Codependency & Enabling: Universal to Alcohol and Other Drug Addiction

Codependency and enabling are deep-rooted features of alcohol and other drug addictions.
Effective treatment of such addictions requires that these two behaviors – so common among spouses, family members, loved ones, and friends of the person suffering from drug or alcohol addiction – be identified and addressed, individually and in conjunction with the addicted person’s treatment.
Codependency most often originates once that spouse, family member, loved one, or friend becomes and stays controlled by their loved one’s addictive behavior. Codependents themselves lack a sense of power in their lives and are unable to take responsibility for their own happiness and well-being. They instead turn to manipulating and controlling others. Almost their entire day-to-day focus is external rather than internal. They live for and/or through another person and obsess over caring for and controlling that person’s actions.
Codependents exhibit ongoing anxiety and worry, ‘sell’ themselves out to care for others, ignore or mistrust their own feelings, tend to isolate, and often experience bouts of depression. Difficulty with emotional intimacy and keeping bad relationships and impairing good ones are also characteristic of the codependent person.
Enabling differs from codependence in that it primarily keeps the person suffering from a substance use disorder from having to face the negative consequences of their addiction(s). Enabling behavior occurs when another person (more often than not a codependent) indirectly and/or directly actually helps or encourages the addicted person to continue using drugs.
Solving the problems of someone affected by alcohol or drug addiction makes the enabler feel as though they are doing something good for the person they care about. The truth, however, is that they are further damaging them by allowing them to continue their self-destructive behavior. Enablers essentially perpetuate their loved one’s addiction. The one thing that all enablers seem to have in common is that they love someone who is out of control, and they take more responsibility for the actions of that person than the person is taking for themselves.
We know from experience that codependents and enablers also share at least one mutual trait, which is their almost total compromise of self. Codependents and enablers fundamentally need to reclaim themselves, to achieve rewarding and healthy lives and relationships. Restoration of self is therefore key to overcoming codependency and enabling, and can be achieved through appropriate counseling and its adjunctive facilitation of the establishment and maintenance of peer support systems.
Learning about, adopting, and using some simple tactics with those suffering from alcohol or drug addiction can help codependents and enablers free themselves of their own unhealthy and hurtful thinking and behavior. These tactics include being honest with themselves – stopping ignoring or minimizing facts, and realizing although painful and challenging, they are true; dealing with their own pasts and any unresolved trauma(s) and pain; disciplining themselves to be less reactive and more self-caring; setting healthy boundaries and realistic expectations; and naming and holding to limits.
Overcoming codependence and enabling isn’t free of difficulty nor does it progress obstacle-free or happen overnight. But surmounting them can and does happen. For that reason alone, we urge all who knowingly suffer from codependence and enabling (and those who think they may be suffering from it) to seek help, much as their loved one with a substance use disorder who wants his or her suffering to end likewise asks for help. Doing so more often than not results in the achievement of a healthy and rewarding life, and lasting, meaningful relationships.

Author
Dr. Gregory Serfer, DO
Tully Hill Treatment & Recovery Medical Director

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What is Alcoholism?

There may have come a time where you were concerned whether it is for yourself, a friend, or a loved one where you question, is that too many drinks? Is it normal to feel the way I do? Should I cut back on drinking? Is it social drinking or is it more than that? This can then lead to an internet search for “what is alcoholism?”. Depending on what you read it can be very overwhelming for any person to sit through all the websites trying to understand what exactly does it mean to be an “alcoholic”.

According to the Mayo Clinic, The clinical definition is that alcoholism is the inability to control drinking due to both a physical and emotional dependence on alcohol. An alcohol abuse disorder refers to a long-term addiction to alcohol. Meaning that a person with this condition does not know when or how to stop drinking. They spend a lot of time thinking about alcohol, and they cannot control how much they consume, even if it is causing serious problems at home, work, and financially. It’s important to understand that an alcoholic does not always drink on a daily basis. Alcoholism is characterized by the inability to control the intake therefore you can have someone who does not drink for a week at a time, however, binges for 3 days until they are completely intoxicated and unable to function. You can also have someone who drinks on a daily basis and is unable to function without the use of alcohol. Both examples are possible.

What does Alcoholism look like?
Alcoholism is a disease. Like drug addiction, alcoholism does not discriminate. It can touch any person from any gender, race, religious background, economic background, socioeconomic status, etc. There are multiple theories in regards to how alcoholism can affect a single person; society’s role, the biological contribution, and the disease concept are the three main theories that are discussed today. Regardless of the theory that you may agree with or how alcoholism started for you or your loved one, there are warning signs to be aware of;

The individual begins to neglect responsibilities in order to drink. It is important to understand that it is possible to be a functioning alcoholic. There are many individuals that can maintain their employment, pay their bills, and carry on with normal activities which can cause a concern for their loved ones when it is revealed that the individual is struggling with an alcohol use disorder due to having everything in order. Over time this does not typically last.
Being arrested for DUIs or public drunkenness. Driving intoxicated is not something that most individuals plan on doing however when you have engaged in the use of alcohol so often it becomes to feel like your reality and normal to you. You begin to make excuses for behaviors including driving. This can become very dangerous as not only are you putting yourself at risk but those around you as well.
Self Medicating. The Use of alcohol as a relaxation or stress aid is very common for most individuals who are diagnosed with an alcohol use disorder. When you are having a stressful day, a fight with a loved one, feeling anxious or depressed, and you resort to the consumption of alcohol to help treat or handle these situations that can be a warning sign.
Avoiding family or friends in order to drink. Have you begun to make excuses to not attend activities because you have either felt too sick to attend due to drinking the day/night before or because you would prefer to stay home and have a few drinks? This can also be a warning sign as it represents isolating behaviors as well as the fear of allowing others to witness the increased consumption of the alcohol beverages. There is also another aspect of this warning sign where you may only be surrounding yourself with those that do engage in drinking alcohol.
Unwillingness to stop drinking, even for a short period of time. Whether it is because of your personal choice to not remain sober for a few days or a longer period of time or it is because of the physical symptoms you are experiencing due to the withdrawal of alcohol, the inability and unwillingness to stop drinking is a primary warning sign.
Uncharacteristic changes in behavior. Have you noticed a shift in your behaviors. Are you more irritable, increased fatigue, increased anxiety, or more depressed? These can be contributors to the increased alcohol consumption which in return can cause a shift in your behaviors even more.
Withdrawal symptoms. Have you experienced physical illness when you have refrained from the use of alcohol? Have you had difficulty with feeling anxious, shaky, headaches, stomach pain, etc. physical symptoms of withdrawal from alcohol can differ from person to person however when you have remained alcohol free for a period of time after consuming large amounts of alcohol for a longer period of time, it is highly likely to experience physical withdrawal.

Where do you go for help when you are struggling with an alcohol use disorder? Here are a few helpful tips:
First understand reaching out for help can cause a lot of anxiety. You are not alone. When you abruptly stop drinking, your body is deprived of the effects of alcohol and requires time to adjust to functioning without it. This adjustment period causes the painful side effects of alcohol withdrawal, such as shakes, insomnia, nausea, and anxiety. It is strongly recommended you engage in assistance from a medical provider as alcohol withdrawal can be life threatening. This can be different for each person that is experiencing withdrawal however it is better to be safe. Most alcohol detox programs utilize medications to help allow you to be comfortable through the process. Treatment centers can also provide personalized care for you while you are working on being sober. Everyone is different and every situation is different therefore treatment needs to be individualized. Hospitals, clinics, and local drug and alcohol centers are your best option to help gain more information on where you can obtain help, what to expect, and what treatment would consist for you. Detox services, inpatient treatment programs, outpatient counseling services, and 12 step programs are very beneficial for individuals who are working on living a sober life.

Accepting that you may have an alcohol use disorder can be overwhelming and cause a lot of anxiety. Remember that you are not alone and there are multiple options for you to utilize. Review the warning signs, reach out to a medical provider, and remember there is help available.

Resources:
Mayo Clinic, (https://www.mayoclinic.org/diseases-conditions/alcohol-use-disorder/symptoms-causes/syc-20369243)
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Can You Be Addiction to a Person?

Understanding the origin of codependency, it’s long-term effects and available treatment options
By Alisha Barnes, M.S.

What Is Codependency
Codependency is the reliance on another person for reassurance, validation and security. A codependent person may present with difficulties making independent decisions, struggle with self-esteem outside of the context of the relationship and a value system that is heavily concerned with the thoughts and opinions of others. While a healthy relationship incorporates the input of both parties, a codependent relationship heavily caters towards one party more than another. Codependency can present itself in various contexts, but universally consists of one individual thriving on needing to be needed, assuming a “giver-rescuer role,” while the other individual comes to rely heavily upon the support of the giving individual and adopts the “taker-victim role.” Although this may appear within romantic relationships, codependency is just as commonly found in platonic relationships and may even be the product of a parent-child dynamic. It is unlikely that an individual is born with a codependent personality; rather, it is developed based upon interactions with primary individuals in the persons’ life. Thus, early childhood attachment is critical in developing healthy relationships with appropriate boundaries. Attachment theory addresses the importance of a bond between an infant and caregiver and how this attachment influences the child’s behavior and emotions into adulthood.

Attachment Theory
There are four different theories of attachment, including secure-autonomous, avoidant-dismissing, anxious-preoccupied and disorganized-unresolved. Each attachment style differs in how the individual communicates their needs in a relationship, as well as how they listen and understand the emotional needs of the other person.

Secure-Autonomous Attachment
The child who forms a secure-autonomous attachment is likely to have been raised in a household where their caregivers were in-tune with the child’s needs, sensitive in the ways in which they responded to these needs and further encouraged the child to express their concerns in a healthy manner. This child enters into adulthood able to communicate their needs, willing to address conflict as it arises and able to respect space within the relationship. This individual is unafraid of rejection, as they have experienced a sense of independence that has previously been respected, without creating a challenge to the relationship itself.

Avoidant-Dismissing Attachment
The child who forms an avoidant-dismissive attachment is likely to have been raised by disengaged caregivers. This child develops into an adult who is logical in nature and therefore, responds well in a crisis, but avoids the communication of emotional needs. This individual tends to perceive relationships as interfering with autonomy and infringing upon independence.

Anxious-Preoccupied Attachment
The adult who presents with an anxious-preoccupied attachment most closely resembles the characteristics seen in the codependent personality. This child was likely raised by caregivers who were inconsistent in their parenting style, who may have been unpredictable and whom often either misunderstood or were unable to meet the needs of the child. This child often develops into an adult whom fears abandonment, rejection and remains anxious of these possibilities within the context of the relationship. The issues of the past tend to intrude upon current relationships, leading the anxious-preoccupied adult to seek reassurance, exhibit needy or clingy behavior and present with poor personal boundaries.

Disorganized-Unresolved Attachment
The child who forms a disorganized-unresolved attachment are likely to have experienced significant losses or traumatic experiences in childhood that were poorly tended to by presenting caregivers. As adults, these individuals tend to present with difficulty regulating emotions, a tendency to engage in dysfunctional relationships and an unconscious pattern of recreating past traumatic experiences.
Attachment styles tend to be passed down from one generation to the next, as individuals tend to parent in the manner in which they themselves were parented. While the above-mentioned attachment styles offer insight into how our emotional connections in adulthood are impacted by childhood, this is not an exact correlation. Ultimately, how emotions are managed is more important than the circumstances that led to the presence of said emotion.

The Role Of Boundaries In Relationships
While the knowledge of attachment theory is crucial in understanding the origin of codependent behavior, of equal importance is the role of boundary setting throughout all phases of life. Healthy boundaries serve to determine acceptable and unacceptable behaviors in a relationship. They further identify ones emotional needs, desires, and value system, while establishing limits. Implementing healthy boundaries requires that an individual be open and honest in communicating who they are and what they want, with healthy boundaries being best derived from a firm sense of self. While boundaries can be influenced upon ones upbringing, they are further developed over the course of friendships, romantic relationships and other interpersonal experiences. An individual’s sense of boundaries may expand over the course of these experiences, as the person grows to better understand who they are and what they are seeking through various relationships. In contrast, unhealthy boundaries involve a disregard from ones own emotional needs and limits. The development of unhealthy boundaries may result from poor self-esteem, uncertainty regarding ones needs and a desire to please others. Part of building healthy and stable relationships is through the use of healthy boundaries, with codependent behavior often being further exacerbated through a lack of healthy boundaries.
So can someone be addicted to another person? In short, yes. Codependency often serves to distract from inner pain or emptiness, that may or may not have been experienced through childhood, but is almost always further exacerbated through unhealthy relationships in adulthood. As a result, codependency only continues to grow and intensify, as the behavior does not address the underlying cause for the emptiness. Instead, the codependent individual attempts to fill this void through having emotional needs met through human relationships and interactions, as opposed to working towards evolving on their understanding of their emotional needs and becoming better able to meet these needs through communicating in a clear and healthy manner.

Addressing Codependency In Treatment
Similar to issues experienced through substance abuse, treatment exists for the codependent individual. As addiction commonly presents as a family disease, family therapy is currently one of the leading treatment recommendations to address codependent behavior. This allows for unhealthy patterns of behavior to be explored as a whole, with the family working to break dysfunctional behavior and to learn new methods of coping and interacting. Treatment further involves processing and resolving past interactions that may have further exacerbated the behavior, while developing a better sense of the importance of boundaries.
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5 Tips to Deal With A Loved One’s Out of Control Drinking This Holiday Season

Holiday joy becomes an empty phrase when you have an inebriated loved one searching for car keys after the family meal. So, what is a family member to do when drinking has become a serious problem in a loved one’s life during the happiest time of the year?
Here are 5 tips to help you help your loved one and keep YOUR sanity throughout the holiday season and throughout the year.

How to prevent a loved one from drunk driving
Tip #1: Set boundaries around driving
Drinking and driving are a deadly combination. So it is important to create boundaries around driving with your family members as in “The car is only available to family members who are going to meetings and staying sober.” This one is easier to stick to when the car belongs solely to you or when the driver is one of your children rather than a spouse.
Tip #2: Seize the opportunity to control the situation by taking the keys
Never get in the car with a person who is driving under the influence or let a child do so. If you have the opportunity to control the situation by taking the keys, do it. If you have a loved one does get into the car inebriated and you cannot stop them from driving away, call the police to stop them so no one is harmed. This isn’t a time to worry about whether they will be angry with you when they sober up. There may not be a tomorrow for them or for the person or people they hit if you don’t take action now!
Tip #3: Use the car as leverage.
Leverage is a negotiating tool. They want the car. You only want them to have it to drive sober. So, in order to have access to the car, they must (fill in the blanks – attend meetings, regularly, take a breathalyzer before getting into the car, go to treatment, follow the discharge plan, etc.) Leverage works best when you have a team of professionals to support you.
Tip #4: Work with a team of professionals
Your BALM Coach, your loved one’s treatment clinician and coach, these professionals know your family and can help you and your loved one work together to come to plans that can really work.
Tip #5: Encourage your loved one to undergo treatment
Of course, the missing ingredient is your loved one’s willingness to participate. Treatment can greatly help a loved one come to the conclusion that it is time to do things differently. You can be the one to help your loved one decide it is time to go to treatment.
In the BALM, you will learn how to gather the facts and script loving conversations to help them move forward. You will learn Motivational Interviewing so you can ask questions that help them look at alternatives for a better future for themselves, and you will learn how to have loving BALM conversations that will go under their denial, from your heart to theirs, in order to help them wake up and choose recovery for themselves.
For more information on the BALM Family Recovery Program go to https://balmfamilyrecovery.com/the-balm-comprehensive/
or give us a call at 1-888-998-BALM (2256).
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Resources Available to Veterans: Seeking Treatment for a Substance Abuse Concern

Understanding the root causes of substance use in Veterans and identifying treatment services available towards those individuals affected:
By Alisha Barnes, M.S.
Presence of Addiction in Veterans
Addiction is categorized as a complex brain disease, characterized by changes in the wiring of the brain and affecting aspects of judgment, decision-making and the management of behaviors. While addiction can exist in isolation, it is often found to be in conjunction with mental health disorders and can serve as a means of self-medicating negative emotions. The general population is subject to both environmental factors and genetic factors that contribute to either prevention or risk factors in reference to the development of substance use disorders (SUD). Common risk factors include the presence of trauma, an increase in stress, poverty and a lack of social attachments. Members of the armed forces are faced with additional risk factors in reference to substance abuse concerns, including episodes of deployment, armed combat, reintegration to civilian life following deployment and any resulting sleep disturbances and/or traumatic brain injuries that may have been sustained while on duty. The unique challenges that these individuals encounter can lead to an increase in traumatic experiences and thus, a higher rate of diagnosed Post-Traumatic Stress Disorder. According to The National Institute of Drug Abuse, Veterans diagnosed with a substance abuse disorder were found to be 3-4 times more likely to receive a dual diagnosis of PTSD than their counterparts. Additionally, military duties have seen an increase in physical injuries, leading to higher rates of prescription pain medication and consequently, opioid dependence. In essence, the nature of the duties required in the services leads to a greater than average risk for both mental health disorders and the development of substance abuse disorder.
Rates of Suicide Among Veterans
Current national estimates note that 17 to 22 Veterans commit suicide daily, with male Veterans being 1.5 times more likely than their non-military counterparts to commit suicide and female Veterans being 2.5 times more likely than their non-military counterparts to commit suicide. In fact, The National Institute for Drug abuse reported that Veterans commit approximately 20% of yearly suicides despite only making up 10% of the national population. Of these suicides, about 30% have been noted to involve the use of substances at the time of death, demonstrating the magnitude of the issue at hand. Given the rise in completed suicides and the overwhelming connection between SUD’s and PTSD, the importance of seeking treatment as early as possible is evident. Yet there continues to be barriers towards treatment services, despite initiatives to improve access.
Stigma In Seeking Services
The availability of services through both The Department of Veterans Affairs, as well as the private sector of medical treatment, would leave one to believe that those desiring treatment have the resources to do so. Yet when polling Veterans requiring treatment, a plethora of barriers were noted interfering with services, including lack of access to insurance, concern regarding the consequence of seeking services on their military career and stigma associated with mental health concerns in the military. Part of overcoming this stigma is in increasing awareness, challenging addiction as a “moral failing” and offering additional education regarding addiction as a disease and thus, in need of treatment. Family involvement can increase ones comfort in seeking services and can offer much needed support in engaging in the process. The Department of Veterans Affairs has identified building a support network as a key process in both the prevention and treatment of SUD’s. As Veterans present with unique needs, it is important to choose a treatment facility that can offer services that provide the best opportunity for recovery.
Choosing A Treatment Center
The key is to make the first call to begin the process. This initial call can provide the individual with the information needed to determine the most appropriate level of care for their treatment based upon the substance of choice and the extensiveness of use. Dependent upon symptoms associated with the substance use, a dual facility may be recommended, as this would better allow the Veteran to simultaneously treat both the substance abuse disorder, as well as any underlying mental health disorder, including PTSD. Developing a firm understanding between the correlations of various disorders can be essential in maintaining recovery. Additionally, one should be cognizant of services offered, including whether or not the facility participates with medical assisted treatment or offers holistic services, as both aspects can offer an additional layer support for the recovering individual. Free substance abuse treatment is available through the Veterans Alcohol and Drug Dependence Rehabilitation Program for those Military Veterans enrolled in The Department of Veterans Affairs healthcare and having received an honorable discharge. Should an individual present with concern in utilizing the VA for services, whether that be a result of availability for seeking treatment (I.e. wait times) or a lack of local facilities, both private and non-profit agencies are available to meet those needs. Regardless of those concerns that may currently be inhibiting treatment, including financial difficulties, an intake representative is waiting and available to offer resources that can overcome these challenges. For the individual entering treatment for the first time, these challenges can seem overwhelming. Yet there is a plethora of information available to assist in streamlining this process and offering the information necessary to assist in choosing the most appropriate services (See below).
Resource Available for Veterans and Their Loved Ones
• Veterans Crisis Line/Suicide Hotline: 1-800-(273)-8255 or send a text message to 838255
• U.S Department of Veterans Affairs: https://www.va.gov/
• SAMHSA-HRSA Veterans Resource Guide: https://www.integration.samhsa.gov/clinical-practice/Veterans_Resource_Guide_FINAL.pdf
• Substance Use Treatment for Veterans: https://www.va.gov/health-care/health-needs-conditions/substance-use-problems/
• A Veterans Guide: https://americanaddictioncenters.org/a-veterans-guide-to-choosing-a-recovery-center
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What would be a fun sober date?

Going on a date sober seems like it can be so simple but if you have been used to living life with drugs and alcohol it can be really overwhelming. Living life sober is a hard decision to make and it’s even more difficult when you are trying to plan a fun date night. A date doesn’t have to include alcohol or drugs and for most individuals it doesn’t. Having the opportunity to do something outside of your comfort zone or something relaxing with someone you enjoy being around is what makes the date fun at the end of the day. The benefits of being sober allow you to genuinely connect and get to know each other on a deeper level. So what does dating sober look like? There are plenty of options if you use your imagination and some creativity!

Whether you engage in a date on a weekly basis or less/more often, here is a list that will help you with some fun new ideas:

Movie and Dinner
Get out of the house and check out a new movie. This can be inexpensive depending on the movie and restaurant you pick. Check out local theaters to find new movies. When going to a restaurant you may feel uncomfortable when asked what you would like to drink. This doesn’t have to be challenging; a simple “water please” is fine. This could be even more interesting if you plan to try a new cuisine that you may haven’t tried before. It can be a fun experience to try with each other while exploring new cultures.
Baking Night
Pick your favorite treat and bake together! Whether its cookies or cupcakes, this activity is something simple and fun allowing you to have some laughs while you’re learning more about each other.
Couples/Friends game night
Invite some of your friends or other couples over for some popcorn and fun! Board games can always provide some laughs and conversation. Whether it is monopoly or trivia it’s something that you can do together or with a group of people.
Roller Skating/Ice Skating
Now is the season for winter fun. Find a local ice skating rink or roller skating venue. Put on some skates, hold hands, and enjoy some fun being together. What makes this date even more perfect, when you finish the night with hot chocolate, after all it is the season!
Try something new
Take turns planning a date with your significant other. This will allow you to challenge yourself to step out of your comfort zone and learn something new that you may even end up enjoying. This can be a new restaurant or hobby (i.e. painting, photography, dancing, or maybe even a massage). Allow yourself to give someone else the ability to make the decision on what a date could include.

Go for a hike
There is nothing more relaxing and refreshing than being outdoors. Use this time to get to know each other. You can make it into a game, like “21 questions” or “2 truths and a lie”. When all you have is time and nature, you can learn a lot about each other.
Ice cream and/or coffee date
Depending on where you live, it’s pretty safe to say there is an ice cream parlor or coffee shop close by. This can be a short date or turn into a long, intimate setting where you learn more about each other. The best part is it can be inexpensive.
Go bowling
You may be surprised at how well you can engage in fun activities now that you have a clear mind. Go for a couple rounds and make it interesting where the winner buys coffee on your next date!
Visit a local fair or Amusement Park
Spend the day playing games, eating cotton candy, and enjoying some of your favorite childhood rides. This date can be a short trip or you can make it an entire day ending with some coffee or ice cream.
Miniature Golf
Miniature golf is the perfect setting for many reasons. First, miniature golf courses don’t sell alcohol or allow alcohol on-site, therefore no temptations present for this date night. Challenge yourself and your partner with a playful activity, and you can make it into a competitive game with a fun prize at the end of the game.
Netflix night
Plan a night where you can binge-watch some Netflix shows or movies. Make some popcorn and sit back and enjoy a relaxing night with just you and your date. This provides you the opportunity to spend an intimate night alone to get to know each other or have some laughs.
Comedy show
There is no better way to learn about someone than to engage in a comedy night. This will give you the chance to have fun and a carefree night with some laughs. Comedy shows can be interesting and informative to help identify common interests with someone you may be dating because it is extremely revealing of their personality.

These are just a few ideas for a fun date night but remember the possibilities are endless. Try to think out of the box and be creative! No matter how you approach dating after achieving sobriety, remember your sobriety is the most important. You have the ability to avoid stressful situations and toxic people, so do yourself a favor and take it slow. Think about the decisions you’re making and ask yourself if they will aid in your recovery process or hinder it. There is a chance at living a fun and healthy lifestyle if you’re open minded and willing.
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Cocaine on the Brain

By Gregg Snook M.A., NCC, LPC
I was planning out some articles and it came up that people are aware of “DRUGS” (said in a spooky and ominous tone). So, it’s more like “DRRRRUUUUUGGGSSSS WOOOOOO,” like a ghost story. I wanted to take some time to discuss and explain further individual drugs, and why they become addictive.

Forming habits and addictions as a learning process.
This is a short article and there are years and years of research that contribute to our understanding of what occurs in the brain during the formation and persistence of addictive behaviors. In discussing how addiction pathways are formed in the brain, let’s first consider these brain regions or systems:

Prefrontal Cortex
Covers the frontal lobe and has a role in planning and decision-making.
Limbic System
Part deeper in the brain (closer to the core than the prefrontal cortex) involved in motivation, learning, and memory. Emotions are also processed in the limbic system, specifically around the amygdala.
Nucleus Accumbens
Let’s keep it simple. This is part of a reward circuit that can learn.

Now for the chemicals
Dopamine
Feel-good chemical that has a lot to do with motivation and the pleasure response.
Serotonin
Another feel-good chemical. Has to do with feeling satisfied.
Norepinephrine
Again, keeping it simple, this chemical is involved in movement and in the fight-or-flight response.

With the above-mentioned chemicals working in the cells in the systems of the brain, an addiction is formed from using cocaine, which stimulates the pleasure areas of the brain. Using this drug enough reinforces the behavior due to the euphoria that is experienced.
Cocaine works by entering into the brain and interfering with the normal recycling process that occurs in an area between brain cells known as the synapse. By preventing naturally-occurring dopamine from being absorbed (recycled) by the cell, a buildup of dopamine occurs in the synapse, resulting in the pleasure response and euphoria that the drug is associated with.
Consider this: there is a Starbucks and a Dunkin’ Donuts across the street from each other. Someone that looks like a customer blocks the entrance to the Starbucks. This causes all the potential zombies…I mean customers, from entering the Starbucks for their caffeine fix, so all the Starbuck’s customers join the Dunkin’ customers already there and the Dunkin’ becomes packed. This is how cocaine blocks the reabsorption or recycling (into the Starbucks) and overstimulates the cell (Dunkin’), resulting in the high. There are too many customers (dopamine) in the Dunkin’ (synapse) because the Starbucks (recycling site) is blocked (by cocaine).
This stimulation and resulting high is experienced in brain cells and has an impact on behavior and the body. The brain is processing all of the information associated with the stimulation is it receiving. The brain taking in and learning and remembering the steps the person took to get high, the places, the tools used, and the people around them. With time, these things associated with the euphoric feeling of using the drug can also trigger pleasure, resulting in an increase in that behavior and subsequent drug use.
To summarize, when cocaine is introduced in the brain, it causes a blockage in sites that would absorb the dopamine between brain cells. This blocking causes both the stimulation of the sending cell that is blocked and the overstimulation of the receiving cell with the dopamine that cannot be reabsorbed or recycled. The learning parts of the brain (such as the nucleus accumbens), along with the memory and emotional areas (the limbic system) can lead to future decisions (made in the prefrontal cortex) to remember the sensation, along with the circumstances under which it occurred, resulting in increased future use.
Here are some of the sources that I consulted if you would like to read more:
Nestler, E.J. (2005). The neurobiology of cocaine addiction. Science & Practice Perspectives, 3(1), 4–10.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851032/
NIH: National Institute of Drug Abuse – Cocaine
https://www.drugabuse.gov/publications/research-reports/cocaine/what-cocaine
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SUD Aftercare: An Indispensable Part of Successful Treatment

Why do patients receiving Inpatient medically supervised detoxification and rehabilitation levels of care for their substance use disorders (SUD’s) usually succeed in achieving their treatment goals? Our experience at Tully Hill Treatment and Recovery indicates that they succeed because their treatment and care occurs in a setting and environment that is highly structured. It also requires that patients make a sincere commitment to Tully Hill’s programming and services.
We know that SUD’s are a chronic illness requiring ongoing care and support after Inpatient treatment. Therefore, an essential component of effective Inpatient treatment and care is aftercare planning, which actually starts the day of admission at Tully Hill. Our treatment team knows that working with patients to formulate and execute an appropriate treatment and aftercare plan following discharge is critical to their continued sobriety and well-being.
What constitutes an effective aftercare plan for patients being discharged from an Inpatient setting? Aftercare planning needs to be individualized and tailored to meeting the needs of each patient. Our team at Tully Hill works to incorporate the following elements into aftercare…

Ensuring the continued wellbeing of discharged patients – once patients are stabilized medically and emotionally in Inpatient and begin achieving their treatment goals, it’s imperative to teach them how to manage their illness and make healthy decisions that support their emotional and physical welfare once they leave Inpatient treatment.
Discharging patients to safe, stable residences – an important part of effective aftercare is placing patients in a sober, safe, and secure living environment. This usually means a return to one’s home or another suitable environment, with appropriate treatment and care.
Active involvement in Outpatient Treatment—inpatient treatment is only the beginning of SUD treatment. All patients will be referred for ongoing Intensive Outpatient or Outpatient treatment following their discharge, as well as being referred for any ongoing outpatient mental health treatment.
Establishing with patients, sober living skills and support systems – teaching patients coping and sober living skills and helping patients establish and learn to keep sober support systems is an Inpatient treatment goal at Tully Hill. Effective aftercare includes establishing relationships and social and community networks that support a patient’s recovery.
Participation in a 12-Step recovery program – for most discharged patients, participating in a 12-Step recovery program has proven to be a significant factor in achieving and maintaining long-term recovery. Our aftercare planning includes impressing upon patients the value of fully utilizing this strongly recommended, and effective, aftercare plan piece.

It’s important to note that referring patients to longer-term residential care is an alternative to an Intensive Outpatient or Outpatient level of aftercare, when and where appropriate. Having a working relationship with agencies that provide either of these levels of care is important, to ensure that they will provide the treatment and care (including mental health care, if indicated) a discharged patient needs.

Continual growth, improvement in overall health and wellness, and resilience characterize effective aftercare plans. Following through with one’s aftercare plan is the key ingredient to experiencing the multiple benefits of successful recovery.

By
Ken Smith, LCSW
Clinical Director
Tully Hill treatment & Recovery

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The Vase, The Coin, and The Gift

How grief comes into our lives and making room for it.
By Gregg Snook M.A., NCC, LPC

So, recently I have had many conversations with people who have lost someone they loved. I find people rarely label the feelings that come from something changing or ending as “grief” unless it has something to do with someone’s death. It is reasonable to consider the connotation of grief as only applying to the death of someone who mattered to us, but I propose the following: grief is a feeling that occurs when our lives irreversibly change and we struggle to adjust to the cognitive, emotional, situational, and/or relational changes. I plan to write more about the different ways that grief enters our lives but today I wanted to focus primarily on how, when, and what we can do when grief comes to us.

Experience of grief.
Grief, as an emotion, can be one of the worst experiences of our lives. The turmoil, worry, confusion, sadness, anger, desperation, and hollow feeling that can result when someone we love passes away can be something that we fear with great trepidation. When it occurs, the overwhelming feeling often escapes the description of words. We express it in sleepless nights, tears, anxiety, fear, and sadness. First, I want to discuss why these feelings, intense and ominous, occur within us after we lose someone.
I like to ask people to reflect on this idea: grief exists on one side of a coin, on the other side is love. This idea is echoed in writers such as Kubler-Ross, Kessler, and Worden. The more intensely we love someone, the greater feeling of grief that results when they leave us. We live our lives with the experience of those we love and we feel it, in many ways, when they depart from our lives.

Grief as a gift we never wanted to receive.
I am sure the idea of grief as a gift is something that is contradictory and difficult. When we share our lives with people we love, they impact us. They change how we think, spend our time, and how we remember the time we spent with them. These impacts are kept by us in memories, idiosyncrasies, and many other ways. These impacts are part of what we miss when we lose them. The gift of grief is what we keep and how strongly we realize what we miss. Realizing that our lives have changed and the persistent experience of grief that occurs afterward is the reason why, once we receive the gift, we can never get rid of it.

Grief as a vase.
This is a metaphor I use with clients and support group members to explain how the feeling of grief never leaves us. I hear often that “time heals all wounds.” That one gets around more than requests for “Freebird.” Considering grief as wounds makes sense in how those affected are left with scars, but rather than the idea of “It goes away with time,” I like to remind people that in healing from grief, the feelings never go away; instead, they change.

The gift of grief is a result of the deep feelings of connection and love we had with the person we’ve lost. But this is a gift we never want to receive. Now to the metaphor. You receive a gift of a vase in the mail one day. You are unsure from where it came or from whom. Also, the vase in question is UGLY. I mean made by a blind person in a horrible mood ugly. It is lop-sided, has the worst color combinations, is disproportional, and has parts that break off, but it can withstand a long drop so it can never be thrown away. Which brings me to why it is a gift that we can not throw away or re-gift. This gift came to us as a result of all of our experiences with those whom we love and have left us. The vase would never have been delivered to us, in all its hideous glory, without first having such love for another person. The gift of the vase is something that represents all of the memories, feelings, hopes, dreams, laughs, and most of all love, that we shared with the person who passed away.

So, what do I do with this vase?
Well, we can’t get rid of it, we can’t smash it, and if we do it’ll still stay with us. Instead, I offer another way to cohabitate with this ugly, disruptive thing. Find out where it belongs. Move it around. Put a hat on it. Put some flowers in it. Collect rain water (tears) in it. Fill it with candy. Do whatever you have to do but do not ignore it. Grief does change as time goes on. The pain never ends but it changes over time. We can take the grief vase and put it on a mantel to observe for months. Then we can take a break and keep it with the holiday decorations. We can keep it in the basement. We can use it as a paperweight, doorstop, a pitcher, anything. We have to get to know it, understand it, and see where it fits into our lives. We will place it in areas that are difficult for us to navigate with it there. Tripping over a vase on your way out of the house will teach us it doesn’t belong there, it will get in the way.

The point of all of these metaphors is that it is a struggle to get used to the feeling of grief when we experience it. The HBO series Six Feet Under described, pretty well, how the average Americans’ approach to grief is very sterile. The main character recounts to someone in the first episode about how in America we clean up the process of a loved one passing and then disassociate from it in order to “maintain our composure.” In many other cultures and countries, death is a very intimate and emotional process of preparing the dead, the funeral rights, and then the aftermath. I, personally, am very fascinated and impressed by the Jewish tradition of sitting shiva. Shiva is a process of grieving in Judaism of observing a person’s death with great attention for a period of about seven days. During this period, the tradition involves sitting on hard chairs and fully experiencing the emotions of the loss. This experience can be shared by others as a way of fully processing what it means to us to lose someone we loved so greatly and meant so much. A full range of emotion, however, can be incredibly difficult, overwhelming, and taxing.

T.E.A.R Model.
William Worden is a psychologist who worked to develop the T.E.A.R. model to address grieving as a process. This is a model I use often when addressing grief issues with clients and it is more dynamic than the precursor work of Kubler-Ross (which has become more nuanced with time and was a major part of developing all grief work by starting the conversation). The T.E.A.R model suggests that there are four tasks of grieving in order to complete and regain equilibrium after experiencing a loss. The first task is working To accept the reality of the loss. This can be difficult, as we often experience times where the loss feels so great that we can’t “accept that they are gone.” The second task is Experiencing/addressing and working with/through the pain of the loss. This is how we get used to our vase and try out the most appropriate place to have it in our lives. The third task is Adjusting to a new environment formed from the loss of our loved one. The fourth and final task is find a new and meaningful connection with the deceased and Reinvest in the new reality.

The way I explain this to people is that the process of the tasks is like accepting the delivery of the vase, really seeing how ugly it is, figuring out where to put it, and remembering why we received it in the first place. The ugliness of the feelings of grief can, again, be seen as how much the person meant to us. As Kessler says, grief is the other side of love.
Addressing our grief is WORK. There is a lot of relief in having time to ourselves when we are faced with grief but this can also be met with how lonely it can feel when others in our support system “move on” and we feel left alone with a menacing feeling: grief. When we love someone, they impact our life. We experience the side of the coin that holds love and connection. When they leave us (through death, separation, or other things), we experience the other side of the coin: grief. We grieve as strongly as we love. We cannot have one without the other or we would never feel the impact of the loss. When we are faced with the experience of that emptiness, we experience grief and can choose to do things that make it meaningful for us. I will write more about the tasks later. In this article, I wanted to talk about the feelings that occur and what we do with the change that comes with loss. The first part is the feeling.

If you are a person who is suffering with a loss and are ready to explore your feelings of grief and loss, please reach out for help. This can be in the form of a support group, a trusted friend, a member of your faith community, or other supports.

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Safe Injection Sites- Where’s the spot?

What we know, as of now, about injection sites.
I am sure you have heard in the news about the controversy regarding the possible Safe Injection Site that is being planned in the Kensington section of Philadelphia. Depending on who you speak with, it may be a hot topic. I assume there is a lot of opinion associated with a safe injection site and not a lot of policy or approaches. It makes sense. The idea of having a place where drug use is encouraged seems completely counterproductive to the mission of a safe injection site. I think the emotion behind these positions and arguments made for them comes down to the difference between abstinence and harm reduction. It is my hope in this editorial that I can provide information rather than address the merits of either position.
The safe or “supervised” injection site that is currently being discussed to open in Philadelphia, called Safehouse, aims to provide an environment that allows for safe oversight of substance use in order to prevent overdose deaths and possibly connect users to treatments. According to the Safehouse website, the facility hopes to: encourage treatment, reduce harm, provide a sterile means of consumption, reverse overdoses, provide wound care and basic medical services, provide onsite education, provide referrals to mental health/substance abuse services, offer safe disposal of supplies, and offer medication assisted treatment.
The site explains how interested individuals would use the safe injection site. First, users are registered at the site, almost as though it was a gym membership. Then, members are able to be provided with sterile equipment, test strips to examine if there is fentanyl (a strong analgesic that often contributes to overdose) in their substances, and they are given a space to use their substances with supervision. Members are NOT provided with any drugs at the site. Employees of the site will NOT aid in the administration of any substances. The substance user is observed by staff in order to identify and prevent overdose in the user. Then, substances and equipment used during the process are disposed of. Users are offered wraparound services and basic medical support. This last part can seemingly include things ranging from a bandage or referral to supports or treatment.
The site stresses that it does not provide, sell, or supply any substances to users (users presumably, provide them on their own). Nor do they assist with the administration of any substances (they’re not helping any one shoot up or consume other substances).
Philadelphia is not the first place to consider having a safe injection site to address the issue of opioid use in the community.
The idea of a safe injection site is not necessarily new. It is reported that there are approximately 120 safe injection sites in Europe. It is also reported that there has been a safe injection site in Vancouver, Canada for about 10 years now. It is reported that no deaths have occurred at any of these sites, and overdose fatalities decreased by 35% in Vancouver after the site opened.
These numbers can be seen as a success regarding mortality rate. It is not unreasonable to discuss how people using these sites would recover or stop using drugs. It was reported that participation in detox services increased by 30% after the site opened in Vancouver. Approximately 52% of IV drug users (injecting drugs) sought treatment. These numbers seem to provide information regarding those who may seek out treatment to work towards possibly not using drugs further.
According to a recent report on National Public Radio (NPR; heard by me on WHYY), an article titled Researchers Released New Data on Secret, Illegally Operating Supervised Injection Site in the U.S. discusses part of the plans and factors for the site. This article discusses how the Philadelphia Inquirer ran a poll and found that 67% of those whom responded were opposed to the site and 22% supported it. Another poll referenced in the article, conducted by the Pew Foundation, reported that 50% were in support and 44% were opposed. The article also reported that more than 1,100 individuals died of drug overdoses last year in Philadelphia.
The community is also important to consider when thinking about the Safehouse injection site. Another NPR article, entitled Kensington Neighbors Angered by Potential Location of Supervised Injection Site, discusses information gathered from residents of the Kensington section of Philadelphia, as well as legal challenges to the site. Brian Abernathy, the director of city management, is reported to not be in support of the location. He is reported in this article and others to be interested in the legality of the site and the benefits to the city. Former Governor of Pennsylvania, Ed Rendell, is a backer of the site and supporter. Another city organizer was reported to have visited an injection site in Toronto, Canada and voiced concerns about the difference between the settings in Canada and the presumed site in residential Kensington. The concerns were regarding how well concerns about use could be contained in a residential area. It was also reported in the article that Pennsylvania State Attorney General, Josh Shapiro, favored another strategy to remove drug dealers from the area via legal involvement.
There is a legal contest to the site by the Attorney General’s office to the site. The legal contest seems to be a result of a war-on-drugs legislation from the 1980’s that extends penalties to any place of business that may be used in or housing the sale of drugs. In some of the reading, the law was summarized as saying that law enforcement can target things like raves or business that engage in the sale of drugs “out the back door” or in addition to another business in a place that was established under legal pretenses. The position of Managing Director Abernathy (seems to be investigating if this law, or laws like it, can apply to the safe injection site (WHYY article Federal Prosecutors Sue to Stop Nation’s First Planned ‘Supervised Injection Site’ in Philly). On a larger scale, the community organizers and the Attorney General seem to feel that the site would increase risks to the residents in the Kensington section of Philadelphia already living in what is often referred to as “the largest open-air drug market in the United States.”
The concerns of those who oppose the site seem to focus on a purported impact. It is reasonable to consider the difficulty in instituting something that may not be new in other countries, but is new in the United States. Below is a pie chart from the Philly.com website for crime in the time between April 12, 2019 and May 12, 2019. The section for “narcotic/drug law violations” was reported to number 140 offenses, accounting for 21.24% of crime in 30 days.

The proposed safe house site is reported to want to work in tandem with the community and local law enforcement, with the goal of decreasing drug-related crimes in the area. According to projections, the site is expected to save the city of Philadelphia approximately two million dollars, mostly in response costs to drug-related issues such as overdose and ambulance rides. Considering that reported crimes in Kensington also includes public intoxication, drug possession, drug paraphernalia charges, and the like, it would make sense that those crimes may decrease if they were contained in a safe house site (assuming the legal contest does not prevent it on the grounds of all use being illegal under federal law). Benefits could also manifest in other ways, such as lowering costs of responders to drug-related health issues (as Narcan is administered in the site), as well as preventing the sharing of needles with the safe observation and disposal that could occur at the site. When the needle exchanged opened in Philadelphia in the 1990’s, it was reported that the HIV rate of transmission via sharing of needles decreased by 95%.
It is also reported that there are conversations occurring in the state of New Jersey and the city of Pittsburgh regarding safe houses. It seem as though the discussion of safe injection sites may be occurring in different areas to address the problem of opiate use and resulting health issues.
As I stated above, I did not want to write this article with the goal of supporting either side of the safe injection site debate. Instead, I wanted to collect information from sources in order to more fully understand the intention of the site and understand the views of the opposition. It is reasonable to consider that the idea of an organized place that helped people get drugs and use them would be absurd. It is also understandable that individuals may feel differently regarding the intentions of the site based on their expectations of the problems it hopes to assess. This again brings us to the difference between abstinence and harm reduction. The position of abstinence based solutions attests to individuals ceasing their drug use entirely. The position of harm reduction asserts that addiction can be a complex issue that often results in relapse. Harm reduction asserts that having options for safety to be considered in someone’s addiction in order to prevent death. This in the hopes that their recovery (ceasing of using drugs in maladaptive and disruptive ways) can eventually be addressed through some kind of treatment. Some of the data from sites in other countries indicate that these sites can lead to individuals connecting with resources and support that would be easier to access due to them being at the site, being registered, and, therefore, available to those who can point them toward treatment options.
The issue seems to be in the planning stage for at least the past year. The legal contest occurred in February of 2019. There will be more to come as the community, site, and authorities consider the site moving forward. The desire of wanting to provide help for those who are using, as well as the concerns of those who are considering the ramifications of having a site in their community will also need to be addressed as time moves on.
To the readers, I would suggest, should you be interested, to continue to read about things that may come out regarding the Safehouse Injection site. This seems to be a complex issue with a lot of people concerned about the well-being of people in the community, as well as those who are struggling with the use of addictive substances. I hope this article was informative.

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