Download SUBSTANCE USE DISORDERS

Addiction is Addiction
LIC 6 Lifestyle Intervention Conference
2016 October 17
Presented by Dr. Raju Hajela
www.healthupwardlymobile.net
E-mail: [email protected]
or [email protected]
Phone: 403-536-2480
Fax: 403-536-2482
Addiction Is…
Check 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 one’s
vice
 Bad choices
 Wilful ignorance of
reality
 Being selfish
 Caused by something
else (i.e., trauma)
 Substance Abuse
 Loss of morals
 A psychiatric disorder
Addiction and Mental Health
Cause or effect?
• Addiction/substance use occurs because of
underlying psychiatric problems, OR…
• Addiction/substance use results in
psychiatric problems…
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
Withdrawal
• Opposite of the drug effect
• Depressant withdrawal – most dangerous –
seizures, Delerium Tremens -> 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…
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!
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
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
The Pickle Line
• A cucumber can become a pickle, but a pickle cannot
go back to being a cucumber...
Abuse
Hazardous - Harmful
Dependence
(Addiction)
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)
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
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
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!
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
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
Brain Circuitry Affected by
Addiction
• Genes- 40-60% of
vulnerability comes from
genetics
• Reward (VTA & nucleus
accumbens); normally
“enough”  with addiction is • Tolerance, Withdrawal 
“more”
“more” or need to feel ‘normal’
• Motivation (Amygdala):
• Cognitive (thinking)
feelings appraisal
problems – brain receiving
• Memory (Hippocampus):
inaccurate info from other
previous experience,
areas, not able to make
exposures
‘choices’
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
Characteristics of Addictive
Thinking
•
•
•
•
•
•
•
•
Irrational
Contradictory
Rationalization
Minimization
Denial
All-or-nothing
Catastrophizing
Skewed time
• Hypersensitivity
• Illusion of control
• Guilt
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
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
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)
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
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
Addiction Is…
Check 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
Definition of Addiction
asam.org
Addiction is a primary, chronic disease of brain reward,
motivation, memory and related circuitry. Dysfunction in
these circuits leads to characteristic biological,
psychological, social and spiritual manifestations. This is
reflected in the individual pursuing reward and/or relief
by substance use and other behaviors. Addiction is
characterized by impairment in cognition and related
behavioral control, craving, inability to consistently
abstain, impairment in executive functioning and
diminished recognition of significant problems with one’s
behaviors and interpersonal relationships. Like other
chronic diseases, addiction involves cycles of relapse
and remission. Addiction is progressive, and can result
in disability or premature death.
ABCDE of Addiction
A.
B.
C.
D.
Inability to consistently abstain
Impairment in behavioural control
Cravings
Diminished recognition of problems with
one’s behaviours and interpersonal
relationships
E. Dysfunctional emotional response
From the American Society of Addiction Medicine definition of
Addiction: www.asam.org
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
ASAM 2011
•
•
•
•
•
ICD-11
• Strong desire or
compulsion (A)
Inability to
consistently Abstain • Difficulties in
controlling
Impairment in
behaviour(B)
Behavioral control
• Progressive neglect,
Cravings
increased time (B)
Diminished
• Persistence despite
recognition of
significant problems harm (A)
• Tolerance &
Dysfunctional
Emotional response Withdrawal
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
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
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”
Addiction
Behaviour
Feelings
Thinking
Motivation
Concentration
Memory
Reward
Brain
Recovery
Behaviour
Feelings
Thinking
Motivation
Concentration
Memory
Reward
Brain
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
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
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
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”
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
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
Another Key Message
Addiction is Addiction!
•Brain does not distinguish between substance or
process
•Addiction without the “s”
•“Cunning and Baffling”disease
•Addicted to something versus Addiction
•Cross, Multiple, Co are misleading terms
•Whack a Mole
Reading recommendation: ASAM Definition of Addiction from
www.asam.org
A Nice Simple “Old”Model
McLellan, 2004
Substance Abusing Patient
Treatment – substance or behavior specific
Harm Reduction or Abstinence
Non- Substance Abusing Patient yet
persistent cognitive, affective and
behavioral problems!
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.
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
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
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.
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
Addiction Concepts
Abstinence Alone Is Not
Enough
• Abstinence is a central component of longterm 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”
Addiction Concepts
Relapse: What to Look For
• An increase in addictive thinking
(precedes all relapse behaviour)
• Continuum of Relapse:
Spiritual-Emotional-Cognitive-SocialBehavioural
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)
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 "incentive
salience circuitry”). Reward-triggered
relapse also is mediated by glutamatergic
circuits projecting to the nucleus
accumbens from the frontal cortex.
(George Koob)
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.
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.
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
A…B…C…D…E…
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.
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 individual’s
treatment plan in abstinence-based recovery activities or can
be a part of harm reduction strategies.
Provider
• Dr. Feelgood - opioids are good for pain relief, so
prescribe short-acting opioids (patient controlled)
– If you have pain, you can’t 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
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 can’t, together we can
• Maintenance “My new lifestyle is
more natural…” watch out for stressors
and/or complacency
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 biopsycho-social-spiritual!
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
Decisional Balance
• Positives of changing, negatives of notchanging
• Positives of not-changing, negatives of
changing (withdrawal, pain, PAWS)
Hajela & Irons, 1998
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…
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 individual’s consistent pursuit
of abstinence, impairment in behavioral control, dealing with
cravings, recognizing problems in one’s behaviors and
interpersonal relationships, and dealing more effectively with
emotional responses.
An individual’s 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.
Like Minded Docs
www.likemindeddocs.com
Addiction Concepts
Holistic Recovery
• Therefore, recovery must be holistic (biopsycho-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
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
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)
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!
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)
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
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…”
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
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
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.
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.
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 individual’s health and
wellness that were previously
compromised by active addiction.
• Abstinence + Recovery = Sobriety!
Johari Window
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
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
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
Supporting Loved Ones
•
•
•
•
Establish an alcohol-free home
Learn about the disease of Addiction
Avoid policing/monitoring your loved one
Don’t 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
Resources
•
•
•
•
Addictive Thinking by Abraham Twerski
The Selfish Brain by Robert DuPont
www.asam.org
Melody Beattie books on Codependence such as The Codependent’s
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
Remember…
Key Messages:
– Addiction is a brain disease
– It is not the person’s 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
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
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
Addiction in the Family
• The Family Laws of Addiction:
– Don’t Talk
– Don’t Trust
– Don’t Feel
(It Will Never Happen to Me by Claudia Black)
• The Family Laws of Recovery:
– Talk
– Trust
– Feel
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
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
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
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
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
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
Boundaries & Communication
• You have the right to vocalize your
needs to others, but don’t 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”
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
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 
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!
Addiction is Addiction
www.addictionisaddictionbook.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