Cravings to drink and what to do about them...

           I'm often asked by my patients how they can manage the cravings to drink that often surface during early recovery. While it's not necessarily easy to handle the cravings and urges that some alcoholics in recovery experience, understanding where cravings come from and how they can be managed goes a long way toward getting rid of them.
          Relapse is a bomb. It is a package of signs and symptoms that only leads to one outcome…an explosive return to the use of alcohol or other drugs. This bomb can be ignited by any number of factors in a recovering person’s life, but stress is a key cause in the lead up to a full-blown relapse.
          Central to the idea that stress is a critical component of relapse is the notion that “hunger memory” cravings for alcohol or other drugs can cause stress. If stress can be defined as anything about change, then there is perhaps no more powerful change agent in the world of the average recovering alcoholic or drug addict than cravings for the drug. Driven by what feels like an internal piston pumping away, the recovering person can sometimes feel the power of desire welling up inside for a return to drug or alcohol use. The thought of using evolves into an obsession about the drug. These unwanted thoughts create pressure inside and a person finds it hard to turn their attention away from the drug. Sometimes a person gets flooded with euphoric memories of the drug and the using lifestyle that went along with it.
           Often these cravings experiences are not just psychological. There can be physical effects of the craving that present as tremors, sweating, upset stomach, diarrhea, or headaches. For opiate addicts this can turn into uncontrollable itching of the arms, legs, and torso, and flu-like symptoms. The alcoholic can literally develop a strong thirst. The amphetamine addict can feel the physical rush of excitement grow as the opportunity to use the drug increases.
          The way out of this cravings canyon of thoughts, emotions and feelings is to carefully apply craving skills on a day-by-day, or sometimes, on a minute-by-minute basis.
          The first, and generally most effective, way to curb cravings is to decide – way in advance – that craving thoughts will not be indulged when they arise. The person makes up their mind, before the cravings are present, what they will do when the cravings occur. They have a routine and they pledge to themselves they will stick with it. 
          The second most effective technique to use are mindful breathing exercises. Surprisingly, careful deep breathing seems to restore balance within the body and the mind by allowing for increased oxygen to those areas of the brain that are working hardest to cope with the craving. Mindful breathing (paying attention to each inhale and exhale) also sets up a rhythmic pattern that can be used for meditation. Its been shown in numerous scientific studies that meditation helps to focus attention on the present moment of experience and helps people push away unwanted thoughts such as those a person  experiences when there are cravings.
          Surprisingly, using these two techniques for curbing cravings can be effective ways to reduce stress and manage the day-to-day changes that everyone’s life presents. To accept the fact that these cravings are normal and that they need to be managed with these techniques can go a long way toward producing the peace of mind that recovery offers. 

AA and "Stinking Thinking"

          The stinking thinking that goes along with the relapse process for people with alcohol or other drug dependency is the hallmark that signals there are problems that need to be faced but go unaddressed. There are five major ways this kind of warped, bent, or distorted thinking enters into a recovering person’s life that can quickly lead to a full-blown relapse.

         The return of denial is the number one tell-tale sign that there are problems with a person’s recovery. Whenever a person rejects the idea that they need to deal with a person, place, thing, or situation that may be causing them problems, they are entering into denial. To try to avoid problems is a natural human reaction to them. But, for the recovering person, such avoidance can spell disaster. To not deal with something causing concern is to develop or deepen the stress that a person experiences in life, and it is stress that can lead to relapse behaviors. The basic trouble with denial is that, over time, the problems are still there and have possibly even gained strength.

         A second area of concern for relapse thinking is corner cutting. A person can either chose to handle a problem with people, places, things, or situations head on, or try to avoid the problem by cutting corners to its solution. People with this mode of operation are those who will only go half way toward solving a problem. Instead of confronting someone with whom they have a growing problem, the person will become sarcastic or otherwise indirect in dealing with that person. They will go to some places that are dangerous – bars, parties, known drinking haunts – and not drink, but sit with a carbonated drink or juice and pretend that they are unaffected by the drinking going on around them. These people will keep that old shot glass or beer stein collection they started when they were drinking. And, they will intentionally get into situations where there are arguments and their resentment can flourish so they can drink the problem away. Instead of dealing with each of these problems directly, a corner-cutting person will try to get over or around them and take the easy way out.

         The third area of stinking thinking has to do with defiance. Sometimes people whose recovery is slipping find they cannot stand being told what to do. It raises the hackles on their back to be told that they are not right and that another way is the right way to go. They resist taking advice and rebel against authority. At the root of this defiance with immaturity. Self-centered immaturity puts people at the center of their own lives and allows them to crave the attention that they think they deserve for “being right.” They often form resentment and anger about situations that are unjustified, and they blame others for their problems. This idea of defying everyone in order to get their own way is a common trait of people in the throes of relapse.

         The defiance they feel is often tagged to grandiosity. Some people think they are immune to the ordinary laws of the universe that govern other mortals. They think of themselves as different, special, and deserving of out of the ordinary attention or consideration that is largely undeserved. Sometimes these folks rise to the level of contempt for other people and it interferes with their relationships in a markedly obvious way to everyone else but themselves. At the heart of this grandiosity is a paradox: Alcoholics and addicts can be grandiose while at the same time having a very strong sense of inferiority. They sometimes feel unworthy of the esteem others show them, so they artificially boost themselves up in order to feel that this esteem is justified.

         Lip service is another way that stinking thinking creeps into the lives of recovering people on their way to full-blown relapse. People sometime mouth insincere statements in order to tell people what they think others want to hear rather than the real deal. The person may be superficially compliant while, underneath the situation, they are doing whatever they can to undermine the other person. People at this level are pretenders and can sometimes be very good at what they do to make other people think they are engaged when they are actually very detached from the relationship.

         These five areas of stinking thinking cause a person to have a muddled way of approaching problem solving. This is a sign of relapse, not recovery. Clear thinkers are aware, honest, eager to learn, accept responsibility for their own recovery, and express humility in their daily lives. Avoiding this kind of negative thinking goes a long way toward improving the chances that a person can stay clean and sober. 

Alcoholism Relapse, Part 2

           Becoming involved with high-risk situations while in recovery from alcoholism is the number one cause of relapse (see “Alcoholism Relapse Part 1: High-Risk Situations”). While the task of avoiding them seems daunting at times, a recovering person can use a number of painless ways to manage high-risk situations.

1.     Like the real estate agent who knows that “location, location, location” are the three top requirements for a successful house sale, recovering people understand that “planning, planning, planning” are the top three ways to avoid the entrapment of a high-risk situation that can threaten recovery. Planning the schedule for the day ahead of time – who to see, where to go, how to get there, when to arrive and leave – is essential for managing day-to-day activities that can either support or threaten recovery. Many people find a written plan is the best because when the task is written down it has a sense of permanence and importance that must be honored.

2.     Writing down a list of high-risk situations and carrying it with you every day can go a long way toward helping to avoid them. Like planning, the written expression of a high-risk situation has to effect of subduing its importance and enhancing awareness of it. Sometimes a recovering person will share this list with a trusted friend who can help them monitor their involvement with the high-risk situation.

3.     Falling into a high-risk situation is sometimes unavoidable. When a person finds themselves in one of these situations, it is important to remove themselves from the situation as quickly as possible. Riding in a car with people who are drinking or using other drugs, being at a party when someone brings out the alcohol or drugs, or bumping into a person who was an old drug connection in a supermarket are all people and places that represent a high-risk for using. Every attempt must be made to quickly leave the situation and seek a safe haven. As awkward as this procedure may be, it will work only if a person does not try to convince themselves they are helpless or make excuses for being there.

4.     Not going to bars, parties, clubs, concerts or other venue where there is a likelihood alcohol will be served is a sure-fire solution to avoid being trapped in a high-risk situation. Painful at it may seem at the time to not go to these places one used to enjoy, the pain is much less than what using alcohol or other drugs will cause. Often, recovering people will go to these places with other people who are also in recovery to get support for remaining clean and sober during the event.

5.     Categorically refusing to be with people who are using alcohol or other drugs in your presence is also a way to avoid relapse. This is difficult for many people because they do not want to lose contact with old friends, but if those friends are using alcohol or other drugs it is usually just a matter of time before a recovering person just falls into line with them. Regrettably, choices usually have to be made among those people a person associates with and one cannot be with recovering people and using people at the same time.

6.     Talking openly and honestly about high-risk situations before they occur takes their alluring power away. The more talk there is about known situations that can threaten recovery the greater the likelihood is that the situation can be disarmed before it occurs. A person can learn how to cope by talking with others about these situations that are very common. Counseling and 12 Step programs are specifically designed to encourage that kind of sharing.

7.     Having a strong support network of recovering people can help thwart the power of impending high-risk situations. Knowing, in advance, that there is the chance this situation will occur usually allows for time to contact others in a support network who can give advice and even join with a person to re-direct their attention away from the negative situation.

8.     There is also a way to use support people in a practical sense. Commonly, situations arise that are threats, but those threats can be minimized if one or more support people actually go through the situation with a recovering person. Having someone to accompany the recovering person to help them face an unavoidable situation – holiday celebrations, anniversaries, weddings, etc. – can go a long way toward protecting them from getting engrossed so far into the situation that they use alcohol or other drugs to cope.

9.     Some people print out the high situations that threaten their recovery and place them on bathroom mirrors, refrigerators, or other private places to help remind them of the need to plan for the situations that may arise. This knowledge of which situations can injure a recovering person goes a long way toward avoiding them. Adding to the list occasionally as new situations arise also helps.

10.  Always have alternative activities available in the event that plans fall through or there is a need to immediately escape from an unexpected high-risk situation. These activities can be based on fundamentally positive things that provide a reward for avoiding the situation that is a challenge.

Despite all of these plans and options, the single most important thing to do is remain positive. Many people have a personal saying that affirms their recovery and if they are able to repeat that to themselves when confronted with a high-risk situation, the power of the affirmation can usually carry the day. “This too shall pass,” is an old 12-Step affirmation that frequently helps people pass through the moment of the situations that arise. Knowing that a person can get through the situation without using and that they will feel much better about themselves because they avoided the danger successfully also helps a person in recovery stay in recovery.

Alcoholism Relapse, Part 1

          Many times people who are addicted to alcohol are confused about the reasons that they drink to excess or wonder about the causes for continual relapse. People who are close to them sometimes wonder as well why it is that an alcoholic will continue to drink despite any threat or consequence. However, more than 50 years ago a researcher discovered that the leading cause of relapse among alcoholics was that there was some high risk situation they encountered while sober that caused them to go back to drinking.

          Two other relapse causes that were also identified – failure to improve unhealthy interpersonal relationships and negative moods that overwhelm a person – but failure to successfully negotiate a risky situation was the number one reason people chose to go back to drinking after making an attempt at sobriety. These high-risk situations come in many forms, but the following ten could be considered deadly for recovery unless they are successfully managed.

1.     The most prevalent high-risk situation to overcome is being around people, places, things, and situations that were previously associated with drinking or the use of other drugs. Being able to avoid these situations depends somewhat on a person’s age. Younger people have a harder time avoiding old drinking friends than older people who seem better able to dissociate themselves from negative people. But, the old 12-Step adage seems to apply here: If you hang around a barbershop long enough, sooner or later you’ll get a haircut. Hanging around old people or places can eventually erode confidence to stay clean and sober to the point where picking up again seems the natural thing to do.

2.     The notion that a person can use another drug other than alcohol and get away without relapsing later on alcohol is also prevalent among relapsers. Often this is called the “marijuana maintenance” program where a person avoids drinking but uses marijuana to enhance pleasure or dispel pain in life. Having sleeping pills, tranquilizers, or prescription medicines in their possession also falls into this category of high-risk situations.

3.     Feeling “Hungry, Angry, Lonely or Tired” – the famous HALT acronym of Alcoholic Anonymous – is a set of situations that can cause relapse. Sometimes a person can get into these states by being in situations that create them. Being bored is frequently listed as a cause of relapse for young people, but the boredom is often a masquerade for depression that is caused by risky situations.

4.     Ironically, having positive feelings can sometimes lead to relapse. Some situations – birthday parties, anniversaries, job promotions, etc. – can cause a person to feel like celebrating because they are associated with drinking alcohol. Sometimes people erroneously reason that if the situation causes them to have pleasure, then perhaps adding alcohol to the situation will cause even greater pleasure, and the allure of that is hard to resist.

5.     Stress is all about change, and it can cause a person to be involved in situations that can lead to using alcohol or other drugs to manage it. People often resist change because of the unpredictability of the outcome that can cause worry and concern. Avoiding the buildup of stress can go a long way to reducing the temptation to use alcohol or other drugs to soften the strain that stress causes on the physical body and the mind.

6.     One part of the HALT slogan mentioned above is “tired” and the role that fatigue plays in relapse is largely misunderstood. When a person gets physically or mental fatigued there is a tendency to not think clearly and to want to take shortcuts. Sometimes the thinking is that fatigue is good because then a person can sleep off the cravings and urges to use that might arise in difficult situations. But, the fact is a person is rarely at their best when tired and they are more vulnerable to distorted thinking.

7.     Eventually, every recovering alcoholic asks themselves the question as to whether they are a “real” alcoholic. The greater the distance they have from their last drink the more likely they will forget that it is only through their daily abstinence that they are able to maintain their attitude of sobriety. There is a natural tendency is to think that, since they have successfully managed risky situations in the past that might have caused relapse, the chances are they are not truly addicted to alcohol and can use it in moderation. Controlled drinking creates even more high-risk situations because an alcoholic who is drinking commonly finds themselves surrounded by people who are using or in places where alcohol is a dominant stimulus. Little do most people know, but it is the situation of successful management that causes this overconfidence, and it is hard for many people to realize that the farther away from their last drink that they are, the closer they may be to their next one.

8.     There is also a tendency to romanticize the past when one is at a distance from their last episode of drinking. The “war stories” that some people tell create a situation whereby their brain, upon hearing the story being repeated over and over again, begins to interpret the story as a normal life occurrence that is acceptable. People then usually conjure up all the old euphoric memories of when things were just fine and their drinking did not cause them untold pain. And, the sense of bravado that is felt by telling the story can unfairly signal to the person that they have control over alcohol.

9.     Cross addictions create hazardous situations for many people as well. Compulsive gambling, sexual activity, eating, spending or working can all lead to unhealthy situations that can lead a person back to compulsive drinking. “Everything in moderation” proclaimed the Oracle at Delphi in ancient Greece, and this message is very important for recovering alcoholics to hear.

10.  The high risk situation that is perhaps most obvious is having a lot of cash on hand that makes it deceptively easy to use alcohol or other drugs. Frequently, because cash is not being spent on drugs or alcohol while in recovery, there is a tendency to have a lot of cash in a pocket or purse and this can lead to the temptation to use it to purchase alcohol or other drugs. Alcoholics are conditioned to believe alcohol can enhance pleasure or reduce pain and when money is no barrier to using it, they will often drink.

                High-risk situations continue to be the single most important threat to recovery from alcoholism. They are easily rationalized as being safe and acceptable behaviors, yet they can cause untold hardship when a person engages in them.

The Revolution in Alcoholism Treatment

Many years ago, two alcoholic men – Bill Wilson and Dr. Bob Smith – met and changed the world.

         Until that point, alcoholism was considered largely an untreatable disease with only three known outcomes…jails, institutions or death. But after these two men met and talked with each other about their common illness, the processes by which people came to understand alcoholism and address it changed radically. No longer would alcoholics be seen as merely weak-willed men and women. No longer would alcoholics be relegated to the insane asylums or jails simply because they could not be treated. And, no longer would people with the disease of alcoholism or other addictions be without hope to arrest the disease. When Bill W. and Dr. Bob sat and talked about their experiences, strengths, and hopes for the future, they gave hope to now millions of people.

          What made the difference in the lives of these men, and the millions who followed them, was that they had restored principles and values to their lives through the practice of a simple daily program of recovery. They reasoned that when they drank they ended up giving away not only money to get the alcohol that would ruin their lives, but they also gave up their morals, values, and principles that governed their lives. The bartender or liquor store owner ended up owning them and their lives as these men indentured themselves to the alcohol: They became slaves to the alcohol and would do whatever the people who had alcohol told them to do. But, in recovery, this servitude ended. They were able to not drink when they were abstinent and they maintained their abstinence by practicing a few simple principles in their daily lives.

         As Alcoholics Anonymous (AA) came to say later, people in recovery from addiction need to “practice these principles in all their affairs.” What were these principles that the men had given up when drinking and were restored to them when they were sober? The first 100 men and women who stopped drinking through AA in those early years set down in writing the steps that they took to get and stay sober. They became known as the famous “12 Steps” of recovery. They reasoned that if they became enslaved to alcohol by gradually giving away all their values, morals, and principles, then they would need to recover those same values, morals, and principles in their lives in order to remain sober. So they listed out the principles they knew they needed to live by. They arrayed them in terms of the step-by-step process they went through to get them back into their lives, and wrote the language for the steps it took in a clear and direct way.

         Here are the principles that they built back into their lives, one-by-one over time, and the steps they took to get them:

Honesty - 1. We admitted we were powerless over alcohol and that our lives were unmanageable.

Hope – 2. Came to believe that a Power greater than ourselves could restore us to sanity.

Faith – 3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

Courage – 4. Made a searching and fearless more inventory of ourselves.

Integrity – 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

Willingness – 6. Were entirely ready to have God remove all these defects of character.

Humility – 7. Humbly asked Him to remove our shortcomings.

Love – 8. Made a list of all persons we had harmed ands became willing to make amends to them all.

Justice – 9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

Discipline – 10. Continued to take personal inventory and when we were wrong promptly admitted it.

Spirituality – 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Service – 12. Having has a spiritual awakening as a result of these steps, we tried to carry the message to alcoholics, and to practice these principles in all our affairs.

         Armed with 12 spiritual principles they had once lost but regained through the 12 Steps, the original founders of the AA program resumed their lives as recovering alcoholics. They passed down a rich tradition to other alcoholics, drug addicts, and others addicted to behaviors that works as an effective way to arrest the effects of addiction and relapse to this day.