SUBSTANCE%20USE%20DISORDERS%20-%20INTERVENTION%20and%20MONITORING:%20%20Framework%20and%20Techniques

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Addiction is Addiction LIC 6 Lifestyle
Intervention Conference 2016 October 17
Presented by Dr. Raju Hajela www.healthupwardlymob
ile.net E-mail rhajela_at_humassociates.net or
rajuhajela_at_hotmail.com Phone [phone] Fax
403-536-2482
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Addiction IsCheck all that apply

• Bad behaviour or a vice
• Self-medication
• Just wanting to get high
• Wrong choices
• Just excessive substance use
• Something that can be fixed or cured
• Controllable

• About enjoying ones vice
• Bad choices
• Wilful ignorance of reality
• Being selfish
• Caused by something else (i.e., trauma)
• Substance Abuse
• Loss of morals
• A psychiatric disorder

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Addiction and Mental Health

• Cause or effect?
• Addiction/substance use occurs because of
  underlying psychiatric problems, OR
• Addiction/substance use results in psychiatric
  problems

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Intoxication

• Use of substances - stimulants, depressants,
  opioids, hallucinogens and inhalants - continuous
  or intermittent, may cause -
• Thought disorders
• Mood disorders
• Perceptual disorders
• Neurological damage
• End-organ damage

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Withdrawal

• Opposite of the drug effect
• Depressant withdrawal most dangerous
  seizures, Delerium Tremens -gt increased mortality
• Stimulants craving
• Opioids most uncomfortable but can be managed
  cold-turkey even in pregnancy recurrent
  relapse is the problem if no treatment or
  engagement in recovery
• Hallucinogens subtle
• Non-specific nausea, vomiting, sleep
  disturbance, temp intolerance, irritability, mood
  swings, acting out

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Addiction Mental Health

• Addiction underlies many psychiatric conditions
  (e.g., Anxiety, Mood disorders, Psychosis,
  Conduct disorder, Personality Disorders like
  Borderline or Antisocial, ADHD)
• Treating the psychiatric disorder does not make
  substance related problems or Addiction go away
• Many treatments focus on behaviour only. Changing
  behaviour alone does not provide full treatment!

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Stress, Anxiety Depression

• Symptoms of intoxication and withdrawal manifest
  as stress, anxiety, and/or depression
• Fear of the future ? anxiety
• Shame from the past ? depression
• Anger about the present ? stress
• Feelings of hopelessness,
  worthlessness are part of Addictionwill all be
  and will be exacerbated in the absence of
  absence of healthy recovery, especiaally
  especially with no substance use or escape/or
  escape/relief

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Substance Use Continuum

• Low-risk use
• Hazardous use
• Harmful use
• Abuse
• continued use despite negative consequences
• Dependence
• pre-occupation, compulsion, obsession (craving)
• loss of control

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The Pickle Line

• A cucumber can become a pickle, but a pickle
  cannot go back to being a cucumber...

Abuse Hazardous - Harmful
Dependence (Addiction)
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Dependence Characteristics

• Withdrawal
• Tolerance
• Use of larger amounts or over a longer period
  than intended
• Persistent desire for the substance (or process)
  or unsuccessful attempts to cut down
• A great deal of time is spent in securing access
  to substance/process
• Social or other activities are given up or
  reduced due to use
• Use despite recurrent or persistent problems
  (family, social, work)

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Addiction is Addiction

• Addiction is not limited to alcohol and illicit
  drugs. It can include
• Gambling
• Food/Eating disorders
• Sex, love, relationships
• Internet/video games
• Shopping
• Exercise/sports
• Work
• Caffeine
• Nicotine
• Prescription medication

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Cravings

• When compulsive and obsessive thought revolves
  around a desire, craving and ritualized behavior
  often evolves
• The drive to appease craving leads to
  powerlessness and unmanageability. Sign that
  Addiction and substance dependence are present
• May continue for months into abstinence. Can be
  physiological and/or psychological
• Drug/Problem behaviour Survival

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Cravings

• Cravings are relieved when a person anticipates
  using or has acquired their substance of choice
• This anticipation releases dopamine, chemical hit
  from the drug is a bonus
• Relief from cravings is not directly tied to
  ingestion of substance or engagement in
  behaviour!

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The Brain

• The brain operates differently with Addiction
  (hippocampus, VTA, nucleus accumbens, amygdala,
  and frontal cortex are impacted)
• Neurotransmitters are involved, particularly
  dopamine and glutamate

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Neurotransmitters

• Neurotransmitters are natural chemicals that
  transmit signals from a neuron to a target cell
  across a synapse. They carry information
• There are many types of neurotransmitters.
  Important ones in Addiction are Dopamine and
  Glutamate, but opioid peptides, GABA,
  norepinephrine, and serotonin are also impacted

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Brain Circuitry Affected by Addiction

• Genes- 40-60 of vulnerability comes from
  genetics
• Reward (VTA nucleus accumbens) normally
  enough ? with addiction is more
• Motivation (Amygdala) feelings appraisal
• Memory (Hippocampus) previous experience,
  exposures

• Tolerance, Withdrawal ? more or need to feel
  normal
• Cognitive (thinking) problems brain receiving
  inaccurate info from other areas, not able to
  make choices

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Addictive Thinking by Abraham Twerski

• Addictive Thinking ? irrational, distorted
  thoughts
• Everyone on the planet has Addictive Thinking in
  some form or another
• Difference with Addiction is
• It escalates and becomes unmanageable
• Consequences are more severe (i.e., relapse)
• Feels overwhelming
• Leads to persistent obsession that takes you away
  from reality

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Characteristics of Addictive Thinking

• Irrational
• Contradictory
• Rationalization
• Minimization
• Denial
• All-or-nothing
• Catastrophizing
• Skewed time

• Hypersensitivity
• Illusion of control
• Guilt

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Hearing Addictive Thinking

• If you are hearing addictive thinking in someone
  else you may feel
• Confused/puzzled
• Irritated/annoyed/angry
• Physically upset (e.g., sick in the stomach)
• These feelings may precede your awareness of what
  you are hearing
• You are hearing the disease in action

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Addiction is Addiction

• Brain cannot distinguish between substances or
  processes like eating, gambling, sex,
  relationships all impact dopamine and other
  neurotransmitters in the brain
• Therefore abstinence from all illicit drugs,
  alcohol, and certain prescriptions (i.e., ones
  that impact reward circuitry) are important to
  form a foundation of recovery
• Can look at abstinence from bottom line
  behaviours that increase vulnerability

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REWARD and ANALGESIA

• Most rewarding (addictive) drugs produce
  analgesia (opioids and cannabinoids)
• Natural rewards, notably highly palatable foods
  such as chocolate, milk or sucrose, can produce a
  naloxone-reversible analgesic effect
• Consumption or anticipation of reward can inhibit
  responses to pain
• Howard L. Fields, 2004 (Proceedings of the 11th
  World Congress on Pain)

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Common Reward Circuitry

• High levels of dopamine receptors seem to protect
  against Addiction, while low levels increase
  vulnerability including obesity and drug abuse
  levels are affected by genetics and experience
  (exposure) (Volkow, 2006)
• Relapse associated with re-exposure to
  substance/behaviour, environment or increased
  stressors

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Deficiency?

• Receptors quantity?
• Function?
• Withdrawal symptoms?
• Anxiety? Depression? Psychosis?
• Social isolation?
• Criminal behaviour?
• Disruptions in Life Meaning, Values, Purpose?
• INTERNAL MECHANISMS DEFICIENT IN MAINTAINING
  HOMEOSTASIS

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Addiction IsCheck all that apply

• A primary, chronic disease
• About brain dysfunction
• About pathologically seeking reward
• About memory distortion
• About seeking relief
• About neglecting self

• About motivation problems
• About distortions in thinking, feeling, and
  perception
• About impaired behavioural control
• About cravings
• Lifelong

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Definition of Addiction asam.org
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ABCDE of Addiction

• Inability to consistently abstain
• Impairment in behavioural control
• Cravings
• Diminished recognition of problems with ones
  behaviours and interpersonal relationships
• Dysfunctional emotional response
• From the American Society of Addiction Medicine
  definition of Addiction www.asam.org

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ABCDE of Addiction

• A, B, C are especially engaged when people are
  active in their disease
• The D and E are the lifelong parts of the disease
• With abstinence and recovery action, their
  presence, power, and impact declines but the
  disease is still there

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ASAM 2011 ICD-11

• Strong desire or compulsion (A)
• Difficulties in controlling behaviour(B)
• Progressive neglect, increased time (B)
• Persistence despite harm (A)
• Tolerance Withdrawal

• Inability to consistently Abstain
• Impairment in Behavioral control
• Cravings
• Diminished recognition of significant problems
• Dysfunctional Emotional response

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Role of Genetics

• Even if a family history of Addiction is not
  known or apparent, there was likely a relative at
  some point in the family lineage who struggled
  with the disease
• There is no untainted gene pool in the world when
  it comes to Addiction
• Not important to figure out how or who or why,
  focus on recovery

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Brain and Behaviour

• Behaviours are NOT the disease nor do they cause
  the disease, they are SYMPTOMS of the disease
• Behaviours can aggravate the disease or help lead
  to recovery!
• Many healthcare providers and families believe
  that if behaviours are changed, the disease is
  fixed or cured
• It is impossible to fix or cure the brain
  completely. Behavioural remission helps
  emotional, social, and spiritual growth if action
  is taken
• Reading recommendation The Selfish Brain by
  Robert DuPont

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Impact of Problem Behaviours

• Problem behaviours, such as eating, sexual
  activity, shopping, gambling, being in a
  relationship, playing video games, and working
  can all have the same impact on the brain as
  substances
• Brain will release dopamine in the same way as
  with substance, telling the brain I want more

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Addiction

• Behaviour
• Feelings
• Thinking
• Motivation
• Concentration
• Memory
• Reward
• Brain

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Recovery

• Behaviour
• Feelings
• Thinking
• Motivation
• Concentration
• Memory
• Reward
• Brain

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Addiction

• As Addiction is rooted in the brain and there is
  a genetic predisposition, the disease exists from
  birth
• Often parents will notice oddities or differences
  in children who later develop active Addiction
  behavioural issues, conduct problems, obsession,
  rumination, emotional instability
• How it manifests depends on environment, exposure
  to substance, trauma, stress, life events

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Addiction Beyond Substance

• Myth Substances cause Addiction
• Fact Substance use is the behavioural
  manifestation of Addiction and can aggravate the
  disease that already existed, plus have
  additional effects on the body and mind due to
  chemicals

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Choice? Or Disease?

• Myth Addiction and substance use are a choice
• Fact Neither are a choice. The brain is
  vulnerable to Addiction from birth. Even using
  drugs or alcohol for the first time is not
  necessarily a choice as brain is seeking
  escape, reward, relief
• Recommendation Watch Pleasure Unwoven by Kevin
  McCauley on YouTube

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A Key Message

• Addiction is a Primary, Chronic Brain Disease,
  NOT a behavioural disorder. A biological
  predisposition to the disease is passed on
  genetically. Other factors (environment, exposure
  to substance, trauma, etc.) impact how the
  disease manifests
• The disease of addiction is part of you, not all
  of you

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Mental Health

• Some individuals will have Addiction and another
  mental health issue
• However, without stabilization of Addiction you
  will not know if other issues persist!
• Addiction must be treated
  first with holistic recovery
  abstinence

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Another Key Message

• Addiction is NOT the result of other mental
  health conditions but a disease in and of itself.
  Treating Addiction will help alleviate mental
  health symptoms including depression, anxiety,
  antisocial tendencies, difficulties in
  relationships, psychosis, lack of interest, lack
  of motivation, and many others!
• Treating mental health issues only will NOT
  facilitate recovery for Addiction

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Another Key Message

• Addiction is Addiction!
• Brain does not distinguish between substance or
  process
• Addiction without the s
• Cunning and Bafflingdisease
• Addicted to something versus Addiction
• Cross, Multiple, Co are misleading terms
• Whack a Mole
• Reading recommendation ASAM Definition of
  Addiction from www.asam.org

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A Nice Simple OldModelMcLellan, 2004
Substance Abusing Patient
Treatment substance or behavior specific Harm
Reduction or Abstinence
Non- Substance Abusing Patient yet persistent
cognitive, affective and behavioral problems!
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Addiction is not the same as intoxication

• When anyone experiences mild intoxication through
  the use of alcohol or other drugs, or when one
  engages non-pathologically in potentially
  addictive behaviors such as gambling or eating,
  one may experience a high, felt as a positive
  emotional state associated with increased
  dopamine and opioid peptide activity in reward
  circuits. After such an experience, there is a
  neurochemical rebound, in which the reward
  function does not simply revert to baseline, but
  often drops below the original levels. This is
  usually not consciously perceptible by the
  individual and is not necessarily associated with
  functional impairments. 

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A Continuing Care Model
ASSESSMENT Motivational Interviewing,
Tailoring Treatment
Withdrawal management, Detox
Rehab Outpatient, Residential, TC etc.
Continuing Care Recovering Patient -
Community Addiction is Addiction - Thinking,
Feeling, Behaviors Concurrent Disorders
Bio-Psyhco-Social- Spiritual Medications,
Therapy, Mutual Support, Monitoring
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Addiction Concepts

• Harm Reduction
• Treat harm reduction as a means to an end, not an
  end in itself
• Viewed as what more needs to be done or what
  needs to be done differently rather than be the
  end treatment goal
• Moderate use/consumption is not possible if
  someone has Addiction

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Harm Reduction

• A treatment and prevention approach that
  encompasses individual and public health needs,
  aiming to decrease the health and socio-economic
  costs and consequences of addiction-related
  problems, especially medical complications and
  transmission of infectious diseases, without
  necessarily requiring abstinence.
• Abstinence-based treatment approaches are
  themselves a part of comprehensive Harm Reduction
  strategies. A range of recovery activities may be
  included in every Harm Reduction strategy.

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Definition of Abstinence

• More than not using substance
• ASAM definition intentional and consistent
  restraint from the pathological pursuit of reward
  and/or relief that involves the use of substances
  and other behaviors
• The pursuit of abstinence is important, which can
  exist even in the context of substance use/relapse

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Addiction Concepts

• Abstinence Alone Is Not Enough
• Abstinence is a central component of long- term
  sobriety
• Need to incorporate focus on whole being
• There is no such thing as a bad feeling
• Life into Recovery compared to recovery into life
• Recovery Supports
• It works if you work it

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Addiction Concepts

• Relapse What to Look For
• An increase in addictive thinking (precedes all
  relapse behaviour)
• Continuum of Relapse
• Spiritual-Emotional-Cognitive-Social-Behavioural

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Relapse

• Persistent risk and/or recurrence of relapse,
  after periods of abstinence, is another
  fundamental feature of addiction.  This can be
  triggered by exposure to rewarding substances and
  behaviors, by exposure to environmental cues to
  use, and by exposure to emotional stressors that
  trigger heightened activity in brain stress
  circuits.
• (Eliot Gardner)

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Relapse

• Relapse triggered by exposure to addictive/
  rewarding drugs, including alcohol, involves the
  nucleus accumbens and the VTA-MFB-Nuc Acc neural
  axis (the brain's mesolimbic dopaminergic "incenti
  ve salience circuitry).  Reward-triggered
  relapse also is mediated by glutamatergic
  circuits projecting to the nucleus accumbens from
  the frontal cortex.
• (George Koob)

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Disease progression

• Over time, repeated experiences with substance
  use or addictive behaviors are not associated
  with ever increasing reward circuit activity and
  are not as subjectively rewarding. Once a person
  experiences withdrawal from drug use or
  comparable behaviors, there is an anxious,
  agitated, dysphoric and labile emotional
  experience, related to suboptimal reward and the
  recruitment of brain and hormonal stress systems,
  which is associated with withdrawal from
  virtually all pharmacological classes of
  addictive drugs. 

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Disease progression

• While tolerance develops to the high, tolerance
  does not develop to the emotional low
  associated with the cycle of intoxication and
  withdrawal. Thus, in addiction, persons
  repeatedly attempt to create a high--but what
  they mostly experience is a deeper and deeper
  low.  While anyone may want to get high,
  those with addiction feel a need to use the
  addictive substance or engage in the addictive
  behavior in order to try to resolve their
  dysphoric emotional state or their physiological
  symptoms of withdrawal.

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Disease progression

• Persons with addiction compulsively use even
  though it may not make them feel good, in some
  cases long after the pursuit of rewards is not
  actually pleasurable. Although people from any
  culture may choose to get high from one or
  another activity, it is important to appreciate
  that addiction is not solely a function of
  choice.  Simply put, addiction is not a desired
  condition
• ABCDE

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Medication Assisted Recovery (MAR)

• A transitional term to help the general public,
  recipients of health care services, and
  professional health care service providers
  understand that pharmacotherapy can be helpful in
  supporting recovery. The manifestations of
  addiction-related problems are addressed in their
  biological, psychological, social and spiritual
  dimensions during addiction treatment, in
  treatment approaches that are abstinence-based,
  and in treatment approaches that are
  harm-reduction-based. MAR is one component of the
  treatment and recovery process.Medication
  Assisted Treatment (MAT), another variation on
  the concept of MAR, may involve pharmacotherapy
  alone. It is essential that addiction treatment
  and recovery approaches address the various
  aspects of biological, psychological, social and
  spiritual dimensions for optimum health and
  wellness. It is hoped that as the public and
  professionals recognize that recovery and
  treatment need to be holistic, appropriate
  pharmacotherapy would be well accepted as part of
  treatment and recovery, such that the terms MAR
  and MAT would be deemed unnecessary.

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Maintenance Treatments

• Pharmacotherapy on a consistent schedule for
  persons with addiction, usually with an agonist
  or partial agonist, which mitigates against the
  pathological pursuit of reward and/or relief and
  allows for remission of overt addiction-related
  problems.
• Maintenance Treatments of addiction are
  associated with the development of a
  pharmacological steady-state such that addictive
  substances are no longer sought for reward and/or
  relief.
• Maintenance Treatments of addiction are also
  designed to mitigate against the risk of
  overdose. Depending on the circumstances of a
  given case, a care plan including Maintenance
  Treatments can be time-limited or can remain in
  place life-long. Integration of pharmacotherapy
  via Maintenance Treatments with psychosocial
  treatments generally are associated with the best
  clinical results. Maintenance Treatments can be
  part of an individuals treatment plan in
  abstinence-based recovery activities or can be a
  part of harm reduction strategies.

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Provider

• Dr. Feelgood - opioids are good for pain relief,
  so prescribe short-acting opioids (patient
  controlled)
• If you have pain, you cant be addicted
• What would you like? I want you to like me!
• Dr. Fingerwagger opioids are dangerous and must
  be used very sparingly, if at all
• If you take opioids, you will be addicted!
• Motivation through shame and fear
• Dr. Compass check all directions when
  prescribing opioids or any other psychoactive or
  psychotropic meds
• Opioids are useful meds that require great care
  in prescribing and ongoing monitoring is
  essential!
• Dr. Reality Check patient-centred care

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Readiness to Change

• Resistant Get off my back-gather
  information, develop rapport
• Ambivalent I am not sure I can provide
  information, preparation
• Action I really want to, who can help
  alone we cant, together we can
• Maintenance My new lifestyle is more natural
  watch out for stressors and/or complacency

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Motivational Interviewing

• Miller Rollnick, 2009 collaborative,
  person-centred, guiding to elicit and strengthen
  motivation for change, improve outcomes SAMHSA
• www.motivationalinterview.org
• Motivation is dynamic, awareness leads to action
  leads to awareness, repetition leads to
  conditioning insight is not enough amotivation
  barriers are bio-psycho-social-spiritual!

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Motivational Interviewing

• Task is to create discrepancy between where the
  patient is at and where she wants to be
  Realistic planning?
• Support self-efficacy, express empathy, roll with
  resistance
• Open ended questions, affirmations, reflections,
  summaries
• Desire, Ability, Reason, Need
• Commitment, Activation, Taking Steps

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Decisional Balance

• Positives of changing, negatives of not-changing
• Positives of not-changing, negatives of changing
  (withdrawal, pain, PAWS)

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Psychotherapy

• Reflect What I am hearing is? What exactly are
  you saying? Can you tell me more? Feelings?
  Thoughts?
• Interpret This is what it means to me What
  does it mean to you?
• Reframe Are there other ways to look at this?
• Humanize Many people in this situation think
  this feel this do this

Hajela Irons, 1998
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Recovery

• A process of sustained action that addresses the
  biological, psychological, social and spiritual
  disturbances inherent in addiction. Recovery aims
  to improve the quality of life by seeking balance
  and healing in all aspects of health and
  wellness, while addressing an individuals
  consistent pursuit of abstinence, impairment in
  behavioral control, dealing with cravings,
  recognizing problems in ones behaviors and
  interpersonal relationships, and dealing more
  effectively with emotional responses.An
  individuals recovery actions lead to reversal of
  negative, self-defeating internal processes and
  behaviors, allowing healing of relationships with
  self and others. The concepts of acceptance and
  surrender are also useful in this process. Since
  some prescribed and non-prescribed medications
  can interfere with recovery, it would be prudent
  to consult with an Addiction Specialist Physician
  in selected cases.

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Like Minded Docs www.likemindeddocs.com
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Addiction Concepts

• Holistic Recovery
• Therefore, recovery must be holistic
  (bio-psycho-social-spiritual) in the context of
  abstinence
• Abstinence from all substances is essential, even
  if it was not your substance of choice as
  consumption puts you at risk
• Recovery for problem behaviours is more
  complicated, must look at bottom line behaviours

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Physical Prognosis Brain

• Proper nutrition for neurotransmitter production
  and function
• Exercise promotes healthy circulation and release
  of feel good chemicals (endorphins and
  endocannabinoids)
• Development of new synaptic pathways with
  reinforcement of healthy thinking, dealing with
  feelings, and behaviours

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Physical Prognosis Body

• Improved heart function and circulation to all
  organs to carry oxygen that is necessary for
  repair and function
• Organ healing (e.g., liver function restored over
  time although some cells may become
  scarred/cirrhosed)
• Improved lung function healthy breathing
  (connection to relaxation and meditation)

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Prognosis

• Addiction cannot be cured or fixed but it can
  be managed or dealt with treatment and support!
• Is progressive (think of a downwards escalator
  that people are climbing up)
• Holistic recovery can provide a quality of life
  and healthy lifestyle people never thought
  possible!

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Holistic Recovery

• Biological
• Regular exercise/physical activity (20-30
  minutes/day, 3-4x/week)
• Walking, yoga, cardio, weights, organized sports,
  Tai Chi, etc.
• Healthy, balanced diet
• Lots of water, fruit, vegetables, lean protein
• May or may not include supplements such as Omega,
  Vitamins
• Medication management (if needed)

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Holistic Recovery

• Psychological
• Focus on identifying and processing emotions
• Journalling, talking
• Individual and group counselling
• Exploration of trauma, mental health and coping
  mechanisms
• Relaxation, meditation, breathing

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Holistic Recovery

• Social
• 12 Step meetings
• Developing recovery peer supports
• Addressing relationship issues
• Work, school, volunteering
• Engagement with others to minimize isolation and
  stigma
• FUN!
• From isolation to connectedness

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Holistic Recovery

• Spiritual
• Re-establishing connection with spirituality
  through individual reflection, prayer,
  ceremonies, group gatherings, etc.
• Reconnecting with universe, idea that you are
  supported and not alone

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Characteristics of Addiction

• Key feelings with Addiction are Shame, anger,
  and fear
• Isolation
• Lack of connection with self, others, and the
  universe
• Holistic recovery provides a platform of healthy
  coping with these challenges

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Remission

• A state of wellness where there is an abatement
  of signs and symptoms that characterize active
  addiction. Many individuals in a state remission
  state remain actively engaged in the process of
  recovery. Reduction in signs or symptoms
  constitutes improvement in a disease state, but
  remission involves a return to a level of
  functioning that is free of active symptoms
  and/or is marked by stability in the chronic
  signs and symptoms that characterize active
  addiction.

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Relapse

• A process in which an individual who has
  established abstinence or sobriety experiences
  recurrence of signs and symptoms of active
  addiction, often including resumption of the
  pathological pursuit of reward and/or relief
  through the use of substances and other
  behaviors. When in relapse, there is often
  disengagement from recovery activities.Relapse
  can be triggered by exposure to rewarding
  substances and behaviors, by exposure to
  environmental cues to use, and by exposure to
  emotional stressors that trigger heightened
  activity in brain stress circuits. The event of
  using or acting out is the latter part of the
  process, which can be prevented by early
  intervention.

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Sobriety

• A state of sustained abstinence with a clear
  commitment to and active seeking of balance in
  the biological, psychological, social and
  spiritual aspects of an individuals health and
  wellness that were previously compromised by
  active addiction.
• Abstinence Recovery Sobriety!

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Johari Window
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Johari Window

• Disease of Addiction thrives in the blind and
  secret panes
• As families/supports are so focused on the
  addict, life may be in the blind, secret, or
  unknown pane
• Recovery goal for everyone is to shed light on
  challenges and move to the open pane

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Lifestyle

• Move from looking at behavioural change to
  lifestyle change with holistic recovery
• Life may look completely different than in active
  Addiction, which can fuel fear and apprehension
• Important that the whole family system look at
  healthy change, not just the person with
  identified Addiction

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Transition

• The transition to this new lifestyle can be
  difficult, comes with lots of challenges and
  emotions
• Important that each family member focus on their
  own personal journey try not to blame, shame,
  judge, or critique others

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Supporting Loved Ones

• Establish an alcohol-free home
• Learn about the disease of Addiction
• Avoid policing/monitoring your loved one
• Dont encourage your loved one to just try
  harder or control their disease, as this will
  fuel feelings of shame
• Support their recovery actions
• Set boundaries
• Engage in your own process of recovery and
  self-care

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Resources

• Addictive Thinking by Abraham Twerski
• The Selfish Brain by Robert DuPont
• www.asam.org
• Melody Beattie books on Codependence such as The
  Codependents Guide to the 12 Steps, Codependent
  No More, and The Language of Letting Go
• Al-Anon and Nar-Anon
• National Institute on Drug Abuse (NIDA)
  www.drugabuse.org
• Hazelden for books, CDs, DVDs on Addiction
  Recovery
• Desire, when sex meets addiction by Susan Cheever
• Facing Life by Nancy Brown
• Deceived Facing Sexual Betrayal, Lies, and
  Secrets by Claudia Black
• Facing Codependence and Facing Love Addiction by
  Pia Mellody

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Remember

• Key Messages
• Addiction is a brain disease
• It is not the persons fault they have this
  disease
• Addiction is not about bad choices or wanting to
  hurt loved ones
• Addiction impacts the whole family unit and
  everyone plays a role in recovery

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Addiction in the Family

• Often the dynamic in families shifts to a focus
  on the identified person with Addiction
• Time, energy, money, and other resources go into
  helping care for this individual
• Meanwhile, the care of other family members is
  not prioritized
• Healthy recovery for the struggling addict
  involves everyone taking steps to be healthy

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Addiction in the Family

• With genetic predisposition, everyone in the
  biological family unit may be at risk of
  developing the disease, or other behavioural,
  emotional, or thinking patterns may be present
  that are counterproductive
• If you are the partner or non-biological relative
  of someone struggling with Addiction, it is
  important for you to look honestly at your
  genetic risk as well as current health

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Addiction in the Family

• The Family Laws of Addiction
• Dont Talk
• Dont Trust
• Dont Feel
• (It Will Never Happen to Me by Claudia Black)
• The Family Laws of Recovery
• Talk
• Trust
• Feel

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Karpman Triangle

• Another way to look at family roles
• People may act as one, two, or all three of these
  roles depending on the time and circumstance

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Karpman Triangle

• Perpetrator Blames and pressures the person who
  is struggling
• Drawback Perpetuates shame
• Rescuer Wants to fix, caretake, keep the peace
• Drawback Enabling of behaviour
• Victim Feeling hopeless, worthless, punished,
  and in an unfair position over which they have no
  power. Vulnerable to persecution and often
  looking for rescuing
• Drawback Lack of personal accountability

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Boundaries

• Personal boundaries are guidelines, rules or
  limits that a person creates to identify for him-
  or herself what are reasonable, safe and
  permissible ways for other people to behave
  around him or her and how he or she will respond
  when someone steps outside those limits

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Boundaries

• Important to remember that boundaries are
  internal we cannot force someone to respect our
  boundary! This is our responsibility to ourselves
• Difference between boundaries and expectations
• Expectations when we expect somebody else to act
  differently
• Boundaries when we act differently as a result
  of an internal line we have set

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Boundaries Are

• Yours
• Internal
• What you will/will not accept for yourself
• Do not need to be respected by others
• Are set by you, for you

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Boundaries

• Become more clearly defined as you gain clarity
  on who you are
• What gives me meaning?
• What do I value?
• What is healthy for me?
• These questions help define boundaries in the
  context of spirituality

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Boundaries Communication

• You have the right to vocalize your needs to
  others, but dont expect them to change as a
  result
• It is also important to have a plan of action in
  case the verbalization of your boundary is not
  accepted
• Please do not raise your voice with me. If you
  do, I will step away from this conversation

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Empathy

• The capacity to recognize and identify emotions
  that are being expressed by others
  understanding
• Understanding does not have to equal acceptance
• You do not have to feel these emotions yourself,
  which can lead to sympathy

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Paradigm shift
Addicted to needs to change to Addiction
involving Alcohol is but a symptom of our
disease AA Big Book RAiAR Remember Addiction
is Addiction Responsible Recovery 9 steps
1,2,3 willing to consider 4,5,6 can and
will (action) and 7,8,9 responsibility
Outcomes to be determined by the grace of our
Higher Power ?
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Addiction Treatment
There is no such thing as treatment
failure Only failure of providing the
appropriate treatment Treatment has to be
comprehensive, ongoing, in the chronic disease
framework, with holistic biological,
psychological, social and spiritual recovery!
99
Addiction is Addictionwww.addictionisaddictionboo
k.com
Addiction is Addiction Understanding the
disease in oneself and others for a better
quality of life Raju Hajela Sue Newton Paige
Abbott Friesen Press, 2015