Alcoholism

Addressing the Stigma that Surrounds Addiction

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nida-banner-science-of-abuse-and-addiction

From the Monthly Blog of Dr. Nora Volkow, Exec. Dir.
NATIONAL INSTITUTE ON DRUG ABUSE

Original Date April 22, 2020

Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. Healthcare already has effective tools including medications for opioid and alcohol use disorder that could prevent many of these deaths, but they are not being utilized widely enough, and many people who could benefit do not even seek them out. One important reason is the stigma that surrounds people with addiction.

Man sitting alone in streetlight at night

Stigma is a problem with health conditions ranging from cancer and HIV to many mental illnesses. Some gains have been made in reducing stigma around certain conditions; public education and widespread use of effective medications has demystified depression, for instance, making it somewhat less taboo now than it was in past generations. But little progress has been made in removing the stigma around substance use disorders. People with addiction continue to be blamed for their disease. Even though medicine long ago reached a consensus that addiction is a complex brain disorder with behavioral components, the public and even many in healthcare and the justice system continue to view it as a result of moral weakness and flawed character.

Stigma on the part of healthcare providers who tacitly see a patient’s drug or alcohol problem as their own fault leads to substandard care or even to rejecting individuals seeking treatment. People showing signs of acute intoxication or withdrawal symptoms are sometimes expelled from emergency rooms by staff fearful of their behavior or assuming they are only seeking drugs. People with addiction internalize this stigma, feeling shame and refusing to seek treatment as a result.

In a Perspective published recently in The New England Journal of Medicine, Dr. Volkow tells the story about a man she met who was injecting heroin in his leg at a “shooting gallery”—a makeshift injection site—in San Juan, Puerto Rico, during a visit to that country several years ago. His leg was severely infected, and Dr. Volkow urged him to visit an emergency room—but he refused. He had been treated horribly on previous occasions, so preferred risking his life, or probable amputation, to the prospect of repeating his humiliation. This highlights a dimension of stigma that has been less remarked on in the literature and that is uniquely important for people with substance use disorders: Beyond just impeding the provision or seeking of care, stigma may actually enhance or reinstate drug use, playing a key part in the vicious cycle that drives addicted people to continue using drugs.

Previously on her montly blog Dr. Volkow highlighted research by Marco Venniro at NIDA’s Intramural Research Program, showing that rodents dependent on heroin or methamphetamine still choose social interaction over drug self-administration, given a choice; but when the social choice is punished, the animals revert to the drug. It is a profound finding, very likely applicable to humans, since we are highly social beings. Some of us respond to social as well as physical punishments by turning to substances to alleviate our pain. The humiliating rejection experienced by people who are stigmatized for their drug use acts as a powerful social punishment, driving them to continue and perhaps intensify their drug-taking.

The stigmatization of people with substance use disorders may be even more problematic in the current COVID-19 crisis. In addition to their greater risk through homelessness and drug use itself, the legitimate fear around contagion may mean that bystanders or even first responders will be reluctant to administer naloxone to people who have overdosed. And there is a danger that overtaxed hospitals will preferentially pass over those with obvious drug problems when making difficult decisions about where to direct lifesaving personnel and resources.

Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Even people in healthcare, if they do not have training in caring for people with substance use disorders, may be at a loss as to how to interact with someone acting threateningly because of withdrawal or some drugs’ effects (e.g., PCP). It is crucial that people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants, be trained in caring compassionately and competently for people with substance use disorders. Treating patients with dignity and compassion is the first step.

There must be wider recognition that susceptibility to the brain changes in addiction are substantially influenced by factors outside an individual’s control, such as genetics or the environment in which one is born and raised, and that medical care is often necessary to facilitate recovery as well as avert the worst outcomes like overdose. When people with addiction are stigmatized and rejected, especially by those within healthcare, it only contributes to the vicious cycle that entrenches their disease.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1(800) 273-TALK. Or click on: www.suicidepreventionlifeline.org.

You can also find help through Narcotics Anonymous at 844-335-2408.

Children Suffer in Families of Addicted Parents or Siblings

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Kids of Addicted Parents

One group that doesn’t get the robust advocacy it needs is young children experiencing the impact of addiction in their family. Kids can be profoundly impacted by a parent’s or sibling’s addiction, and they grow up at greater risk of developing addiction themselves. And yet, insurance doesn’t cover care and prevention efforts for such children or the family, and children and families generally get scant mention in policy plans like the 2020 National Drug Control Strategy or relevant federal budgets (see here and here). That’s why advocates like our Jerry Moe and Sis Wenger, the CEO of the National Association for Children of Addiction, say children are the first hurt and the last helped.

National Children of Addiction Week just wrapped up, and we spent the week advocating for “kiddos,” as some of our Children’s Program counselors like to say. Jerry spoke in Ohio and did interviews with media from nearby West Virginia, two states hit hard by the addiction crisis. Lindsey Chadwick and our Children’s Program in Colorado hosted an art show featuring the drawings and paintings of young children growing up in families affected by addiction, and discussed it on a Denver TV station. And, Jerry fielded online, anonymous questions in real-time during a Reddit AMA (Ask Me Anything) hosted by NPR. That Q&A lives on—please help advocate for children by sharing it with others who may have questions about how to support kids affected by addiction in their family. Jerry will continue to answer questions over the next couple of weeks.

Find Help Near You

The following can help you find substance abuse or other mental health services in your area: www.samhsa.gov/find-treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. Also, a step by step guide on what to do to help yourself, a friend or a family member on our Treatment page.

 

Narcotics Anonymous National Hotline: 1(877) 276-6883
Alcoholics Anonymous Website: https://www.aa.org
You can also visit https://www.allaboutcounseling.com/crisis_hotlines.htm

“I’ll Quit Tomorrow!”

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It is mind boggling how alcoholism impacts people from all cultures, races, socioeconomic class, gender, religion, profession, and academic background. Interestingly, all alcoholics are ultimately alike. The disease itself swallows up differences and creates a universal alcoholic profile. The personality changes that go with alcoholism are predictable and virtually inevitable.  Alcohol can precipitate the onset of a disease with a predictable, inexorable course. It can ultimately destroy the physical, emotional, spiritual, and mental life of the sufferer. Alcoholism is typified by a progressive mental “mismanagement” and an increasing emotional distress that can reach suicidal proportions.

Hidden costs of alcoholism are not small. Alcohol-related expenses cost federal, state and local governments $223.5 billion. Of that amount, tax payers are footing the bill for $92.4 billion.

Drinking Was Fun, Once Upon a Time

drinkers

Early drinking is a mood-swinger, typically in a positive direction. It gives the drinker a warm, good feeling, that may lead to giddiness. When the effects wear off, the drinker feels normal. It does not take long to learn how to set the amount and select the mood. As the typical social drinker gets deeper into the booze, getting drunk begins to have a very different effect. Heavy drinking creates a sort of undertow that drags the drinker back beyond normal and into pain. This might be the point where euphoria is reached at a big cost—if it’s achieved at all. Now the booze is consumed in order to feel no pain. In other words, to get back to some degree of normal. This is the beginning of harmful alcohol dependence.

In addition to dependency, this phase also involves a rising emotional cost. We we see a significant and progressive deterioration of the personality of the alcoholic, and (eventually) a visible physical deterioration. Ultimately, the alcoholic’s whole emotional environment is torn to pieces and destroyed. Of course, most active alcoholics are in complete denial of the impending bottom.

There is now a progressive emotional cost for every single drink. The carefree days are gone, but the alcoholic is dimly aware of this fact at best. The rising cost is willingly paid. This is proof that dependency has become truly harmful. Of course, the drinker fails to comprehend the increasingly clear signs of destruction by alcohol. Frankly, at this point the alcoholic is learning to depend more and more on rationalization. Intellect begins to blindly defend against reason—indeed, against intervention. Eventually, the alcoholic will be completely out of touch with emotions. Internal dialog will become the soundtrack of an increasingly impenetrable defense system.

Denial is Not Just a River in Egypt

The tragedy is that rationalization actually works! This form of defense—which I employed constantly during my active addiction—continues to operate as the disease progresses. The alcoholic’s behavior will become increasingly bizarre, and the innate and unconscious ability to rationalize will be practiced to the point of perfection. The drinker finds it increasingly difficult to accept blame. Time passes, and the alcoholic condition worsens. Over a period of months and years the alcoholic’s self-image continues to wane. Ego strength ebbs. Feelings of self-worth sink low, and excessive drinking continues, producing painful and bizarre behavior. Eventually, emotional distress becomes a chronic condition. The drinker feels distress unconsciously even when not drinking.

Unfortunately, rationalization works. The tragedy is that this form of defense will continue to operate as the illness progresses.

Now, “mood swings” or personality changes are evidenced while drinking. The kind person becomes angry or hostile; the happy person becomes sad or morose; the gentle person becomes violent. Alcohol causes one’s guard to drop, and chronic unconscious negative feelings are laid bare. The drinker becomes truly self-destructive. All this drinking and emotional distress may lead to a vague but poignant feeling, I just might have a drinking problem. There is a general malaise so strong felt that desperate measures to escape are actually attempted. Geographical cure, a new job, divorce.

The Pathology of Alcohol Dependence

The final stages of alcoholism are close at hand. Continued excessive drinking and accompanying behavior bring on chronic suicidal feelings. I remember thinking many times, I should just go jump in the Susquehanna River! If the course of the disease is not interrupted, the end of all this is suicide—either slowly by continued drinking or in a direct manner. This is because as emotional distress mounts, and deterioration of the personality accelerates, these negative feelings are not clearly discernible. Quite the opposite is true: They are more effectively hidden.

A pathological use of alcohol can be measured by how the individual answers the following questions:

  • Have you ever drank early or first thing in the morning?
  • Have you ever drank alone?
  • Have you ever drank an entire fifth of alcohol in a day?
  • Have you ever felt remorse after drinking?
  • Is there a growing anticipation of the welcome effects of alcohol?
  • Has the anticipation moved into the realm of preoccupation?
  • Do you hide your booze in unusual places?
  • Are you unable to be honest about how much alcohol you consume?
  • Do you suffer blackouts or experience an inability to remember chunks of time?
  • Are you having difficulty with personal relationships, work, or the law due to drinking?

Counselors gather a history of the behavior patterns by questioning those who spend meaningful or extended time around the alcoholic. Here, the basic goal is to discover whether there has been a changing lifestyle secondary to the use of alcohol, which would indicate a growing dependence.

Drug and alcohol counselors often explore this changing lifestyle by asking probing questions. Has there been a growing tolerance to alcohol? Does it take more booze for the drinker to get the desired effect? Does the alcoholic start drinking in the kitchen before bringing drinks for guests into the living room? (I often drank secretly before drinking in front of guests or family.) To what lengths is the alcoholic willing to go to get the amount of alcohol needed? The degree of ingenuity used to get more booze becomes the scale for determining how far dependency has progressed. All instances of harmful dependency that show up in alcoholic behavior patterns indicate a maladaptation of the lifestyle to (a) growing anticipation of the welcome effects of drinking, (b) an increasingly rigid expected time of use, and (c) a progressive cunning in obtaining larger amounts of alcohol.

Rational defenses and projection take hold. Why is it that the alcoholic cannot see what is happening? Simple. They have lost the ability to see it at all. The reason alcoholics are unable to perceive what is happening to them is actually understandable. As the condition develops, self-image continues to deteriorate. Ego strength grows increasingly weaker. For many reasons, they are progressively unable to keep track of their own behavior and begin to lose contact with their emotions. Their defense systems continue to grow, so that they can survive in the face of their mounting problems. The greater the pain, the higher and more rigid the defenses become—and this whole process is unconscious. Alcoholics do not comprehend what is happening. Quite literally, they are victims of their own stinkin’ thinkin’.

stinkin-thinkin

As the emotional turmoil grows in chemically-dependent people, rational defense activity turns into real mental mismanagement. The drinker erects a wall around him or her. The end result is that the alcoholic is cut off from increasingly negative feelings about themselves. They are unaware of the presence of such destructive emotions.

Not only is the drinker unaware of the powerful, highly developed defense systems, they are also unaware of the intense feelings of self-hate buried inside them. Moreover, the problem is being compounded by the fact that these defenses have now created a mass of free-floating anxiety, guilt, shame and remorse, which becomes chronic. In other words, the alcoholic no longer drinks from a “normal” point, experiencing an upswing in mood to feeling great or euphoric; rather, they must start from where they feel depressed or pained and drink to feel normal again.

Drink Takes a Man

Alcoholics drink because they drink. A Chinese proverb says, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” The drinking pattern becomes thoroughly unpredictable or compulsive. The alcoholic quits, then resumes, and does not know why he or she is drinking again. And whenever they do start again, the resumption is at the level of chronic emotional deterioration. Conditions worsen with each new episode, trapping the drinker in a deadly downward spiral.

Depression and low self-esteem become so great, the alcoholic begins to employ projection—a defense mechanism in which unwanted feelings are displaced onto another person, where they then appear as a threat from the external world rather than from within. The alcoholic does not know this is happening. The more hateful alcoholics see themselves, the more they will come to find themselves surrounded by hateful people. Depending on the personality of the drinker, such projection can present itself in ways ranging from gentle complaining to outright aggression. It is obvious the easier targets are those people typically spending time with the alcoholic, including the most meaningful. Although alcoholics tend to hate themselves, their projection works so well that they actually believe they are attacking hateful people.

People who live and exist around the active alcoholic have predictable experiences that are also psychologically damaging. As they meet failure after failure, their feelings of fear, shame, frustration, inadequacy, guilt, resentment, self-pity and anger mount. So also do their defense mechanisms. They too use rationalization as a defense against these feelings. The chemically-dependent—and those around them—all have impaired judgment; they differ only in the degree of impairment.

People who are chemically-dependent on alcohol have such a highly-developed defense system that they become seriously self-deluded. The rigid defenses that have risen spontaneously around their negative feelings about themselves, and therefore around their behaviors that caused these feelings, would be quite enough, were they the only deluding factors, to draw these people progressively and thoroughly out of touch with reality. Not only do these defense mechanisms become more rigid, but such individuals develop a growing rigidity in their very lifestyle. They are less able to adapt to unexpected change. They eventually reach a point where even schedules are burdensome. This is primarily because, paradoxically, they are less likely to plan ahead. Or, when they do plan something, they tend to feel trapped as the moment closes in.

To Make Matters Worse

Chemically-dependent people have two factors progressively working together to draw them out of touch with reality: Their defense mechanisms and distortions of memory. Consider euphoric recall, which is the tendency for an alcoholic to remember their drinking escapades euphorically or happily—in only the best light—with gross distortion of the truth. They believe they remember everything in vivid and accurate detail, thinking that all was “just fine.” Of course, this will only serve to bury the drinker’s antisocial or destructive behavior. There is a destructive distortion of perception itself. There is a lack of ability to see and appreciate reality. No recognition or acceptance that they are on a downward spiral, fast approaching rock bottom.

Rock Bottom Became the Foundation

Either of these defense mechanisms seriously impair judgment. The time inevitably comes when it is plain that alcoholics cannot see they are sick. Yet they are acutely ill with a condition that will ultimately lead to death and destruction, and which will seriously impair their constitution emotionally, mentally, and spiritually during the final months of year of their active addiction. Accordingly, treatment for acute alcoholism cannot concern itself merely with putting the drink down. It also has to do with restoration of adequate ego strength to enable the alcoholic once again to cope with life.

The Best Approach

Therapy for acute alcoholics must address the whole person. The alcoholic suffers emotionally, mentally, physically, and spiritually. Treatment often involves physicians, psychiatrists, sociologists, psychologists, pathologists, and clergy. If the whole person is not treated simultaneously, relapse is simply… inevitable. If, for example, the emotional disorder alone is addressed, the alcoholic may believe he or she feels “so good” now that they can handle the drink. When treatment is short-sighted or limited, friends and family of the alcoholic may be heard commenting, “He was easier to live with when he was drinking!” This is akin to being a dry drunk. As this “dry” condition worsens, mental gains erode away and the alcoholic inevitably reverts to drinking to feel normal.

A description of despair by Søren Kierkegaard found in his book The Sickness Unto Death. Human despair is found at three distinct levels. First is the despair that expresses itself in sentences such as, “Oh what a miserable wretch I am! Oh, how unbearable it is to be me!” Second is the despair  that expresses itself by crying out, “Oh, if only I were not what I am. If only I could be like that person!” This is deeper despair because it considers self to be so worthless as to want to abandon it completely. But the third, deepest, despair of all is despair that does not believe one is a self at all. In other words, “I used to be… but not I am not.”

Physical complications, mental mismanagement, and emotional disorder are accompanied by a similarly progressive spiritual deterioration. Guilt, shame, and remorse exact their inevitable and immobilizing toll as time goes on. Feelings of self-worth begin to decline. As meaningful relationships wither on the vine, the growing estrangements lead to spiritual collapse. At the end, these feelings produce suicidal moods, ideation, and, unfortunately, suicidal attempt and/or death. If asked, “Can’t you see you’re drinking yourself to death?” the alcoholic replies, “So what? Who cares?”

Concluding Remarks

When asked how alcoholism is treated, people commonly think of either the 12-step program of Alcoholics Anonymous (AA) or inpatient drug and alcohol rehabilitation. There are, however, a variety of treatment modalities currently available. Today’s treatment for alcoholism naturally rests upon decades of research. AA was founded by Bill Wilson (“Bill W.”) and Bob Smith (“Dr. Bob”) in Akron, Ohio in 1935. AA’s program of spiritual and character development is based on the premise that turning one’s life and will over to a “personally meaningful higher power” is the key to recovery. It is, in fact, referred to as the key of willingness. Another central idea is that sobriety or recovery depends on the admission of powerlessness with respect to alcohol or other substances.

Treatment for alcoholism has made significant advances in the last 20 years. Researchers are constantly seeking novel approaches for improving the effectiveness, accessibility, quality, and cost-effectiveness of treatment. Alcoholism is a treatable disease. Regardless of how someone is diagnosed as alcohol-dependent, or how they came to realize they have a drinking problem, the first step to treatment is a sincere desire to get help. Overcoming an alcohol problem is an ongoing process that sadly might involve relapse. Granted, relapse is not a “requirement” for recovery—you don’t have to change your sobriety anniversary!—but it is merely a setback and not an indication that you will fail in your attempt to get sober.

 

Preface to The Surgeon General’s Report on Alcohol, Drugs and Health

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Before I assumed my position as U.S. Surgeon General, I stopped by the hospital where I had worked since my residency training to say goodbye to my colleagues. I wanted to thank them, especially the nurses, whose kindness and guidance had helped me on countless occasions. The nurses had one parting request for me. If you can only do one thing as Surgeon General, they said, “Please do something about the addiction crisis in America.”

I have not forgotten their words. As I have traveled across our extraordinary nation, meeting people struggling with substance use disorders and their families, I have come to appreciate even more deeply something I recognized through my own experience in patient care: that substance use disorders represent one of the most pressing public health crises of our time. Whether it is the rapid rise of prescription opioid addiction or the longstanding challenge of alcohol dependence, substance misuse and substance use disorders can—and do— prevent people from living healthy and productive lives. And, just as importantly, they have profound effects on families, friends, and entire communities.

I recognize there is no single solution. We need more policies and programs that increase access to proven treatment modalities. We need to invest more in expanding the scientific evidence base for prevention, treatment, and recovery. We also need a cultural shift in how we think about addiction. For far too long, too many in our country have viewed addiction as a moral failing. This unfortunate stigma has created an added burden of shame that has made people with substance use disorders less likely to come forward and seek help. It has also made it more challenging to marshal the necessary investments in prevention and treatment. We must help everyone see that addiction is not a character flaw – it is a chronic illness that we must approach with the same skill and compassion with which we approach heart disease, diabetes, and cancer.

I am proud to release The Surgeon General’s Report on Alcohol, Drugs, and Health. As the first ever Surgeon General’s Report on this important topic, this Report aims to shift the way our society thinks about substance misuse and substance use disorders while defining actions we can take to prevent and treat these conditions.

Over the past few decades, we have built a robust evidence base on this subject. We now know that there is a neurobiological basis for substance use disorders with potential for both recovery and recurrence. We have evidence-based interventions that prevent harmful substance use and related problems, particularly when started early. We also have proven interventions for treating substance use disorders, often involving a combination of medication, counseling, and social support. Additionally, we have learned that recovery has many pathways that should be tailored to fit the unique cultural values and psychological and behavioral health needs of each individual. As Surgeon General, I care deeply about the health and well-being of all who are affected by substance misuse and substance use disorders.

This Report offers a way forward through a public health approach that is firmly grounded in the best available science. Recognizing that we all have a role to play, the Report contains suggested actions that are intended for parents, families, educators, health care professionals, public policy makers, researchers, and all community members.

Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves. Despite the significant work that remains ahead of us, there are reasons to be hopeful. I find hope in the people I have met in recovery all across America who are now helping others with substance use disorders find their way. I draw strength from the communities I have visited that are coming together to work on prevention initiatives and to connect more people to treatment. And I am inspired by the countless family members who have lost loved ones to addiction and who have transformed their pain into a passion for helping others. These individuals and communities are rays of hope. It is now our collective duty to bring such light to all corners of our country.

How we respond to this crisis is a moral test for America. Are we a nation willing to take on an epidemic that is causing great human suffering and economic loss? Are we able to live up to that most fundamental obligation we have as human beings: to care for one another?

Fifty years ago, the landmark Surgeon General’s report on the dangers of smoking began a half century of work to end the tobacco epidemic and saved millions of lives. With The Surgeon General’s Report on Alcohol, Drugs, and Health, I am issuing a new call to action to end the public health crisis of addiction. Please join me in taking the actions outlined in this Report and in helping ensure that all Americans can lead healthy and fulfilling lives.

Vivek H. Murthy, M.D., M.B.A., Vice Admiral, U.S. Public Health Service, Surgeon General

To read The Surgeon General’s Report on Alcohol, Drugs, and Health click on the following link: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf

Insane Impulse?

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How is the alcoholic to account for that insane impulse which prompts him to reach for the first drink that starts him off on another binge? Is it a sane act? Is he obsessed? Is it the result of an urge which is sponsored by irrational thinking? Does it involve thinking at all? Does sanity in an alcoholic implicate his power to accept or reject that first drink? We think it does as we do not believe that he can help himself. We believe and know from experience that a power greater than himself can remove his obsession, straighten out his thinking, and restore him to sane thought and behavior.

Those who disapprove the use of the word sanity in Step Two are usually alcoholics who have been fortunate enough to escape the more serious aspects of alcoholism. They reason that they were perfectly normal between drinking bouts. The alcoholic who did himself no serious damage during his drinking career should find solace in that fact. He should take a broad view of the insanity of alcoholism, however, as most of us were surely deranged over varying periods of time.

He must also remember that in the progressive development of alcoholism the power of reasoning is slowly demoralized. This encourages deception as to our real mental health and fitness; it breeds a superior feeling of false security. Evidence to support this fact is found in the following danger symptoms commonly seen in all alcoholics:

  1. Acceptance of that first drink as we minimize the knowledge of the physical and mental suffering of the past by saying, “This time it will be different.”
  2. The continued use of alcohol to escape the realities of life and dependence upon it for energy or courage to accomplish given work.
  3. The necessity of the drink “the morning after.”
  4. Our inability to be self-critical of the sanity of our behavior over prolonged years of drinking – our refusal to consider the harm we have done to ourselves and others.
  5. Childish faith we placed in excuses for our drinking and the alibis we thought we were getting away with.
  6. The reckless abandon we displayed in drunken driving – the argument that we drive better drunk than sober and our resentment toward those who differed from this opinion.
  7. The acute physical condition we reach and the continued suffering we endure from uncontrolled drinking.
  8. The financial risks taken – the shame, sorrow and often poverty that we inflict upon our families.
  9. The asinine resentments that clogged our minds – our decided loss of responsibility – our retreats to childish levels of hilarity – the erroneous assumption that we can “take it or leave it alone’ – our unnecessary squandering of money.

These are a few of the infinite number of danger symptoms that indict alcohol as poison to alcoholic men and women, and prove that their power of reason is affected, as well as their behavior, when even small doses of this drug are consumed.

There is no point in deceiving ourselves regarding the fate of the alcoholic, the uncontrolled drinker, if he continues to use alcohol. He has just two escapes from drinking. One is insanity. The other is an alcoholic death. The purpose of the AA program as a “way of life” is to avoid both by arresting the disease of alcoholism. As alcoholics, we cannot undo our past behavior. We can, however, use the knowledge of our escape from insanity and alcoholic death as an incentive to contact God for help in keeping us from future drinking.

From The Little Red Book: The Original 1946 Edition, Published August 1946.

 

The Accidental Addict

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Up until a few months ago, Susan started her day by getting high. She’d crush a cocktail of drugs that included Oxycontin and Roxicodone, two forms of the narcotic painkiller Oxycodone, and then snort them so they’d get into her system faster. Within hours the symptoms of withdrawal would set in. An unbearable panicky feeling, muscle cramps, diarrhea and nausea. So she’d quickly snort another round. If there were no drugs left, she’d find a way to get more. Either from someone she knew or by buying them from a dealer.

This scenario wouldn’t seem shocking if Susan were a junkie living on the street, but that’s not the case. She’s a 32-year-old, well-educated, middle-class mom holding down a job as a nurse. Her spiral into addiction started seven years ago, when she was 25 and often in debilitating pain. After finally being diagnosed with fibromyalgia, she was relieved to have a name for her condition and a prescription to ease her suffering. “The Oxy didn’t just take away the pain. It gave me energy and helped me feel less stressed,” says Susan. “When I took those pills, it was like I could get everything done.” But soon the drug stopped giving her that false sense of control, and she needed to take more and more just to feel normal. When popping pills wasn’t working, she started snorting them. By the time Susan realized her drug habit had become a problem, this real-life “Nurse Jackie” was powerless to quit.

Chances are, you know a Susan even if you don’t realize it. “After alcohol and marijuana, prescription pain relievers are the most widely abused drugs in the United States,” says John Coleman, PhD, president of the Prescription Drug Research Center. Why are pills so ripe for abuse? They’re easily available. Last year, 139 million prescriptions were written for hydrocodone-containing drugs like Vicodin (up from 112 million just four years ago), making them the most-prescribed drugs in the country. They’re also highly addictive. Especially painkillers like Vicodin, Percocet and Oxy, which come from opium or a synthetic version of it. They are actually chemically related to heroin, but without the stigma. “People who would never dream of trying an illicit street drug may be prescribed Vicodin or Percocet for pain relief after a car accident,” says Coleman, “and after just a few weeks they can end up dependent on these drugs.”

“About 10 percent of the population has a genetic predisposition to addiction, whether it’s to painkillers, alcohol or substances like nicotine,” says Russell Portenoy, MD, chairman of the Department of Pain Medicine Palliative Care at Beth Israel Medical Center in New York City. “A personal or family history of alcohol or substance abuse suggests that you may be one of those people.” Other risk factors include suffering from a psychiatric condition like depression, anxiety or bipolar disorder, or having experienced past trauma such as sexual or emotional abuse.

Unfortunately, most people who become addicted to narcotics can’t stop on their own. That’s what Susan is in the process of doing. Her wake-up call came one morning when she realized she’d finished a month’s worth of her prescription in less than a week. This time, instead of trying to get more pills, she decided she’d had enough. She sat on the bathroom floor, sweating and shaking. She opened the phone book and called one rehab center after another until she found one with a bed open for her. She went in to treatment the following morning.

Addiction is defined as the compulsive need for and use of a habit-forming substance (such as heroin, alcohol or narcotic pain medication) characterized by tolerance and by well-defined physiological symptoms upon withdrawal. In other words, persistent compulsive use of a substance known by the user to be harmful. If you’re struggling with addiction, please pick up your phone book or go online and find the number for Narcotics Anonymous or Alcoholics Anonymous. Don’t wait 30 years to seek help like I did. Know this: If you find that when you drink or take narcotics you cannot control the amount you consume or, if when you want to, you find you cannot stop, then you are at that jumping-off point where it will never get better. Only worse.

Crossing the Thin Line

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How does it happen that some people become alcoholics, while most who drink do not? This is a question that haunts people who are troubled about alcohol, and it is a question that, in the end, seems to have no easy answer. Perhaps people who choose alcohol as a way of coping with life are not too different from persons who choose overeating, or working too much, or gambling, or spending too much money, or becoming too dependent upon other people. All seem to need an extra measure of outside reassurance in order to live comfortably. All seem unable to summon up the inner resources that exist somewhere within us to sustain us in difficult times. It’s as if they need constant validation.

All theories about the causes of alcoholism seem to contain some of the truth of the matter, but none fully answers the haunting question of why it happens. Perhaps it is not even an appropriate question. Looking for causes inevitably encourages fault-finding, blaming, guilt, self-pity, and recriminations. And the whole process doesn’t really solve anything. Perhaps, instead, we should be looking at how alcoholism develops – at the patterns and the signs.

Most people who drink do so for pleasure, without feeling particularly self-conscious about it, and without worrying too much about it one way or the other. For these people, alcohol is something to be enjoyed, occasionally alone but more often with friends and family. They have standards about alcohol use that they adhere to more or less dependably.

The American Medical Association defines alcoholism as “an illness characterized by preoccupation with alcohol and loss of control over its consumption such as to lead usually to intoxication if drinking is begun; by chronicity; by progression; and by tendency toward relapse. It is typically associated with physical disability and impaired emotional, occupational, and social adjustments as a direct consequence of persistent and excessive use of alcohol.”

When one’s drinking is out of control either frequently or now and then, it’s no longer so much a matter of choice as a compulsion. In this stage, too, there can be periods of remission: the alcoholic may carefully abstain or control drinking for periods of time – days, weeks or months – before another episode of uncontrolled drinking. Or perhaps there is no remission at all. It seems that once one has experienced loss of control through drinking, survived the experience, and returned to this experience again, something changes within the whole person, and the risk of creating that experience again is great. Similarly, people who have remained mildly intoxicated for many of their waking hours over long periods of time have great difficulty in living without alcohol, and the risk of loss on control is great. In both cases, the urge to drink supersedes thought – just before uncontrolled drinking recurs.

We know that alcoholics do not fit the humorous picture of the “happy lush” that we sometimes see on TV or in the movies. If alcoholics are pleasure seekers, they have chosen a difficult source of pleasure in heavy drinking, because the evidence is that most alcoholics report chronic fatigue, agitation, anxiety and depression. The very experience of becoming “high” involves changes in motor control and some measure of disorientation that can be pleasurable at first, but that can become increasingly painful, especially when there is some memory loss. Alcoholics rarely get good healthy sleep. Insomnia, nightmares, and exhaustion are often their bedfellows, even if they spend long hours in bed to avoid the stress of wakefulness.

Alcoholics often fail to eat properly; alcohol provides many empty calories, but a regular pattern of nutritious meals is often lacking. Alcoholics may experience an inability to concentrate at times when they are sober, as they carry with them into the day the anxiety and remorse of the hangover. Physically, intoxication is sometimes the pleasant experience they sought – sometimes not. But how much drinking and physical distress are required before we call this alcoholism?

Alcoholism is sometimes referred to as “the lonely illness,” and that description seems to fit pretty well. If we look at alcoholism as a social behavior, we see that it isolates the person from the society of others. Alcoholics usually find it difficult to be dependable in relationship with others. Little things trip them up: oversleeping because of a hangover and missing an appointment, arguing a point too strongly, insulting a mother-in-law that is a little to vivid, embarrassing a spouse or the children. As time passes, more serious social problems can develop: being fired from a job, alienating friends because of erratic behavior, getting arrested for driving while intoxicated. But how much inappropriate drinking and social isolation are required before we call it alcoholism?

The urge to feel “high” is a completely natural one. Little children love to get dizzy spinning around on a merry-go-round, swinging high on swings; people love the thrill of riding on a roller coaster. Long-distance runners talk about the ecstasy of breaking through the pain barrier. However, when people need to get high to face themselves and the tensions and pressures they perceive in their relationships with others, something is wrong. Alcoholics are people who have moved beyond the natural inclination to drink for pleasure and have entered into stress-relief drinking. They use alcohol as a temporary problem solver instead of the means to celebrate life. They use it to blot out negative feelings. These feelings may range all the way from vague notions of personal inadequacy, insecurity, and mild apprehension to serious to serious problems of self-hatred. Drinking simply increases the level of self-doubt, despite the temporary reassurance that it provides. But how much drinking and self-doubt are required before we call this alcoholism?

Maybe this blog post will encourage people to consider the facts about their own drinking. Help them recognize that they have experienced too much physical, social and emotional distress because of their excessive drinking – that they have crossed the thin line between social drinking and alcoholism. If so, I hope that they will take heart. I hope they will summon up the courage to ask for the help they so desperately need.

 

A Niece’s Open Letter

/ The Accidental Poet / 2 Comments

The following is included in the book “Alcohol & Drug Abuse: Breaking Free & Staying Free,” by June Hunt. The book is part of the Hope For The Heart Series published by Aspire Press. Please check your local Christian book store for this and other helpful publications.

Dear Friend,

I wish you had known my Uncle Billy. He was quite bright. His teachers said that he was the kind of student who could make straight As without even coming to classes! He was handsome with dark brown hair and a deep set dimples in both cheeks. Everyone wanted to be around Uncle Billy, but he wouldn’t allow much closeness. He kept his distance.

Although my uncle was smart and capable, I always felt sorry for him because he was somewhat the “black sheep” of the family. By the time I was a teenager, Uncle Billy had gone through many tough times. One day he awakened to find out  he had lost his small refrigerator-freezer business-his business partner ran off with his wife and all of the company’s money. He was devastated.

His life loomed as a dark picture of losses. He lost his wife, his business, his health, and his self-respect. He completely lost control of his life because something else had control of him. You see, my Uncle Billy was an alcoholic, and he died as a result of suicide. We all loved Uncle Billy, but in the end we lost him.

I have often wondered, What could have helped my Uncle Billy? What could have saved him from his own self-destruction? Like my uncle’s, countless other lives have been destroyed by a chemical addiction, leaving family and friends struggling with similar questions: What set up this struggle with substance abuse? What could I have done to help?

With addictions affecting so many, you may be wondering, Can those in the throes of a chemical dependency be set free-permanently? The answer is yes! There is hope. In order to break free from an addiction, there must first be the recognition that there is a problem so that healing can take place. But the most important step is turning to God, allowing His strength to help carry the burden. Isaiah 41:13 says, “For I am the Lord, your God, who takes hold of your right hand and says to you, Do not fear; I will help you.”

If you are struggling with a chemical addiction, the heavenly Father is waiting for you with open arms, beckoning you to come to Him. He will walk with you each step of the way in your journey to freedom. Like His prodigal son who “was lost and has been found” (Luke 15:32 NASB) -you need not be lost anymore.

Yours in the Lord’s hope,

June Hunt

Entirely Ready

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Steps Four and Five give us a blueprint as alcoholics to take an honest and thorough look at ourselves, and to admit the exact nature of our wrongs. This can only happen after we complete several crucial beginning steps. First, we must admit that we are powerless over alcohol and that our lives are unmanageable. The statement in the First Step that we are “powerless” refers to the lack of control over our compulsion to drink, which persists despite any negative consequences we might endure as a result.

We need to recognize that only a higher power can restore us to sanity.  Once we come to believe in a higher power, we need to turn our will and our lives over to God. After coming to grips with our addiction, we then need to examine our past errors and admit them to God, to ourselves, and to another human being. Part of the purpose of the Twelve Steps is to learn how to live life with a new code of behavior.

Step Six says, “Were entirely ready to have God remove our defects of character.”

As we work on changing our character, we need to look at how we think about and talk to others. Do we curse a lot? Do we make crude remarks, or use biased or prejudiced language? Do we gossip? Are we unduly sarcastic? Are we prone to anger or violence? Do we hold grudges or engage in “paybacks.” As we take a look at these behaviors, we consider how they fit in with a spiritual approach to living. We ask ourselves what value we have as a human being. What do we have to offer to others in the way of service, wisdom, and support? Who are we becoming? How can we increase our worth as a person? How do we define ourselves?

I believe that although pride is at the top of the list of seven deadly sins, healthy pride is a necessary part of self-esteem and character growth. This is not the pride of arrogance, egotism, grandiosity or narcissism.  It will not harm our spiritual growth to feel pride when we freely admit to ourselves that our progress is not made by us alone. Humble pride acknowledges the guidance of others and a faith in God. With humility, we learn to have healthy pride in our good works. We are able to recognize the grace we have been granted by God.

Before we got into recovery, many of us wanted what others had, but we didn’t know how to get it. In fact, we were willing to take what we wanted without working for it. Now, in recovery, we are happy with the miracles we receive as we progress. We have discovered that doing is more important than having, and experiencing is more important than possessing.

It is important to put all our habits into the context of becoming entirely ready. If we overlook one little addiction, or one minute bad habit, or one small defect, are we just a “little” addictive? How can we claim abstinence if we still hold on to our bad habits or character defects? Remember, half measures avail us nothing. It is important that we realize Step Six is not just about alcohol or drugs or overeating or gambling. It is about putting our lives back in alignment. How honestly we work Step Six is in direct proportion to our willingness to take a look at everything.

In order to be entirely ready to let go of our character defects, we must have a fairly accurate idea of how we view life and how we operate. We need to be thorough about this. We cannot be deluded about our behaviors. We must take the time to closely examine our manner of living. The Twelve Steps provide us with a great opportunity to reclaim our lives. By accepting help from God and others, we learn to think clearly. We become able to honestly examine our lives, play fairly, and give generously. Our values change in recovery as we become less selfish and more useful.

We no longer seek out situations that only comfort us; we also find ways to comfort others. We find that we feel better about ourselves when we help others. We learn from the Twelve Steps that what we were searching for our whole life is wrapped up in being of comfort and aid to others. Our most valuable relationship is the one we have with God. In a way, when we reach out and help others we come closer to God. That is precisely why Matthew 25 says when we help “even the least one of these” we do it unto the Lord.

I can see now why Step Six is the one that separates the winners from the losers. It’s gut check time. Are we ready to change our way of living or not? This is not a “maybe” proposition. It’s likely that many of us approached this step in a less active manner. Odds are we may still be battling some pretty major defects of character. Step Six requires commitment and specific action. There is no better time to get to it than right now. The values we develop as a result of working the Twelve Steps look different from the ones we held while in active addiction. Every day brings a new opportunity to work on our character defects. Our values no longer change with every passing fancy. Our life now means something, and counts for things that are good.

The Anatomy of Alcoholism

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Many different types of people become alcoholics, but all alcoholics are ultimately alike. The disease itself swallows up differences. The personality changes that go with the illness of alcoholism are predictable and inevitable. Alcoholism can destroy the physical, emotional, spiritual and mental life of the sufferer.

Early drinking is characterized by a mood swing in a positive direction. It creates a warm and fuzzy feeling, and may even lead to giddiness. When the effects wear off, the drinker feels normal. It does not take long to learn how to set the amount and select the mood. As the typical social drinker gets deeper into the booze, getting drunk begins to have a very different effect. Heavy drinking creates a sort of undertow that drags the drinker below normal and into pain. At this point, booze is often consumed simply to not feel pain. In other words, to get back to some degree of normal. This is the beginning of harmful dependence.

This dependency has a rising emotional cost. There is typically a significant and progressive deterioration of the personality of the alcoholic, and often even a visible physical deterioration. Ultimately, the alcoholic’s whole emotional environment is torn up and destroyed. There is an emotional cost for every drink. The carefree days are gone. Of course, the alcoholic is dimly aware of this fact. For some reason, the rising cost is willingly paid. This is proof that dependency on booze has become truly harmful. Of course, the drinker fails to comprehend the increasingly clear signs of destruction by alcohol.

The alcoholic is learning to live more and more by way of rationalization. Intellect will blindly defend against reason, against intervention, and will hide disintegration, right up to the edge of the abyss. Eventually, the alcoholic will be completely out of touch with his or her emotions. Internal dialog will become the audio of an increasingly impenetrable defense system.

The tragedy is that rationalization works. This form of defense continues to operate ever more successfully as the disease progresses. As time goes on, the alcoholic’s behavior will become increasingly bizarre, and the innate and unconscious ability to rationalize will be practiced to the point of perfection. The alcoholic finds it increasingly difficult to accept blame. Time passes, and the condition worsens. Over a period of months and years the alcoholic’s self-image continues to wane. Feelings of self-worth sink low, and excessive drinking continues. Eventually, emotional distress becomes a chronic condition. The drinker feels distress unconsciously even when not drinking. The mantra is I’m just no damn good.

Mood swings and personality changes are evidenced while drinking. The otherwise kind person becomes angry or hostile; the usually happy person becomes sad and morose; the normally gentle person becomes violent. Alcohol causes the guard to drop, and chronic unconscious negative feelings are exposed. The drinker becomes truly self-destructive. All this drinking and emotional distress may lead to a vague but poignant feeling that a problem exists. There is a general malaise so strongly felt that desperate measures to escape are proposed or actually attempted. Geographical cure, new job, divorce.

Continued excessive drinking and accompanying behavior bring on chronic fatalistic feelings. If the course of the disease is not interrupted, the end of all this is suicide, either slowly with alcohol, or in a direct or deliberate manner. We need to remember that as emotional distress mounts and deterioration of the personality accelerates, these negative feelings are not clearly discernible. Quite the opposite, they are more and more effectively hidden.

You may wonder if you have a drinking problem. Ask yourself the following questions. Have you ever drank in the morning? Have you ever drank alone? Have you ever drank a fifth a day? Have you ever felt remorse after drinking? Do you have a growing anticipation of the welcome effect of alcohol? Has it moved from anticipation to preoccupation?

There is another principle to be applied when examining whether you are an alcoholic. Is there evidence of a growing tolerance to alcohol? Does it take more and more for you to get the same welcome effect? Do you sneak drinks in the kitchen before bringing other drinks in to the living room or the den? And to what lengths are you willing to go to get that extra amount of alcohol? The degree of ingenuity used to get more becomes the scale for determining how dependent you are on alcohol. All instances of harmful dependency that turn up in the behavior patterns of the alcoholic at this stage of addiction indicate a growing anticipation of the welcome effects of drinking, an increasingly rigid expected time of use, and a progressive ingenuity in obtaining larger and larger amounts of alcohol.

Rational defenses and projection set in. Why is it that the alcoholic cannot see what is happening to him or her? The answer is, simply, because they can’t. The reason alcoholics are unable to perceive what is happening is understandable. As alcoholism develops, self-image continues to deteriorate, and ego strength ebbs. For many reasons, alcoholics are progressively unable to keep track of their own behavior, and begin to lose contact with their emotions. Their defense systems continue to grow, so that they can survive in the face of their problems. The greater the pain, the higher and more rigid the defenses become; and this whole process is unconscious. Alcoholics do not know what is happening inside of themselves. They’re victims of their own defense mechanisms.

As emotional turmoil grows in chemically dependent people, rational defense activity turns into real mental mismanagement, which serves to erect a secure wall. The end result is that the alcoholic is cut off from increasingly negative feelings they have about themselves. They are unaware of the presence of such destructive emotions. Not only is the drinker unaware of the powerful highly developed defense systems, they are also unaware of the intense feelings of self-hate buried inside them. Moreover, the problem is compounded by the fact that these defenses have now created a mass of chronic free-floating anxiety, guilt, shame, and remorse. In other words, the alcoholic no longer starts drinking from the “normal” point (where they could always start before), and swing up in mood to feeling great or euphoric; rather, they must start from where they feel depressed or pained and drink to feel normal.

Alcoholics drink because they are alcoholics. As a Chinese proverb says, “First the man takes a drink, then the drink takes a drink, then the drink takes the man.” At this stage, the drinking pattern becomes thoroughly unpredictable or compulsive. The alcoholic quits, then resumes, and does not know why he or she starts drinking again. The resumption is at the level of chronic emotional deterioration. Conditions worsen with each new episode. The drinker is trapped in a deadly downward spiral.

Chemically dependent people have two factors progressively working together to draw them out of touch with reality. First, there is their defense mechanisms. Second, there is their distortion of memory. Either one of these alone would seriously impair judgment. The time inevitably comes when the alcoholic cannot see that he or she is sick. In reality, they are acutely ill with a condition that will ultimately lead to death, and which will seriously impair their constitution emotionally, mentally and spiritually during the final months or years.

Treatment for acute alcoholism is not merely concerned with putting the drink down; it also has to do with restoration of adequate ego strength to enable the drinker once again to cope with life. Therapy for acute alcoholics must address the whole person. The alcoholic suffers emotionally, mentally, physically and spiritually. Often, treatment involves physicians, clergy, psychologists, sociologists, pathologists and psychiatrists. If the whole person is not treated simultaneously, relapse is inevitable. If, for example, the emotional disorder alone is addressed, the drinker may believe they feel so good now that they can handle the drink. It’s like having two broken legs, but only seeking treatment for one.

If you’re struggling with alcoholism, realize that you are ill on numerous levels. The problems linked to alcohol dependence are extensive, and affect the person physically, psychologically, emotionally, spiritually and socially. Drinking becomes a compulsion for a person with a drinking problem. It takes precedence over all other activities. Alcoholics are obsessed with alcohol and cannot control how much they consume, even if it is causing serious problems at home, at work or regarding finances. The alcoholic is viewed as dealing with a physical allergy to alcohol, a mental obsession to keep on drinking, and an underlying spiritual malady that means willpower is not enough. Unless all three aspects of the condition are treated, the drinker will not be able to escape his or her addiction.

Many people lead lives of quiet desperation, trying to fill the God-shaped hole in their soul and cover the pain with shopping, eating, gambling, and a million other distractions. But addicts and alcoholics are physically predisposed to escape or numb themselves in ways that go directly into a downward spiral of self-destruction. When I drink or take drugs, my life is little more than an isolated routine of coming to, muddling around, getting drunk, or taking Vicodin or Oxycodone, in order to make things fuzzy until I pass out. Of course, this is little more than sleepwalking through life.

After getting “sober,” I returned to church. I considered myself a “Christian in recovery.” Although I was able to stay away from alcohol, marijuana and cocaine since 2008, I started abusing narcotic pain killers. I was teaching Bible study at the county prison, but I was hiding my addiction. I was in denial. I wish more pastors didn’t still view addiction in primarily moral terms. Yes, addictive behaviors often begin with a moral failing like selfishness or overindulgence. But full-blown addiction is a disease that involves physiological and psychological components that go beyond sin or even choice. Trying harder, reading the Bible more, or praying more are rarely the solution.  I have finally come to believe that I cannot drink or use opiates safely no matter how spiritual I may think I am.

I, like Paul, war against my flesh. He said, “For the good that I would I do not; but the evil which I would not, that I do…Now if I do that I would not, it is no more I that do, but sin that dwells in me.” (Romans 7:16,20) The magnitude that one’s spiritual life plays in recovery from addiction is hard to measure. I do believe, however, that without addressing the spiritual malady of alcoholism, recovery is often no more than just putting the cork in the bottle with little lasting effect. I want to make something absolutely clear. A spiritual approach alone, without working a recovery program specifically for addiction, is problematic. Worse, it’s all too easy for addicts and alcoholics to convince themselves they’re covered through meditation or church attendance or the blood of Jesus. They tend to do nothing to address their addiction, their character defects, or their self-centered fear.  Remember, faith without works is dead. Thankfully, I know Christ died on the cross that I might live my life free from the bondage of addiction. It is now up to me to take certain steps.