Ideally, a person with substance use disorder, as part of an evidence-informed treatment plan, would be assisted with tapering in a combination of activities and practices that are approximations of what substances did for a person, while tapering out substances that have become problematic. The intention would be to seek and maintain a steady state of well-being.

That process would take several steps:

1. Identify the purpose and meaning of the use of substances for the individual, whether frequently or infrequently, whether alone or with others.
2. Identify one’s individual strengths, interests, and preferences.
3. Over time – acknowledging that no one source, perhaps even combinations of sources, might ever equal the complete experience substances offered – identify possible practices, activities, and conditions that might serve as replacements, however approximately, for substances and their use.
4. Use knowledge of one’s strengths and preferences to experiment with a variety of practices, activities and conditions that might by helpful to the individual. Become aware of feelings, thoughts, physical sensations, and attention and use them as feedback to monitor stability.
5. Adjust. Keep, and possibly expand, what helps with steadiness. Jettison what doesn’t. Maintain a list of future possibilities to try.

Unfortunately, most people with substance use disorder are mandated to abstinence. What the substances did is no longer being done. This can throw – even slam – people into instability.

“Do not attempt to take away a person’s main means of trying to cope with pain and suffering until you have another effective coping strategy in place.”
– Alan Marlatt, Ph.D., 2004

As a person with substance use disorder, then, as quickly and efficiently as I can, I need to try to figure out a few things that substances did for me, note a couple of my strengths, try to become aware of some preferences, then create a short list of things that might possibly serve in the place of substances for me individually, and then use my strengths to try to make those things happen.

Here’s a brief version of this post as a printable worksheet entitled A Look at the Purposes of Substances and What Might Replace Them (.pdf opens in new tab).

Purposes of Substances and Substance Use

What do I think substances, or use of substances, did for me?

_____ Enjoyment, pleasure, reward
_____ Relief from emotional pain
_____ Relief from physical pain
_____ Relief from existential despair, i.e. a helpless, hopeless feeling from not knowing if your life has meaning or if anything matters
_____ Relief from strong feeling states: anger, frustration, sorrow, agitation
_____ Relief from worry
_____ Relief from social anxiety
_____ Relief from anxiety
_____ Relief from depression
_____ Relief from racing or disturbing thoughts
_____ Relief from bad memories: trauma, neglect, abuse, witnessing violations against others
_____ Relief from grief and loss
_____ Relief from boredom
_____ Release from isolation and loneliness
_____ Sense of absence or escape
_____ Sense of protection
_____ Sense of belonging, being a part of, fitting in, or being accepted
_____ Sense of love and comfort

Now, let me rank order the top three, or more if I choose, by placing a “1” by the most important, a “2” by the next most important, etc.

What were the top three purposes served by substances and/or substance use for me?

1) ______________________
2) ______________________
3) ______________________

What insights did I gain from thinking about the purposes and meanings of substance use for me?

Strengths

People with substance use disorder often don’t feel very good, or feel very good about themselves. Instead of thinking of myself as either good or bad, let me suspend judgment for a moment. Let take a look at myself with objectivity and kindness.

If I see some traits I don’t like, for now, I simply shift my attention away from those thoughts, and look again for my strengths.

If I’m having trouble, I can remember the praise others have given me and name the strengths they saw in me.

If I’m doing this exercise right now, even if I don’t really want to, that’s the strength of discernment. I  might be penalized by an authority or someone I care about if I don’t take a look at these things. Discernment includes the strength of telling the difference between what’s helpful and what’s not helpful.

What other strengths do I have?

_____ Courage

_____ Creativity

_____ Kindness

_____ Generosity

_____ Problem-solving

_____ Determination

_____ Perseverance

_____ Honesty

_____ Fairness

_____ Leadership

_____ Love of learning

_____ Forgiveness

_____ Humor

_____ Teamwork

_____ Appreciation of beauty

_____ Empathy

_____ Awareness

From this list, what do I think are my top three strengths?

1) ______________________
2) ______________________
3) ______________________

Interests and Preferences

What are three activities that I like doing, or used to like doing?

1) ______________________
2) ______________________
3) ______________________

Where are three places I like to be with people, or don’t mind being with people?

1) ______________________
2) ______________________
3) ______________________

Preferences for Self-Care

According to research, medications are the first line of treatment for longings, urges, and cravings that accompany deprivation from substances in people with substance use disorder. Research is inconclusive about self-care behaviors (SCBs) that can assist with abstinence. Some studies suggest that the practices listed below may be helpful.

Which of the following activities, practices, or situations might be potentially helpful to me?

_____ Exercise
_____ Sleep hygiene: managing sleep time/wake time/length of sleep
_____ Managing caffeine intake and timing
_____ Managing nicotine intake and timing
_____ Managing quality, quantity, and timing of meals and snacks
_____ Engaging in focused breathing or breathing patterns
_____ Engaging the senses: see, hear, taste, touch, smell, motion
_____ Engaging in focused activities, such as cooking using a recipe, doing a repair, drawing, painting or coloring, playing a game, working a puzzle, journaling
_____ Engaging in social gatherings and activities that foster social connection

Which of these self-care behaviors is already a strength for me?

____________________

Which one, with a very small change, might move it up to tie with my top self-care behavior?

____________________

What would that small change be?

____________________

Replacement Preferences

I identified the top three purposes served by substances and/or substance use for me. They are normal, human, understandable needs. What might, even minimally, for me, serve in their places?

Enjoyment, pleasure, reward ____________________
Relief from emotional pain ____________________
Relief from physical pain ____________________
Relief from existential despair ____________________
Relief from strong feeling states ____________________
Relief from worry ____________________
Relief from social anxiety ____________________
Relief from anxiety ____________________
Relief from depression ____________________
Relief from racing or disturbing thoughts ____________________
Relief from bad memories ____________________
Relief from grief and loss ____________________
Relief from boredom ____________________
Release from isolation and loneliness ____________________
Sense of absence or escape ____________________
Sense of protection ____________________
Sense of belonging ____________________
Sense of love and comfort ____________________

What’s Next?

Based on what I’ve discovered about what substances and substance use did for me, what my strengths and preferences are, and what research suggests is helpful to people who are trying to abstain, with the intention of increasing my sense of stability and well-being, what are three things I might be able try this week in place of substances?

1) ______________________
2) ______________________
3) ______________________

What is the smallest, gentlest step I might be able to take on my own to help myself try to make one of these things possible?

A small step I might be able to take is:

____________________________________________
____________________________________________
____________________________________________.

“It’s my life. Don’t you forget.”
– “Talk, Talk,” The Music Machine

This post is part of a series.

The table of contents for the series is here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. 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.

A lot of people with substance use disorder (SUD) – popularly termed “addiction” – stop using substances on their own, a few stop through 12-step recovery, and many successfully practice harm reduction. The rest of us have to scramble.

Before 2016, no research-backed guide to substance use disorder treatment existed. Once the Surgeon General’s report, Facing Addiction in America, was published in November, 2016, however, most* of the data about what works and what doesn’t is now available to the public. What that means, though, is that many people living with addiction today have been incorrectly treated, even maltreated, for decades, resulting in acute, seemingly intractable cases.

Based on my fierce and determined study of the 400+ pages of the Surgeon General’s report, research for our literature reviews, and secondary sources that cite research, I outlined an initial, evidence-informed treatment plan for substance use disorder. I expanded that outline for clinicians who assist people with alcohol use disorder.

Logically, then, if I have substance use disorder, and can receive evidence-informed treatment from medical professionals and other trained health care professionals, I should be able to abstain from problematic substances, be able to use legal and prescribed substances in non-problematic ways, or engage successfully in harm reduction, right?

Realities trump logic.

• Substance use disorder treatment is hard to find in America, especially in rural areas. If treatment is available, many people don’t have health insurance to cover it, or their policies have limited coverage for addiction treatment, including medications. Expenses can be beyond the means of many people.
• Evidence-informed substance use disorder treatment is hard to find in America, period. Many treatment facilities still use a 12-step model which does not, according to research, result in abstinence for most people, most of the time.
• Whether evidence-based or not, where affordable or subsidized addiction treatment is available, wait lists are long.
• Abstinence is required to remain in treatment for the illness of addiction, yet inability to abstain is the symptom of the illness.

Although addiction is a medical condition, it is considered a moral and criminal one. People with the medical condition of addiction have lost their jobs, lost their kids, lost their licenses, even lost their freedom through incarceration.

Society’s primary measure of achievement of recovery from substance use disorder is negative urine drug screens for illicit and non-prescribed substances. Secondarily, society requires reduced contact with 1) the criminal justice system, 2) emergency health care services, and 3) child protective services.

Achievement of legal negative urine drug screens requires abstaining from illicit and non-prescribed substances. However, the National Institute on Drug Abuse (NIDA), a division of the National Institutes of Health (NIH), states, “Addiction is a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”

If my survival instinct, willpower, abilities to choose or decide could have kicked in, they would have. I would be abstaining. I would “piss clean.” I have experienced extensive, significant, harmful consequences, as have others, as a result of my continued substance use. Continuing to use doesn’t make sense to me or to others. But according to the definition of addiction, my repeated behavior wouldn’t be about sense, logic, or reason. It is about malfunctions in the brain.

Let me see if I’ve got all this.

I have a medical illness of the organ of the brain. I can get limited or no medical care for it. The primary symptom of the illness is repeating a behavior. I am expected to, on demand, right now, not display the symptom of the illness in order to prove I’m healing from it.

That’s a diabolical, no-win, Catch-22, gaslighting, crazymaking, double bind.

And it’s a malfunctioning view of addiction. In the Philippines, they shoot their people with addiction. About that, our president said, “Great job.”

In the short-term, I just don’t see anything to do about society’s views, or about federal law, state law, insurance company policy, and/or medical board policy that restrict treatment for addiction.

Dogs put in horrible experiments where they couldn’t avoid electric shocks just laid down helplessly.

No! Not us!

If people with substance use disorder – of which I am one – want to get and keep jobs, stay out of jail, and get our kids back, the only solution I see is to take treatment matters into our own hands.

In my estimation, help is not on the way.

What we need is a guide to do-it-yourself, evidence-informed, addiction treatment.

The primary problem with that approach is this:

“A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use.”
– Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health, November, 2016, Page 4-1

Medical illnesses need medical care. Since most of us are not medical professionals, nor ethically able to treat ourselves if we were, our first priority needs to be to figure out how to get medical care for ourselves, or to get on wait lists to receive it.

In a modern, industrialized country, taking health care treatment matters into our own hands might seem radical and revolutionary. It should be unnecessary. But the current state of addiction treatment in the U.S. creates a third-world nation of deprivation, a post-apocalyptic, Stone Age realm in which people must use the tools at hand to fashion their own survival. Luckily, thanks to advocates like Maia, Vivek, and others, we don’t have to rely on word-of-mouth folk wisdom, rocks and twigs. Advanced, evidence-based tools are at hand.

In low-income countries, lay people help each other with health issues all the time. Nora Volkow, M.D., Director of NIDA, advocates for crowdsourcing addiction treatment. Virtual assistance (telemedicine) with addiction care is on the horizon.

All right, then. Let’s help each other. Let’s create a guide to evidence-informed, do-it-yourself, addiction treatment.

*most of the information in the Surgeon General’s report:

1. Our literature review concludes that Twelve-Step Facilitation, TSF, is not an evidence-based addiction treatment protocol.
2. We challenge ranking naltrexone with methadone and buprenorphine as first line treatment for opioid use disorder, rather than listing it as an alternative.
3. We assert that the evidence does not support rehab as an effective protocol for achieving abstinence.

Last updated 12/31/17

This post is part of a series.

The table of contents for the series is here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. 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.

If I can become aware, in the moment, of what I am giving my attention to, what I am feeling, what I am thinking, and what physical sensations I am experiencing, and do so without judgment, I can use this information to help myself decide what would be most helpful for me to say or do next – or not say or not do.

ATTENTION

“To what am I giving my attention right now?”

Here are ways to help myself become more aware of to what I am giving my attention:

• Try an Awareness Check-in.
• Watch the Headspace YouTube videos about basic meditation.
• Use the Basics pack in the Headspace app.
• Take a sensory tour of where I am living. Ask myself, “What was the most notable sight, sound, touch, smell, taste (if available), and motion I noticed on my tour today?”

FEELINGS

“What am I feeling right now?”
“On a scale of 1 to 10, what is the intensity of that feeling?”

Here are ways to help myself become more aware of what I am feeling, and to adjust the intensity of my feelings to a range that feels stable to me:

• Identify and name my feelings using the Feelings Wheel or other online source.
• Imagine an inner volume control on my feelings. Imagine myself matter-of-factly dialing down the volume if my feelings are ramped up too high for me to feel stable, or dialing up the volume if my feelings get so low that I feel unmotivated.

THOUGHTS

What am I thinking right now?

Here are ways to help myself become more aware of what I am thinking:

• State my thoughts to myself in simple sentences: “I am thinking ___________.”
• Imagine two piles for my thoughts, one pile for “helpful” and one pile for “unhelpful.” As I become aware of my thoughts, I name them “helpful” and “unhelpful” and mentally place them into one of the two piles.
• While I might want to label my thoughts “good” or “bad,” “right or wrong,” “sensible” or “crazy” – and I might be right that they are one or the other! – I simply shift my attention to one question: “Is this thought ‘helpful’ or ‘unhelpful’?”
• I acknowledge that my attention will be drawn to both piles. When my attention shifts to the “unhelpful” pile, I simply disengage my attention, shift it, and re-engage it with the “helpful” thoughts. No harm, no foul, no judgment, just disengage and shift.
• I shift and re-shift my attention to the pile of helpful thoughts, rank order them in importance, and give my attention to the most important thoughts.

PHYSICAL SENSATIONS

What physical sensations am I experiencing right now?

Here are ways I can help myself become aware of the physical sensations I am experiencing, and separate them from what I am feeling, from what I am thinking, and from who I am:

• I say to myself, “I am not what I am sensing.”
• I do a quick body scan. I start with the top of my head, move through my body to my toes, and become aware of what is going on within my body.
• I identify which parts of my body are feeling comfortable and which are feeling uncomfortable.
• To help myself feel more comfortable and more stable, I consciously move or breathe.

Regardless of what is going on in my life, or what kind of distress or stress I might be experiencing, I can pause, become aware, and collect specific information about what’s going on with me. I can practice a few skills to kindly steady myself, then I can continue to take helpful, skillful action on my own behalf.

Photo: “Self-hug” of Casey Sapienza by Mia Sapienza

How I Help Myself Now to Handle What’s Next as a handout  (.pdf opens in new window)

Awareness Check-in

This post is part of a series.

The table of contents for the series is here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. 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.

I calm and reassure myself as I become aware of what is up with me.

BODY

Please do a quick body scan. Start with the top of your head, move through your body to your toes, and become aware of what is going on within your body.

Right now, the most comfortable part of my body is _____________________________________.
Right now, the most uncomfortable part of my body is _____________________________________.

FEELINGS

Please become aware of what you are feeling. Choose one of the “Big Four Feelings” – mad, sad, glad, afraid – OR use words from the Feelings Wheel handout, ” OR use your own words.

Right now, I feel ________________________________.

THOUGHTS

Right now, I am thinking:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.

CATCHING NEGATIVE SELF-TALK

I caught myself using this sentence to criticize or judge myself:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.

REPLACING WITH HELPFUL SELF-TALK

I used this helpful, supportive sentence about myself to replace my negative self-talk:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.

NEEDS

I am aware of these three, current needs I have:
1) _______________________________
2) _______________________________
3) _______________________________

WANTS

I am aware of these three, current wants I have:
1) _______________________________
2) _______________________________
3) _______________________________

PRIORITIES

The most important thing for me to talk about today is: _________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.

QUESTION

The question I would most like to hear an answer to today is:
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________.

Here is a printable version of the Awareness Check-in. (.pdf opens in a new tab.)

This post is part of a series.

The table of contents for the series is here and posts are published in the category entitled Guide.

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. 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.

At the end of 2012, I experienced myself having out-of-control feelings and thoughts, alarmed by images and memories, in severe emotional and physical pain, flooded by waves of panic, fighting longing,  in circumstances I couldn’t change or influence, isolated and alone. I felt anguished and agonized, helpless, and hopeless that anything could change. I love my life and wished so much better for myself!

With professional assistance and through my own studies, I was able to derive a formula for an inner dialogue that helps me no matter what is – or isn’t – happening.

Today, I am contented enough, enough of the time, to thrive.

. . . . .

I pause.

I give myself permission to step back from everyone and everything, even just for a moment.

I say to myself, “I am here for me.”

I say to myself, “I will not leave myself, no matter what.

I say, “I am kind to myself. I will stay kind to myself no matter what.”

 

Gently, patiently, but muscularly, I become aware of to what I am giving my attention.

I acknowledge the reality of what has my attention. It may be in the physical world or it may be a feeling, thought, image, or memory in my interior world. Without judgment, I simply name it.

If I am longing for substances, I strong-arm my attention.

I then use my attention to focus on what I am feeling, thinking, sensing, and doing.

I ask myself, “What am I feeling?”

I use my attention to become aware of my feelings and name them. I note the intensity of my feelings and adjust the volume on my inner state to a level that feels stable to me.

I ask myself, “What am I thinking?”

I become aware of my thoughts and, with mercy, acknowledge my thoughts without judgment.

Without judging each thought as good or bad, right or wrong, positive or negative, rational or irrational, I simply consider whether or not the thought would be helpful to me right now. I sort my thoughts into helpful and unhelpful piles.  I focus my attention on the helpful thoughts. I rank order my helpful thoughts and give my attention to the most important ones.

I ask myself, “What am I sensing?”

I become aware of physical sensations I am having and become aware of what information they give me. To help myself feel more comfortable and more stable, I consciously move or breathe. I shift my attention to information from my senses: to what I see, hear, taste, touch, sense, or to motion.

I ask myself, “What am I doing?”

I simply become aware of what actions I am taking, whether with my physical body or with my brain.

As a result of using my attention to become aware of my feelings, thoughts, and physical sensations,

I can then access the best of both my heart and my mind

which is my inner wisdom.

I can consult my inner wisdom to guide me in deciding what’s most helpful for me to say or do next – or not say or not do – with regard to myself and others.

. . . . .

When I become aware I am experiencing trauma symptoms, I have found this version of my inner dialogue  to be helpful.

This post is part of a series. The table of contents for the series is here and posts are published in the category entitled Guide.

Last updated 12/23/17

The views expressed are mine alone and do not necessarily reflect the positions of my employers, co-workers, clients, family members or friends. 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.