to function and physical withdrawal symptoms will result without the substance. Humans are dependent upon the substances of water and air to function and experience physical symptoms without them. People who cease taking antidepressants can experience withdrawal symptoms. People who cease taking blood pressure medication can experience withdrawal symptoms. People who do not persist in negative consequences, but experience withdrawal symptoms when ceasing substances, are not addicted to those substances.

Similarly, babies born to mothers dependent on substances – whether opioids, antidepressants, nicotine or others – may experience withdrawal symptoms, but are not born addicted to those substances. Babies are developmentally incapable of persisting in behavior despite harmful consequences.

Making it through withdrawal from substance dependence is not a treatment nor a cure for addiction.

The neuroscience of addiction suggest that through compromising the brain’s basal ganglia, extended amygdala, and prefrontal cortex, addiction under-sensitizes people to pleasure, over-sensitizes them to pain, automates use of the substance to feel, not necessarily good, but normal, weakens decision-making abilities, magnifies emotional highs and lows and incapacitates the ability to regulate them, interferes with recognizing cause-and-effect relationships, and confounds the ability to make a plan and follow through with it.

Co-occurring disorders are medical – including physical illnesses and substance use disorders – and mental illnesses, that may occur simultaneously in an individual. The medical condition of substance use disorder may co-occur with mental illnesses such as anxiety, mood, and or personality disorders, and/or physical illnesses.

Determining which symptoms go with which disorder, how to manage symptoms, and treat the conditions, is an on-going conundrum. Which are due to brain malfunctions, cognitive distortions, perhaps unregulated emotions?

Further, the definition of addiction is conflated with the symptoms of the illness. Although some people with substance use disorder may engage in behaviors that are perceived by society to be immoral, criminal, or illogical, behavior related to addiction results from brain functioning, not from moral functioning, and persists despite negative consequences. Ergo, moral or religious instruction would not be a treatment for a brain disorder. Counseling might help a person with substance use disorder manage symptoms of the illness, but would not directly treat the brain for a brain condition.

Evidence-based treatment is what research reports works for most people, most of the time, better than other treatments, and better than no treatment. Specifically, that means the treatment is supported by numerous, peer-reviewed scientific experiments with rigorous methods that include control groups, randomization of subjects to experimental conditions, and bias-free samples, with statistically significant results. Some treatments that are evidence-based to work for groups may not be helpful to a particular individual, however. It is imperative that individuals engage their treatment teams to continually monitor their condition and progress.

Anecdotal data is an individual’s personal experience. Research data – the evidence resulting from research experiments – is conflated with “anecdotal data.” Data from a sample size of one does not provide sufficient information from which a generalization can be made about a group or population. Principles believed to account for outcomes from inspirational individual stories, practitioner wisdom, or theories based on logic, cannot be safely applied to others without first subjecting those principles to rigorous research.

Medical care is the first line of treatment recommended by the medical professionals and researchers who authored Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health. Medications approved by the FDA for treating substance use disorder are listed here. Currently, no licensed treatments are available for stimulant use disorder.

Terms not used in this guide:

Addict and alcoholic. The complexity of human identities defies the limits of definition by trait or condition. This guide, as does the new edition of the Associated Press style manual, uses the terms “person with addiction” and “person with alcoholism.”

Substance abuse. “Abuse” means to wrongly maltreat. “Self-abuse” is a pejorative term for masturbation. “Sexual abuse” and “child abuse” are heinous acts. Use of the term “substance abuse” conflates addiction with sexual acts and violation, misrepresents the medical illness of addiction, perpetuates stigma, and needs to be jettisoned from any reference to addiction.

Disease. Although carefully defined by NIDA, the term “disease” used to explain addiction can be unhelpfully misunderstood by laypeople. Scientists and researchers may decide other terms may be more accurate. Terms used in this guide include “disorder,” “condition,” and “illness.”

Dopamine. The neurotransmitter dopamine is conflated with “pleasure.” But dopaminergic pathways involve reward-related cognitions that include incentive salience (desire or “wanting”), pleasure (“liking”), and positive reinforcement, i.e. a desired event occurs. Most laypeople are not qualified to discuss addiction at this level. Addiction is more complicated than simply stating, “It’s all about dopamine.”

Enablingcodependency, “hit bottom,” and “tough love.” People with medical illnesses that can result in premature death need care, support, and treatment, especially when their symptoms are severe and life-threatening. For further reading:

Trading one addiction for another. Use of substances, for any reason, prescribed or not, where behavior does not persist despite negative consequences is not addiction.

. . . . .

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health, November, 2016, Page 4-1

“Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
– National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), 2014

“People suffering from addictions are not morally weak; they suffer a disease that has compromised something that the rest of us take for granted: the ability to exert will and follow through with it.”
Nora Volkow, M.D., Director of NIDA, 2015

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
Alan Marlatt, Ph.D., 2004

“Love, evidence & respect.”
– Maia Szalavitz’s answer via Twitter to the question, “What fights addiction?”, 2016

“It’s my life. Don’t you forget.”
– “Talk, Talk,” The Music Machine

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. However, when treatment is scarce or denied, people with addiction must take treatment matters into their own hands. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Addiction Recovery: Realities and Possibilities

The goal of an evidence-based treatment plan for the medical illness of addiction would be to assist individuals in living healthy, functional lives, in connection with others, such that substance use does not result in negative consequences for themselves, others, or society.

A glass half fullHowever, society’s primary measure of recovery from addiction – and its measure of merit to receive continued treatment for addiction – is negative urine drug screens for illicit and non-prescribed substances. Secondarily, society measures addiction recovery progress in terms of reduced contact with 1) the criminal justice system, 2) emergency health care services, 3) child protective services, and 4) social services programs.

Achievement of legal negative urine drug screens requires abstaining from illicit and non-prescribed substances. (The illogic and injustice of citizens with a medical illness being required to prove they are asymptomatic of that illness to receive treatment for it is beyond the scope of this post.)

After medical care for the medical condition of addiction, this is what research suggests helps most people, most of the time, better than other ways, and better than nothing, to increase the likelihood of abstaining from substances:

Maintain a state of stability: physically, emotionally, cognitively, relationally, spatially, geographically, financially. Practice on-going awareness and, if any factors become unstable, adjust until they’re stable again.

Regulate emotions. Without judging feelings, adjust the “volume” on the intensity to a stable state while providing self-acceptance, self-reassurance, and self-soothing.

Sort thoughts, without judging them, into the categories of “helpful” and “unhelpful.” Focus on the “helpful” thoughts. Recognize and accept that opposing thoughts – for example, “I want to use” AND “I don’t want to use” – may both be true.

Consult your inner wisdom, your “Wise Mind.” Having given your attention to the truth of what you’re feeling, thinking, and sensing, what is your inner wisdom’s guidance?

Manage attention. Become aware and stay aware. Monitor your needs and wants. If you can become aware, in the moment, of what you are giving your attention to, what you are feeling, what you are thinking, and what physical sensations you are experiencing – and do so without judgment and without alarm – you can use this information to help yourself decide what would be most helpful for you to say or do next – or not say or not do.

Monitor environmental cues. Limit or eliminate exposure to items, individuals, locations, and situations that may produce a longing to return to use.

In addition:

Over time, identify the purpose and meaning of substances and substance use in your life.

Over time – acknowledging that no one source, perhaps even combinations of sources, might ever equal the complete experience substances offered – identify possible practices, activities, and conditions that might serve in place of substances.

Do research, consult with others, and discover evidence-based, therapeutic modalities recommended for any mental illness you might have. Help yourself with any trauma you may have experienced. Do self-paced therapeutic exercises, or receive counseling for that particular disorder. Examples: cognitive behavior therapy for depression; dialectical behavior therapy for bipolar disorder.

Attune to yourself, learn your preferences, and attach to yourself.

Attune to others to increase the possibility of connection, closeness, attachment, and bonding.

. . . . .

Here is a shortened version of this post as a printable handout. (.pdf opens in a new tab.)

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. However, when treatment is scarce or denied, people with addiction must take treatment matters into their own hands. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

When Replacing Substances, Good Enough Will Have to Do

When the rung on the bottom shelf of my refrigerator broke, I bought a roll of white duct tape and, as carefully as I could, cut short lengths of duct tape to hold it back in place. I will not win a repair design contest. It’s not “good as new.” The shelf can no longer hold heavy items. But I treasure sandwiches for lunch. Plastic jars of yellow mustard and light mayo reside there reliably. Good enough will do.

Good enough will do

Similarly, if I need to abstain from problematic substances, if I can figure out what purposes substances served for me – what needs and wants they filled for me – I might be able to find replacements for them. Since addiction is a brain condition requiring medical care, this effort is unlikely to have a direct, immediate effect on my brain’s functioning. Figuring out the needs and wants that substances assisted me with may not cover the full scope of, or explanation for, my initial or repeated substance use prior to developing addiction. But understanding what substances did for me may help me with my self-care efforts.

Since substances can magnify experience beyond what the brain naturally experiences, I’m unlikely to find identical, snap-in substitutes. Given the interrelated neurocircuitry of love and addiction, this reality creates a deep loss to grieve. While no analogy is perfect, the idea of finding good-enough, duct tape-like replacements might be helpful.

What did substances do for me? Answering that question feels overwhelming! But analyzing my last return to use may help get me started. Let’s break it down.

First, here’s the usual information to gather when seeking self-understanding:

What was I giving my attention to, what was I feeling, what was I thinking, and what physical sensations did I experience?

Many people cannot remember what they were feeling and thinking just prior to use, so that data is usually missing.

Let’s try different time frames – 24 hours, 1 week, 1 month.

Answering these questions might be useful:

1. ATTENTION:  What was getting – perhaps splitting – my attention prior to my last return to use? 24 hours before? 1 week before? 1 month before?

2. FEELINGS: What was I feeling prior to my last return to use? 24 hours before? 1 week before? 1 month before?

3. THOUGHTS: What was I thinking prior to my last return to use? 24 hours before? 1 week before? 1 month before?

4. PHYSICAL SENSATIONS:  What physical sensations was I experiencing prior to my last return to use? 24 hours before? 1 week before? 1 month before?

5. AWARENESS OF NEEDS AND WANTS THEN: Having become aware of 1) what I was giving my attention to, 2) what I was feeling, 3) what I was thinking, and 4) what physical sensations I was experiencing, what needs and wants did I seem to have prior to my last return to use? 24 hours before? 1 week before? 1 month before?

6. SELF-KINDNESS AND SELF-CARE: AWARENESS OF NEEDS AND WANTS NOW: What needs and wants do I have now? What might I do to kindly and supportively help myself meet these needs and fulfill these wants?

7. What insights have I had as a result of doing this exercise?

8. In what ways can I continue to customize and individualize my treatment plan to help get my needs and wants met? Some good-enough, duct tape-like replacements, perhaps, may decrease the likelihood of my return to use.

The idea is this: If I can become aware, in the moment, that I have unmet needs and wants, strong feelings, intense thoughts, or physical sensations similar to those I experienced prior to past returns to use, I might be able to help myself with them without substances.

. . . . .

Here is a version of this post in the form of a printable handout. (.pdf opens in a new tab.)

If different substances served different needs, printing out multiple copies of the handout and answering the questions for one substance at a time might be helpful.

Last revised 12/7/17

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

About Abstaining

Rightly or wrongly, society wants people with substance use disorders to abstain.

Many factors interfere with abstaining from substances.

Art by Jesi Pace-BerkeleyAddiction is a brain condition, not a moral or criminal one. What an individual is supposed to do with his or her brain to abstain right here, right now, is unknowable. For most individuals and scientists alike, the brain is a black box of mystery.

Substances serve purposes. When the substances are absent, the purposes aren’t served. This absence is experienced as stress, distress, and suffering.

Humans need social connection to survive and thrive. Due to the brain’s automaticity with regard to environmental cues, abstaining usually requires cutting oneself off from anyone or anything that may trigger a return to use. Isolation is experienced as pain.

The brain has evolved to withdraw the being it inhabits from pain. Abstinence requires fighting the brain’s automatic function to relieve pain by returning to substances.

Negative consequences don’t work. Punishing an individual with negative consequences for returning to use – or an individual on his or her own trying to fear negative consequences to prevent a return to use – doesn’t work. That’s because the primary symptom of addiction is the brain’s drive to return to use despite negative consequences.

Addiction is a chronic illness. Who wants to chronically treat a chronic illness? Most people with chronic illnesses drop out of treatment, even quit filling their prescriptions for meds, and their symptoms return.

Humans naturally, normally, wondrously seek pleasure and avoid pain. Denying oneself substances can feel like self-inhumanity.

In sum, for people with acute substance use disorders, abstaining is nearly impossible, especially long-term. Relapse rates can be are high, similar to those for other chronic conditions. People with substance use disorders can be considered to be at risk for 5 years.

(Note that I didn’t even mention physical withdrawal from substance dependence. A mere annoyance compared to the anguish of the other factors.)

What tools can be helpful to people who need or want to abstain?

  • Stop putting energy into things that, according to research, don’t work for most people, most of the time, better than other treatments, better than no treatment.
  • Other than some medications for some substance use disorders, shrug your shoulders and accept that what directly results in abstinence is unknown. Indirect, imperfect means are all we know to try.
  • Use periods of successful abstinence to attempt to identify, personally and individually, what did work for you.
  • Jettison this punishing mindset: “I must make myself not use.” Research suggests that direct attempts are very unlikely to work, even help.
  • Adopt this generous mindset: “I can help myself not use.” Research offers a bounty of possibilities for practices that can, however indirectly and imperfectly, help people not use.
  • Learn additional methods and practices that help people abstain, experimentand find the ones that work for you.

Art by Jesi Pace-Berkeley

This post is part of a series on evidence-informed self-care for addiction. Self-care is NOT an evidence-based treatment for addiction. The introduction and table of contents are here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.

Tapering In Replacements for Substances

Ideally, a person with substance use disorder, as part of an evidence-informed treatment plan, would be assisted with tapering in a combination of activities and practices that are approximations of what substances did for a person, while tapering out substances that have become problematic. The intention would be to seek and maintain a steady state of well-being.

Wonders can come together at one time

That process would take several steps:

  1. Identify the purpose and meaning of the use of substances for the individual, whether frequently or infrequently, whether alone or with others.
  2. Identify one’s individual strengths, interests, and preferences.
  3. Over time – acknowledging that no one source, perhaps even combinations of sources, might ever equal the complete experience substances offered – identify possible practices, activities, and conditions that might serve as replacements, however approximately, for substances and their use.
  4. Use knowledge of one’s strengths and preferences to experiment with a variety of practices, activities and conditions that might by helpful to the individual. Become aware of feelings, thoughts, physical sensations, and attention and use them as feedback to monitor stability.
  5. Adjust. Keep, and possibly expand, what helps with steadiness. Jettison what doesn’t. Maintain a list of future possibilities to try.

Unfortunately, most people with substance use disorder are mandated to abstinence. What the substances did is no longer being done. This can throw – even slam – people into instability.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt, Ph.D., 2004

As a person with substance use disorder, then, as quickly and efficiently as I can, I need to try to figure out a few things that substances did for me, note a couple of my strengths, try to become aware of some preferences, then create a short list of things that might possibly serve in the place of substances for me individually, and then use my strengths to try to make those things happen.

Purposes of Substances and Substance Use

What do I think substances, or use of substances, did for me?

_____ Enjoyment, pleasure, reward
_____ Relief from emotional pain
_____ Relief from physical pain
_____ Relief from existential despair, i.e. a helpless, hopeless feeling from not knowing if your life has meaning or if anything matters
_____ Relief from strong feeling states: anger, frustration, sorrow, agitation
_____ Relief from worry
_____ Relief from social anxiety
_____ Relief from anxiety
_____ Relief from depression
_____ Relief from racing or disturbing thoughts
_____ Relief from bad memories: trauma, neglect, abuse, witnessing violations against others
_____ Relief from grief and loss
_____ Relief from boredom
_____ Release from isolation and loneliness
_____ Sense of absence or escape
_____ Sense of protection
_____ Sense of belonging, being a part of, fitting in, or being accepted
_____ Sense of love and comfort

Now, let me rank order the top three, or more if I choose, by placing a “1” by the most important, a “2” by the next most important, etc.

What were the top three purposes served by substances and/or substance use for me?

1) ______________________
2) ______________________
3) ______________________

What insights did I gain from thinking about the purposes and meanings of substance use for me?

Strengths

People with substance use disorder often don’t feel very good, or feel very good about themselves. Instead of thinking of myself as either good or bad, let me suspend judgment for a moment. Let take a look at myself with objectivity and kindness.

If I see some traits I don’t like, for now, I simply shift my attention away from those thoughts, and look again for my strengths.

If I’m having trouble, I can remember the praise others have given me and name the strengths they saw in me.

If I’m doing this exercise right now, even if I don’t really want to, that’s the strength of discernment. I  might be penalized by an authority or someone I care about if I don’t take a look at these things. Discernment includes the strength of telling the difference between what’s helpful and what’s not helpful.

What other strengths do I have?

_____ Courage

_____ Creativity

_____ Kindness

_____ Generosity

_____ Problem-solving

_____ Determination

_____ Perseverance

_____ Honesty

_____ Fairness

_____ Leadership

_____ Love of learning

_____ Forgiveness

_____ Humor

_____ Teamwork

_____ Appreciation of beauty

_____ Empathy

_____ Awareness

From this list, what do I think are my top three strengths?

1) ______________________
2) ______________________
3) ______________________

Interests and Preferences

What are three activities that I like doing, or used to like doing?

1) ______________________
2) ______________________
3) ______________________

Where are three places I like to be with people, or don’t mind being with people?

1) ______________________
2) ______________________
3) ______________________

Preferences for Self-Care

According to research, medications are the first line of treatment for longings, urges, and cravings that accompany deprivation from substances in people with substance use disorder. Research is inconclusive about self-care behaviors (SCBs) that can assist with abstinence. Some studies suggest that the practices listed below may be helpful.

Which of the following activities, practices, or situations might be potentially helpful to me?

_____ Exercise
_____ Sleep hygiene: managing sleep time/wake time/length of sleep
_____ Managing caffeine intake and timing
_____ Managing nicotine intake and timing
_____ Managing quality, quantity, and timing of meals and snacks
_____ Engaging in focused breathing or breathing patterns
_____ Engaging the senses: see, hear, taste, touch, smell, motion
_____ Engaging in focused activities, such as cooking using a recipe, doing a repair, drawing, painting or coloring, playing a game, working a puzzle, journaling
_____ Engaging in social gatherings and activities that foster social connection

Which of these self-care behaviors is already a strength for me?

____________________

Which one, with a very small change, might move it up to tie with my top self-care behavior?

____________________

What would that small change be?

____________________

Replacement Preferences

I identified the top three purposes served by substances and/or substance use for me. They are normal, human, understandable needs. What might, even minimally, for me, serve in their places?

Enjoyment, pleasure, reward ____________________
Relief from emotional pain ____________________
Relief from physical pain ____________________
Relief from existential despair ____________________
Relief from strong feeling states ____________________
Relief from worry ____________________
Relief from social anxiety ____________________
Relief from anxiety ____________________
Relief from depression ____________________
Relief from racing or disturbing thoughts ____________________
Relief from bad memories ____________________
Relief from grief and loss ____________________
Relief from boredom ____________________
Release from isolation and loneliness ____________________
Sense of absence or escape ____________________
Sense of protection ____________________
Sense of belonging ____________________
Sense of love and comfort ____________________

What’s Next?

Based on what I’ve discovered about what substances and substance use did for me, what my strengths and preferences are, and what research suggests is helpful to people who are trying to abstain, with the intention of increasing my sense of stability and well-being, what are three things I might be able try this week in place of substances?

1) ______________________
2) ______________________
3) ______________________

What is the smallest, gentlest step I might be able to take on my own to help myself try to make one of these things possible?

A small step I might be able to take is:

____________________________________________
____________________________________________
____________________________________________.

“It’s my life. Don’t you forget.”
– “Talk, Talk,” The Music Machine

This post is part of a series.

The table of contents for the series is here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.