Chapter 8 - Early Abstinence

The second stage in treatment of addiction is early abstinence. After the patient acknowledges the need for treatment and shows at least a preliminary commitment to treatment, the counselor and patient must begin to work on early abstinence issues.

These include:

1. Recognizing the medical and psychological aspects of cocaine withdrawal.
2. Identifying triggers to drug use and developing techniques for avoiding these triggers.
3. Learning how to handle drug craving without using.

The counselor should encourage the patient to establish a drug-free lifestyle that involves participating in self-help groups to aid in one's recovery, avoiding social contact with drug-using associates, and replacing drug-related activities with healthy recreational activities. This period of treatment lasts from the preliminary establishment of motivation toward abstinence to approximately 3 months into recovery, assuming the patient makes reasonable progress.

The topics described here are particularly relevant to the needs of the patient at this point in treatment. The order in which they are presented is generally the order in which they often emerge as treatment issues. But, the counselor should use discretion and address these issues as they seem appropriate for each individual patient.

Discussions of these topics may be repeated as needed. The counselor should base the relative emphasis placed on each topic on the patient's needs in recovery. No more than two topics should be introduced to the patient in a session. However, in reviewing topics previously introduced, the counselor can address all appropriate topics. Although the order in which they are presented and the relative emphasis are flexible, all the issues identified here should be addressed in the counseling sessions.

1. Teach the addict to recognize and avoid the environmental triggers that lead to drug use.
2. Teach the addict to engage in alternative behaviors when he or she experiences craving.
3. Help the patient to achieve and sustain abstinence from all drugs.
4. Urge the patient to participate in healthy activities.
5. Encourage participation in self-help groups.

1. Addiction and the associated symptoms
2. People, places, and things
3. Structuring one's time
4. Craving
5. High-risk situations
6. Social pressures to use
7. Compulsive sexual behavior
8. Postacute withdrawal symptoms
9. Use of other drugs
10. 12-step participation

Addiction and the Associated Symptoms

The counselor should review with the patient the concept of addiction and the behavioral and medical/physiological symptoms of the disease. When discussing symptoms, the counselor should focus on cocaine but can include other drugs as appropriate.

The concept of addiction is that the behavior, or use of something, becomes compulsive, leaving the addict no control over the behavior. Because the addict has no control over this behavior, he or she will continue to use the drug despite the resulting impairment to physical and emotional health, social and occupational functioning, and intimate relationships.

The behavioral symptoms of addiction include narrowing of one's behavioral repertoire, predominance of the drug in the person's daily life, spending time achieving or recovering from drug effects, and continuing to use in spite of the severe problems associated with use. The counselor will review with the patient the specific symptoms of addiction that he or she has demonstrated. The counselor will focus primarily on the life-overwhelming nature of addiction and the importance of avoiding abusable substances in order to provide the best chance for preventing a relapse.

The medical/physiological symptoms also should be reviewed with the patient. They can include increased pulse and blood pressure, anxiety, paranoia, hallucinations, seizures, cardiac arrhythmias, cardiac arrest, and cerebrovascular incidents (strokes). The relative risks for each of these adverse effects will be reviewed. For example, anxiety and paranoia are much more common than seizures or cardiac arrest. The cocaine withdrawal symptoms of depression, low energy, and insomnia will be described, along with the fact that these symptoms do not occur in all cases.

If the patient's route of administration of any drug used has included injection, and/or the patient has engaged in unsafe sexual behavior, perhaps impulsively when using cocaine, then infection with the HIV virus is a medical condition that may co-occur with cocaine addiction. The topic of HIV infection should be introduced here. The counselor must assess the patient's level of knowledge and sophistication about the topic and present information at an appropriate level. If the patient has engaged in high-risk behavior, or the counselor believes the patient may have engaged in high-risk behavior even though he or she denies it, then the patient's risk factors or potential risk factors should be identified, and behavioral changes to reduce risk should be encouraged at this point.

The medical effects of other abused substances, including alcohol, also should be reviewed if the patient has or has had problems with these drugs.

People, Places, and Things

People, places, and things are a way of designating the external triggers that initiate craving or the urge for a drug. The patient must learn how to deal with these triggers in order to achieve continued abstinence. This topic is central to addiction counseling and usually requires repeated discussion throughout treatment. First, the counselor should help the patient to identify the people, places, and things that will trigger or lead to a cocaine craving or urge. Then the counselor should point out that the patient must avoid the people, places, and things that trigger craving and have the patient discuss how he or she can avoid the triggers. The patient should be encouraged to avoid those triggers that are possible to avoid easily (for example, having one's paycheck deposited directly or taking public transportation to and from work rather than drive through a risky area). The patient and counselor should collaborate to develop strategies to help the patient avoid or manage those things that are more difficult to stay away from (for example, a drug-using partner or spouse or a crack house on the block where one lives).

During an individual's addiction, he or she has learned to associate cocaine use with people, including one's dealer or other users; places, like a particular crack house or corner; and things, especially money and drug paraphernalia. The counselor should strongly encourage the patient to avoid those people, places, and things that were previously associated with drug use and assist the patient in developing strategies for avoiding these triggers. These strategies may include having someone the addict trusts handle his or her money, cutting up his or her automatic teller machine card, getting rid of drug "works," i.e., paraphernalia (preferably with someone else's help); staying away from certain neighborhoods, blocks, or areas of his or her community; and avoiding drug-using friends and family members. Triggers that cannot be avoided altogether can sometimes be faced more safely in the company of another, non-using person, such as one's sponsor or one's spouse or child.

Structuring One's Time

If the patient has a chaotic, disorganized lifestyle, the counselor will help the patient to identify what he or she does each day and help to structure his or her days to encourage abstinence. People with drug-use disorders often live in an impulsive and chaotic manner. Order and structure can help to lessen the risk of relapse. One of the defining features of drug addiction is the priority that the drug assumes in the individual's daily existence. Many addicts organize their entire daily routine around obtaining, administering, and recovering from the effects of their drug(s). Because of the time these behaviors require, many people with a drug-use disorder experience a void, or a sense of loss, shortly after stopping the drug. They have spent so much time working for drugs and associating with people, places, and things associated with taking drugs that they have difficulty imagining what to do when they are not using drugs.

The counselor must try to counteract this lifestyle, as well as restructure the content of the addict's daily activity, by trying to help organize the patient's daily routine. One way to help the patient achieve a better organizational pattern is to work out a daily schedule for the week, or until the next session, and to review it. Structuring one's time is an important aid to recovery, because having definite plans and staying busy helps the recovering addict not to have excess free time, which is all too likely to be spent thinking about using drugs. When newly recovering addicts have too much free time, they are likely to recall the "good times" they had using their drugs. This experience is called "euphoric memory" and understandably tends to lead to desire for the drug.

Also, a structured life helps the patient to reduce residual physical symptoms from the cocaine use and to decrease negative emotional effects, such as depression or boredom. The counselor will discuss how the patient spends his or her time and help the patient structure the time to support abstinence. This structure should include getting up each morning and going to bed at night at regular times, scheduling time for 12-step meetings at least 3 to 4 times a week, and including time for handling personal responsibilities and engaging in healthy recreational activities.

Sample Schedules

Danny's Daily Schedule
7 am	Wake up, get dressed
8 am	Walk dog
9 am	Counseling
10 am	NA Meeting
11 am	Return home
Noon	Lunch
1 pm
2 pm
3 pm
4 pm
5 pm
6 pm
7 pm
8 pm	Watch TV or go out
9 pm
10 pm
11 pm	Turn in if at home

Following are two sample schedules. The counselor can choose whichever one is more suitable for the patient's lifestyle and needs. A schedule form can be given for the patient to complete as homework prior to the session, or the patient and counselor can complete a schedule together and simultaneously discuss it during the session.

Planning a daily schedule together is helpful when the patient's life is very chaotic or organized primarily around the drug addiction. With a daily schedule, the counselor and patient can look at the patient's day and identify the patient's dangerous times and plan healthy activities to fill those times. The counselor also should remember to support and encourage anything the patient is doing that is positive, such as attending 12-step meetings, taking care of his or her dog and getting some exercise, attending counseling regularly. The issue of boredom, which is a common trigger for patients, can be addressed at this time, and ways to keep busy in order to reduce boredom can be encouraged.

Danny is unemployed, and his life is very disorganized. The counselor and Danny have been working on getting him to attend his counseling sessions regularly, two mornings a week, and to attend an NA meeting every day. This approach is helping Danny begin his day at a consistent time every morning. From the schedule, obviously Danny has too many empty hours in the afternoon and evening, and boredom is likely to be a problem. Now the counselor and Danny need to plan how he can fill some of these hours, perhaps by working out, visiting a nondrug-using family member, going to school, working part time or doing volunteer work, going to a second 12-step meeting, or spending time with recovering peers.

Preparing a weekly schedule is helpful for the patient who has some structure in his or her life, perhaps a job, but who has a particular time that is very dangerous or a trigger for her. In Elaine's case, she is pretty responsible during the week, but Friday night through Sunday afternoon is a dangerous period for her, because her children's father (they are separated) takes the children. Also, Elaine feels stressed and burdened by the responsibilities of her week, and she needs to do something to relax and pamper herself over the weekend. Unfortunately, many people turn to drug use to "nurture" themselves when they feel very stressed by their daily life, because it is such a "quick fix" even though it ultimately causes them to feel more stressed and unhappy.

In this situation, the counselor probably wants to acknowledge that Elaine handles a lot of responsibilities well during the week and has little time for herself. Then the counselor can discuss with Elaine how she feels about her free time over the weekend and what she can do to avoid drug use during this time. They can problem solve to identify things that she can do to take care of herself during her free time over the weekends. Possibilities include joining a bicycling club, taking a dance class, reading a good book, having her nails or hair done, or visiting a recovering friend or a family member.

Preparing a weekly schedule also is helpful if a patient in recovery seems to be overscheduling himself or herself and cannot fit in a needed additional 12-step meeting or some personal time to relax. If a recovering patient seems to be overzealous and compulsive about keeping busy as a way to stay clean, a weekly schedule can be a way to illustrate and discuss this tendency.

Elaines's Weekly Schedule
Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
7 am Get Up	7 am Get Up	7 am Get Up	7 am Get Up	7 am Get Up
9 - 2 work		9 - 2 Work		9 - 2 Work
	12 noon NA Meeting		12 noon NA Meeting
3 pm Pick up kids	3 pm Pick up kids	3 pm Pick up kids	3 pm Pick up kids	Free time		3 pm Pick up kids
4 - 9 pm Make dinner, spend time with kids	4 - 9 pm Make dinner, spend time with kids	4 - 9 pm Make dinner, spend time with kids	4 - 9 pm Make dinner, spend time with kids	Kids are with their father		4 - 9 pm Make dinner, spend time with kids
11:30 pm Turn in	11:30 pm Turn in	11:30 pm Turn in	11:30 pm Turn in			11:30 pm Turn in

Craving

The counselor should discuss the concept of craving with the patient. Craving is the strong desire an addict experiences for his or her drug of choice, such as cocaine. Some patients may not identify with the word craving but instead may use the word urge. Individuals appear to experience craving differently, but they usually describe physical and psychological symptoms. In the case of cocaine, these symptoms include heart palpitations, rapid breathing, obsessional thinking about the drug, and planning how one can get the drug or get the money needed to buy it. Craving is thought to be due in part to biological factors and in part to learning. Probably all cocaine addicts experience craving for cocaine.

The counselor must help the patient to understand and recognize what craving or having an urge feels like. Recognizing craving will help the patient to maintain abstinence. The counselor should communicate to the patient that he or she can experience and recognize a craving but choose not to act on it in the usual, self-damaging way. Craving, however strong, does not have to lead to drug use. One can just "sit the craving out," and it will pass. A useful analogy may be likening the craving to a strong ocean wave. The wave will feel very strong when one is in the throes of it, but it will wash over and pass. Also helpful is explaining that the strength of cravings will decrease over time if the patient does not use, but if he or she uses the drug, the craving phenomena will remain strong.

High-Risk Situations

High-risk situations are those times that involve the people, places, and things that trigger the addict's cocaine craving. The counselor should discuss situational triggers with the patient and help the patient to avoid them if possible or learn to cope by developing the alternative responses necessary to deal with these situations without using. This topic should be largely a review of what the patient has learned about people, places, and things in general but with an emphasis on the actual situations that recur in the patient's own life and trigger a craving for cocaine. Learning how to avoid these times or to develop alternative responses to whatever triggers the desire for cocaine is central to recovery from addiction and bears regular repeating. The counselor will review with the patient actual and potential "high-risk" situations that might occur and what can be done to avoid them. Examples of high-risk situations are being offered drugs, being around a drug-using friend, or attending a social function where drugs are available. The counselor should rehearse with the patient alternative responses to exposure to these situations. Identifying such situations well in advance and rehearsing how one could deal with such exposure should provide a better chance of avoiding a relapse from such exposure.

After the patient identifies his or her particular high-risk situations, the counselor and patient should work together to develop strategies for avoiding these situations. Other potential high-risk situations also should be considered. The counselor should offer reasonable alternative responses to unavoidable high-risk situations, such as calling a friend or talking to one's partner or spouse. The patient should be encouraged to use the support of drug-free or recovering friends, family members, and AA/NA/CA acquaintances.

Social Pressures To Use

Many addicts report that their entire social life revolves around their addiction. Addiction limits the scope of their social interactions to the point where all of their social contacts are with other addicts, usually creating a lot of social pressure to use in order to remain within the group. Addicts have to face this social pressure. Other addicts might not want the addict to recover, because they are reminded of the failings and liabilities of their own illness. They will put pressure on the addict who is trying to break the cycle of addiction. This pressure may be blatant, such as offering the recovering addict drugs or demeaning him or her for trying to recover. Alternatively, they may use more subtle techniques, such as mentioning previous "good times" involving drug use.

The counselor should ask the patient if he or she feels pressured by peers to continue or resume using drugs. If so, the patient's peer group, the experience of the pressure, and the patient's response to the pressure should be discussed.

The simplest resolution to this problem - the avoidance of all drug users - should be strongly encouraged. Recovering addicts who are feeling more dependent and greatly need to fill the void left by the drugs may be lonely. The patient needs to realize that the people with whom he or she was getting high were not true friends and begin to forge positive relationships with drug-free and recovering people. Participation in AA, NA, or CA should be encouraged as a way of filling the void left by the loss of drug-using peers. Establishing a new, recovering peer group within the 12-step program creates positive social pressure to remain abstinent that often is very helpful.

Compulsive Sexual Behavior

Frequently, sexual encounters become associated with the use of cocaine, because many people believe that cocaine enhances sexual experience. In actuality, cocaine distorts the sexual experience so that it eventually becomes an emotionally painful, compulsive quest to get the best high or rush similar to the experience of using cocaine.

Many cocaine addicts have a problem with compulsive sexual behavior, which should be addressed at various points in the addiction treatment. In early abstinence, the first issue to address is whether sex or the potential for sex is a trigger for the addict. If the patient's craving for cocaine or any drug is triggered by sex, the counselor needs to encourage the patient to avoid those sexual stimuli that trigger craving. The counselor should explore with the patient the sexual situations that lead to craving, as well. For example, the patient may prostitute to get drugs or meet with a prostitute to get sex in exchange for drugs. Also, a patient may be aroused by sexual experiences involving pornography or sexual paraphernalia, along with the use of cocaine. The patient needs to avoid such triggers, and the counselor should help the patient to identify healthy alternative ways to fulfill appropriate sexual desires.

For some patients, the message in the beginning of treatment can be to avoid sexual stimuli for a while. Later, when the patient is more stable, the counselor and patient can work on establishing healthier means of sexual expression for the patient. For other patients, asking them to abstain from sexual behavior for a while is not practical. In these cases, the counselor and patient must ascertain what types of sexual behaviors are emotionally affirming rather than compulsive. The patient should be encouraged to participate only in these more positive kinds of sexual experiences.

If the patient has participated in impulsive or promiscuous sexual behavior, information about HIV infection, safe sex practices, and the patient's risk factors should be addressed.

Postacute Withdrawal Symptoms

Some people, particularly those who have used cocaine in large amounts over long periods of time, will experience long-lasting changes in mood, affect, and memory. These changes may continue for days or weeks after the cocaine use has been stopped. Anxiety and/or depression, often accompanied by difficulty in sleeping, are some of the symptoms that may occur. Other patients experience panic attacks that persist for varying time periods after episodes of cocaine use. Some complain of difficulties in short-term memory, such as alcoholics experience after detoxification. Another problem is feelings of anhedonia or lack of pleasure in life; the addict experiences depression or other symptoms of a mood disorder that can persist beyond the period of acute detoxification. These symptoms are known as postacute withdrawal symptoms (Gawin and Kleber 1986).

Other patients with cocaine addiction do not have any of these symptoms after stopping drug use. Those who have the symptoms usually experience them for a relatively short time. The drug counselor must be aware of the symptoms of postacute withdrawal and discuss them with the patient. The aim is to help the patient identify them if they occur and to label them appropriately as symptoms that have resulted from cocaine use. The danger is that the patient will interpret the symptoms as being fundamental problems with himself or herself that can be reversed or corrected by self-administration of cocaine or other drugs. The counselor is to be very firm in telling the patient that such symptoms are most likely a result of drug use rather than an independent disorder and that they will be, in fact, made worse, not better, if cocaine is used.

Use of Other Drugs

Frequently patients see themselves as being addicted only to their drug of choice in spite of the fact that they frequently use another drug or drugs as well. For example, if the individual is in treatment for cocaine addiction, he or she may believe that alcohol or marijuana still can be used nonaddictively. The counselor should strongly encourage the patient to accept the necessity, if he or she is to achieve full recovery, for total abstinence from all drugs (excluding, of course, any appropriately prescribed medications).

The counselor must first find out what, if any, mood-altering substances the patient is continuing to use. If the patient denies use of any mood-altering substances, this topic should still be addressed briefly before discussing other issues. If the patient continues to drink alcohol or use another drug, the counselor should engage the patient in a discussion of the pros and cons of continuing to use these drugs.

The counselor should also point out the following reasons for total abstinence:

1. Other drugs, such as alcohol, are likely to trigger a craving for cocaine.
2. An addict may transfer the addiction to the other drug and begin using it compulsively.
3. An individual who uses alcohol or marijuana, for example, will not learn how to cope with daily stressors, relax, or have fun without the use of mood-altering substances.

If the patient is particularly resistant to giving up use of his or her secondary drug(s) on a permanent basis, the counselor may be more successful by avoiding the power struggle and encouraging the patient to abstain temporarily (for the length of the time that he or she is in treatment), rather than directly confront the resistance. This issue then will reemerge at a later point in treatment, giving the counselor and patient another opportunity to discuss the importance of abstaining from all mood-altering substances to achieve recovery.

12-Step Participation

All patients who are treated for addiction are advised to participate in one or more self-help groups. The most popular self-help groups are the 12-step groups, including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA). The addiction counselor must be familiar with the general 12-step philosophy and the 12 steps and be able to review them, and the principles involved, with each patient. Reviewing these concepts will serve to familiarize the patient with the 12 steps in a very general way and help the patient to apply the 12-step approach to specific aspects of his or her recovery program.

As the patient attends counseling sessions, the counselor will want to monitor the patient's participation in self-help groups. The counselor should inquire about the patient's participation in, and thoughts and feelings about, 12-step groups and follow up by providing whatever further information or encouragement the patient needs about self-help groups and the 12-step philosophy; for example, giving patients a current meeting list for their neighborhood or describing where the local NA clubhouse is. Also, if the patient expresses some hesitancy about attending meetings because of the people, the counselor might assess what kind of people the patient would be likely to be most comfortable with and recommend that type of meeting. The counselor should explain to the patient that there are gay and lesbian meetings, women's meetings, nonsmoking meetings, medical professionals meetings, and so forth.

Once the patient is attending 12-step meetings, sponsorship should be discussed and encouraged. The role of a sponsor is to be a guide and a support person for the recovering addict. The sponsor will take a special interest in the addict's recovery and will draw from his or her own experiences in recovery and personal relationship with the 12-step program to aid the addict in recovery. The patient should select a sponsor from among the more advanced recovering individuals he or she has met in the group. The sponsor should be someone who is working through the program in a healthy way, has the patient's respect, and has something to offer the patient emotionally toward personal recovery. Also, if the patient is heterosexual, the sponsor should be the same gender to avoid the complication of sexual attraction and the potential for sexual acting out between sponsors and sponsees. Important to the patient's recovery is feeling that he or she can have an intimate relationship with the sponsor and that this relationship does not become sexualized. No specific parallel rule applies if the patient is gay or lesbian; however, the principle remains the same. Recovery must not sexualize the sponsor-sponsee relationship.

In reviewing the 12-step program, the counselor should emphasize the importance of participating in self-help groups and also make the patient comfortable with the 12-step process, including sponsorship. Discussions about the 12-step program also will serve to introduce the idea of continuous, even lifelong participation in a personal recovery program.

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