An elephant in the room when people talk about addiction is the subject of return to substance use after a period of abstinence. People with addiction who are maintaining abstinence may think, “Will I return to use?” or “Can I return to just a little use?” People who care for people with addiction may think, “Will you return to use?” and “How could you possibly return to use after all you’ve put me through?” People who have lost loved ones to addiction often think, “How could I have let them return to use?” and “How could I have been a better parent, partner, sibling, fill-in-the-blank so they wouldn’t have returned to use?”
So many conflicting, understandable thoughts in one room! Such fear with which to empathize!
The American Heritage Dictionary of the English Language defines “ambivalence” as “1. The coexistence of opposing attitudes or feelings, such as love and hate, toward a person, object, or idea,” and “2. Uncertainty or indecisiveness as to which course to follow.”
I posit that the majority of ambivalent feelings and thoughts about addiction are created by belief-based social norms rather than reason and research. This extends to return to use after a period of abstinence, commonly termed “relapse.”
The American Heritage Dictionary defines “relapse” as “1. To return to a former state. 2. a. To become sicker after partial recovery from an illness. b. To recur. Used of an illness. 3. To slip back into bad ways; backslide.”
The third dictionary definition is the one usually applied to people with addiction. When people were abstaining, they were observing “good ways.” When they returned to use, they were “slipping back into bad ways.” This implies that return to use is a matter of morality, a good-bad duality.
For addiction, however, it is the second definition that is confirmed by research. Addiction is defined as a medical illness, not a moral one. Therefore, for some people, return to use may well be “to become sicker after partial recovery from an illness.” Addiction has also been determined to be a brain disorder that causes substance seeking and use, despite negative consequences. Ergo, if a person is “not sicker,” no longer seeks substances, and no longer experiences negative consequences from using them, by research-backed definition, the person is in remission from this medical illness. When substance use is optional and without negative consequence, it is not indicative of medical illness.
Proponents of the moral model of addiction rage at these statements. However, the statements are supported by data. Humans have used substances for at least 12,000 years. The vast majority of people – 70 to 80% for substances in general, 92% for people who use opioids – do not develop addiction from substance use. Of those who do, research indicates that brains are made susceptible to developing addiction from trauma, particularly in early childhood – including the chronic trauma of poverty and economic hardship – challenges with attention, autism spectrum disorder, and other factors.
[The primary argument against helping people with addiction – even after acknowledging the evidence from brain research that addiction is a medical illness – is that since people “chose” to use the substance in the first place, they deserve what they get.
Let’s check the facts.
- Nearly 99% of Americans have “chosen” to use some combination of the legal, experience-altering substances alcohol, nicotine, and caffeine.
- Two out of three Americans have “chosen” to use the substance of food in ways other than maintaining normal body weight, such that complications from obesity cost taxpayers an estimated $190 billion per year.
- 70,000+ Americans died from “choosing” drug use that ended in overdose in 2017.
- 300,000+ Americans die annually from “choosing” to use the substances of food and beverages that end in obesity-related complications.
- 480,000 Americans die annually from “choosing” to smoke tobacco products containing the legal substance nicotine. (Without choice, 41,000 Americans die annually from secondhand smoke exposure.)
Using the logic of “choice” to exclude people from medical care, the debate over universal health care should be tabled since nearly no Americans deserve it due to their “choices.”]
If all elephants were led gently from the room, all debates silenced, and all criminal penalties for having a medical illness removed, a person who has been diagnosed with substance use disorder – the clinical term for what’s commonly called addiction – actually only has one concept to consider: harm. “Would my return to use cause harm to myself or others?” On the surface, that question seems simple. However, for many substances, there is no safe level of use. For example, ethyl alcohol is a neurotoxin, on the list with lead, nitric oxide, and Botox, served by the glass. The decision to return to use requires a complex cost-benefit analysis with rank ordering of risks and priorities.
Before that analysis can begin, the person with substance use disorder who is considering a return to use needs to achieve remission from the illness. Essentially, summarizing this definition and this one, the person needs to be able to live well enough without problematic substances. “Well enough” would be individually defined, not socially defined, or defined as a loved one might wish.
Based on the neuroscience of addiction, the brain without substances to which one has become addicted creates anguish akin to losing air, water, a limb, and one’s beloved, all at once. How to live with anguish is the first task in achieving remission.
This is why research has found that medical care, counseling, and support – in that priority order – are the foundations of achieving remission from substance use disorder. Through specific, comprehensive assessments, medical professionals can find physical and mental sources of anguish and ease them with medical treatment: medications, medical appliances, physical therapy – the list of medical help and support is nearly endless.
Developing addiction requires continued use over time. Addiction creates in the brain what’s termed “automaticity,” i.e. learned action such that conscious thought is not needed and does not occur, like brushing one’s teeth in the morning, or braking while driving. Prior to developing the automaticity of addiction, people first used substances for reasons. They continued to use substances for reasons. Once addiction occurs, addiction adds automaticity to continued use. But harkening back to the reasons for first use, then for continued use, offers clues to what needs and wants the substances met. Finding alternative ways to meet those needs and wants – beginning with medical care for this medical illness – is the second task in achieving remission.
(Automaticity explains why “Just say no” is cruel advice as a care strategy for the complex medical illness of addiction. “Just saying no” to automatically braking while I’m driving would take a lot of time and training on my part to recreate thought before action. And from you, I would need to see proof with my own eyes that your alternative strategy for saving myself from crashing works. Treatment outcome data for rehabs certainly does not support abstinence as a safe alternative to use. If I go to rehab, I only have a 30% chance of not crashing?! If I have opioid use disorder and stop using opioids, I have only a 20% chance of not crashing?!)
Emotion regulation is the ability to become aware of the onset of strong feelings states that can become destabilizing, then to be able to simply adjust one’s inner “volume” to a more stable range. Lack of skill with emotion regulation – termed “emotion dysregulation” – is characterized by a sharp onset of strong feelings, a quick spike, continued intensity, and difficulty returning one’s inner state to a stable range. This is experienced as distress beyond bearing. Emotion dysregulation is a challenge common to people with substance use disorders and the conditions that can accompany them, such as trauma symptoms and mental illness. Substances can be used to effectively regulate emotions. Some substances are used as medications for this purpose. Illegal substances can do this work as well.
The more skill people have with regulation of emotions, the less likely they will be to seek and use substances to ease an emotionally dysregulated state. This is why cognitive behavior therapy, motivational interviewing, and contingency management are the top evidence-based methods for helping people with substance use disorders. Through various mechanisms, all of these assist with acquiring skillful emotion regulation, the third task of achieving remission from substance use disorders.
If I’m able to respond to medical care, can co-exist with what might remain an ever-present longing for the experience substances gave me, replace what substances did for me with alternatives, and learn skills to effectively regulate my emotions without illegal or non-prescribed substances, I might achieve remission from substance use disorder. Half of people achieve remission on their own, without treatment. Further, I may be able to return to use without experiencing negative consequences.
In consultation with medical and health care professionals, I might reconsider and expand the initial questions: “Would a return to use harm me or others? Use of what substances, in what amounts, with what regularity would reduce the risk of harm? What do I learn from doing a pros-cons, cost-benefit analysis with rank ordering?” Personally, I consider the possibility of return to use with simple I-statements: “If I want it or need it, I can’t have it.” A close second is, “If I think I deserve it or think I have earned it? I can’t have it.”
If I’m thinking something like, “I can’t take this anymore,” or “Only this substance will help,” or any version of “Blankety-blank this blank,” I reach out immediately for help. I’ve done my best to regulate my emotions but whatever I’m feeling and thinking as a result of what’s happening within or without has overwhelmed my skills. I can’t use substances in a state of stress or distress, not because using is morally wrong, but because the opposite of automaticity is consciousness. Brain science tells me that emotions can trump thoughts. As a person in remission from substance use disorder, I can’t risk automaticity kicking in again. It’s simply practical to require myself to be in a stable state to use substances, likewise to do almost anything that risks harm to me or others.
I reach out to others because social support is an evidence-based protocol for helping people with substance use disorders. The kind sound of others’ voices helps hum me and my brain back to a stable range.
If, after deep and probing conversations with myself and health care professionals, in my individual case, I/we determine that the potential benefits of returning to use outweigh the potential costs, I would create a safer use plan (again, for many substances, there is no level of use considered safe) and a post-use monitoring plan. I would also run these plans by health care professionals.
Tragically, medical illnesses cause misery to the people who have them and to those who love them. This is the human condition. Self-blame, other-blame, and second-guessing are no more merited for addiction than for any other medical illness.
Let’s free the elephants in the room. Let’s keep talking openly, directly, and factually about substance use.
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Anne Giles, M.A., M.S., L.P.C., is a counselor in private practice in Blacksburg, Virginia. She can provide counseling services to residents of Virginia only. This content is for informational purposes only and is not a substitute for medical or professional advice. Consult a qualified health care professional for personalized medical and professional advice.
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