SSyynneerrggyy BBrreeaakktthhrroouugghhss
IInntteerrvveennee An Emergency Guide to Heavy Drinking and Alcoholism
Step One of Ten
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Learn About Definitions, Steps and Stages
Introduction The information in this program is not intended to be taken or interpreted as medical advice or advice of any other type – for medical or other advice, please consult your doctor or other qualified health professional. Most of what I’m going to say will be based on research. So if you don’t agree, please don’t shoot the messenger! This program will include information on AA, but it will not be about AA. My intention was not to provide one answer, but a smorgasbord of information from which you could tailor your own solutions. And, one final thing: Please have patience and hang in there as we cover this topic. For example, there will be times when you may think I’m saying that genetics is a big deal, and other times when you may think I’m saying it’s not – but try to take all of this with a grain of salt, because there are opposing views on many of these topics. I am trying to give everything its fair due so that, in the end, you can make your own choices. As for my background, I have a degree in Psychology and Masters’ degrees in Education and Organizational Behavior, and I have spent my career mostly as a trainer and technical writer. But my background in alcoholism and addiction is from self-study. Like you, I wanted answers and set out to find them. So I have done my best to find, interpret, and provide information, and I hope to make you aware of lots of tools and information; but, for medical or other advice, please contact a qualified healthcare professional.
OK, let’s get started . . . Heavy drinking and alcoholism do not occur in a vacuum, and these problems are not resolved in a vacuum, either. I believe that, as the popular saying goes, “We are the change we’ve been waiting for” – and this means you, me, and the drinker. I’d like to start out by giving you a little background on me. I came from a family of heavy social drinkers, and my sister married into a family of social drinkers. Out of that marriage came my nephew, Ray, a precious baby that I
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bounced on my knee and developed a special relationship with, as the years went by. I believe that, generally, too much alcohol will eventually make things difficult for almost everyone, and statistics indicate that one out of every two Americans is affected in some way by alcoholism. It was particularly hard on my nephew. However, we were trying to follow the prevailing wisdom – or so we thought – that said, “Wait ‘til they hit rock bottom” and “You can’t help them until they ask for help.” At the same time, this felt uncomfortable. I remember once, when my sister said to me, “This is counterintuitive to what a mother would do. If you’re a mother and your child gets hurt, you run and help him. This is like the opposite.” Imagine our shock when we found out that this actually was NOT the prevailing wisdom – even though we had been told this by so-called experts. I’d like to quote former presidential candidate and Senator George McGovern, in the Preface to the book, Love First, about his daughter: “During the years of Terry’s drinking, with its frequently sad results, she did seek help in treatment, counseling and Alcoholics Anonymous programs. But we were repeatedly told by well-meaning, supposedly informed friends that we would have to wait until Terry really “hit bottom.” The trouble is that when she ‘hit bottom,’ she died.” So heavy drinking and alcoholism can be very slippery slopes, and drinkers are sometimes at the bottom of these slopes. And if you leave the heavy drinker or alcoholic to face these challenges alone, I believe that you may be asking for a lot more trouble and heartache down the road. This is precisely why I created this teleconference/webinar – to learn, to share knowledge and solutions, and to brainstorm solutions with each other. As a friend of mine likes to say, “We may not have it all together, but together we have it all.” Sometimes this journey is like being lost in a dark forest, and maybe some of you can relate to that. I know this was true for me and my sister. But you can be the person in the dark forest, not seeing the forest for the trees, or you can be in the helicopter above, with the navigation equipment, the searchlight, and the view of the whole forest. This is what this program aims to be for the topics of heavy drinking and alcoholism. You can find answers and solutions, and they can make a difference! It was too late for me and my sister, but I hope it won’t be too late for you. You may have figured out by now that the two greatest myths about alcoholism are: “You have to wait ‘til they hit rock bottom” and “You have to
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wait ‘til they ask for help.” These are brutal philosophies that an evolved civilization does not follow willingly. Experts in the field of addiction do NOT support this philosophy, even though you might hear it from a medical or other health professional. There are many health professionals who do not know much about alcoholism, and we will discuss this later. You may even talk to some long-time AAers who support this philosophy – perhaps because they have become habituated to the idea of alcoholics being abandoned by everyone except AA. But the tide started turning over10 years ago, and we will be covering at least some of the information and approaches that have evolved over the years. This program is basically designed to be a roadmap of STEPS to take when problems arise due to heavy drinking or alcoholism. In addition, we’ll look at STAGES of heavy drinking and alcoholism, how each stage may AFFECT this roadmap of steps, and what this may mean as far as modifying the steps, or changing your response to a given situation. In the early stages, problems are less noticeable, and your days may pass, as usual. But in the later stages, problems may be overwhelming and you may feel that you’re racing against the clock. Because alcoholism is a progressive and fatal disease, your drinker may even die. The latter is what I am hoping the knowledge from this program will help to prevent.
Overview Let me give you an overview of the modules of this program: Step One: LEARN ABOUT THE DEFINITIONS, STAGES, AND STEPS OF DRINKING.In this step, we’ll look at definitions, stages, and steps related to drinking, how the stages are related to the steps, and how this may apply to you and your drinker. We’ll also look at what I mean when I say this is an emergency guide, why the clock is ticking, and why, if you didn’t need to spring into action yesterday, you may need to spring into action today. Step Two: KNOW ABOUT THE RISK FACTORS, HEALTH COMPLICATIONS, HEALTH INSURANCE, AND LASTLY ASSESSMENTS FOR DRINKING. We’ll look at the risk factors of alcoholism, health complications of alcoholism, assessments for alcohol abuse and alcoholism, the ins and outs of health insurance, and why it is so important to check into health insurance BEFORE your drinker receives a medical diagnosis (IF you can do that SAFELY), and what you can do if the drinker has no insurance or can’t get insurance. Step Three: INTERACT AND COMMUNICATE DIFFERENTLY. We’ll clarify terms like “enabling” and “co-dependence,” learn what enabling is, and what
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it is NOT, and look at better ways to interact and communicate that can lead to successful outcomes for you and your drinker. Step Four: BE PREPARED FOR CRISIS SITUATIONS. We’ll talk about and brainstorm how to handle crisis situations with your drinker. There are many kinds of crisis situations, and each of them is unique. Step Five: UNDERSTAND DETOX, INTERVENTION, AND TREATMENT MODELS. We’ll be looking at the detoxification process, different intervention models, and treatment models or belief systems that drive people in the direction of certain kinds of treatments. This will really help to give you a bird’s eye view of the treatment landscape, and why people feel and act so differently from others when it comes to treatment. We’ll also look at effective counselor communication styles, and the lessons they may have for all of us. Step Six: TAILOR INTERVENTION AND TREATMENT. We’ll look more specifically at isolated treatments, and also at treatment programs (not specific treatment centers, but types of programs). I will be presenting the latest treatments that I was able to find, but will also be presenting traditional treatments that are still in use. I will also talk about alternative treatments. Then we’ll talk a little about tailoring treatment to the needs of your drinker, although most of this work will be done individually and, if desired, in your groups. Step Seven: DISCOVER AND USE SUPPORT SYSTEMS. We’ll discuss support systems like AA and Al-Anon – how they work, what the 12 steps are, if you have to believe in God to belong to AA, if you have to stop drinking to belong to AA, and other things related to support organizations. Step Eight: CARE FOR THE CRITICALLY ILL DRINKER. We’ll talk about what to do when your drinker is critically ill. This can sneak up unexpectedly, so you’ll want to have an idea of what to do so that you can spring into action before it’s too late. This is an invaluable module for anyone, given that an estimated one-third of Americans are currently caring for a loved one, and given that, at some point, you may have a loved one who has an accident, becomes critically ill, or dies. Step Nine: SUPPORT YOUR DRINKER DURING AND AFTER TREATMENT. We’ll learn about relapse prevention, how your drinker feels in the recovery process, and how you can support him in sustaining the benefits he has received. We’ll learn some new things, but you’ll also be able to reflect on how what you’ve learned so far, applies to this step. You will also finish this final step in your Action Plan, and put the final touches on your Action Plan.
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Step Ten: CREATE YOUR ACTION PLAN. Throughout this process, you will be answering questions and creating an Action Plan. By the time we get to this last step, you will have designed an Action Plan specifically for supporting you and your drinker.
Defining and Identifying Heavy Drinking and Alcoholism So let’s look at defining and Identifying Heavy Drinking and Alcoholism. To do this, we’re going to look at a “continuum” – from average drinking on one end of the spectrum, and alcoholism on the other.
Average Drinking Average Drinking: Average or low-risk drinking on any given day, as defined by the Centers for Disease Control and Prevention, is no more than one drink a day for women, and no more than two drinks a day for men.1 ONE DRINK is defined as having no more than ½ ounce of pure alcohol in it. Examples of one drink would be: 12 oz. of beer
8 oz. of malt liquor
5 ounces of wine 1.5 ounces or a “shot” of 80-proof distilled spirits or liquor2 Now, you may be thinking that this is a very small amount of alcohol; but if you are, you might want to step back and consider that this is “average,” and that you may be on the “higher than average” part of the scale. One’s own drinking habits can tend to skew one’s perception as to what a little bit or a lot is – and this can also affect how, when, or even if we identify drinking as a problem.
Heavy Drinking Excessive alcohol use is the third leading lifestyle-related cause of death [italics mine] for people in the United States each year.3 And, as defined by
1 Centers for Disease Control and Prevention, Alcohol and Public Health: “What Does Moderate Drinking Mean?” Last updated May 10, 2012. Accessed August 15, 2012. http://www.cdc.gov/alcohol/faqs.htm#moderateDrinking. 2 Centers for Disease Control and Prevention, http://www.cdc.gov/alcohol/faqs.htm#standDrink.
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the Centers for Disease control and prevention, it is when you drink an average of more than 1 drink a day for women, or more than 2 for men. And keep in mind that this is not more than one or two on any given day. What they mean is that, if you average the amount of drinking, say, for example, over a month, and the average for every day is more than one for women or more than 2 for men.4 Now, you might be thinking, “Well, is heavy drinking really such a big deal? I mean, lots of people get smashed now and then.” Well, it is a big deal, and this is why: Whether you’re talking heavy drinking, binge drinking, or alcohol abuse, in just ONE INSTANCE of heavy or binge drinking, a person could kill themselves or someone else. It happens every day. An innocent person is killed on the road, or the drinker dies from alcohol poisoning or from an unintended consequence involving reckless, unmonitored behavior. In a matter of seconds, you can go from having a boatload of fun, to having a boatload of serious, lifelong problems. So, what if you drink at home, to avoid these problems? Well, many of these problems can happen at home, and even if they don’t, drinking can still be a problem when it seriously affects the family dynamic, and your health and your life over the long term.
Binge Drinking Binge drinking is drinking 4 or more drinks in a single occasion for women, and 5 or more drinks for men. The averages for men are more, because their average body weight is more; but of course, there are exceptions.
Passing Out This is losing consciousness, but having full memory of the events that preceded it.
Blackouts Blacking out is different from losing consciousness – it refers to having complete or partial memory loss of events in the waking state. Blacking out can happen to anyone, from the heavy drinker to the alcoholic. It is believed by some that blacking out is more likely to occur when a lot of alcohol is consumed very quickly, as opposed to drinking over a longer period of time.
3 County Health Rankings and Roadmaps, “Alcohol Use.” Accessed November 15, 2012. http://www.countyhealthrankings.org/health-factors/alcohol-use 4 Centers for Disease Control and Prevention, http://www.cdc.gov/alcohol/faqs.htm#heavyDrinking.
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(Wikipedia, 06.19.12, Blackout (alcohol-related amnesia). http://en.wikipedia.org/wiki/Blackout_%28alcohol-related_amnesia%29)
Alcohol Abuse Alcohol abuse is a pattern of drinking that results in harm to one’s health, interpersonal relationships, or ability to work, and continuing to drink despite these problems. It leads to problems, but not physical addiction. Examples would include:
Failure to fulfill major responsibilities at work, school, or home.
Drinking in dangerous situations, such as drinking while driving or operating machinery. Legal problems related to alcohol, such as being arrested for drinking while driving or for physically hurting someone while drunk.
Continued drinking despite ongoing relationship problems that are caused or worsened by drinking
Alcoholism Now take all the problems from alcohol abuse, and add physical addiction to them – this is when you get alcoholism. Can alcohol abuse LEAD to alcoholism? Yes! How can you tell the difference between alcohol abuse and alcoholism? Sometimes it’s difficult. Dr. Kevin McCauley, who has worked as an expert in this field for many years, states the following: “If I want to be totally honest with you, I can’t tell the difference between a really, really bad drug abuser, and a not-so-bad drug addict . . . because we’re in the realm of the brain here, and we don’t have good tests for brain diseases yet, there’s no way in addiction medicine to distinguish definitively between the really, really bad drug abuser, and the not-so-bad drug addict, and that causes a lot of confusion.” Now, when you hear the word, “drug,” you might be thinking that Dr. McCauley works only with drug addicts. But here’s another little insight: alcohol is defined as a psychoactive drug. And yes, he does work with alcoholics. So it may be difficult for even the experts to tell the difference, but as far as we – the family, loved ones, and coworkers of the drinker – are concerned, we just want to observe as to whether our drinker is struggling in
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various ways, and whether we see a correlation between the amount of alcohol consumption and the struggling. Alcoholism is also characterized by: Craving – A strong need, or compulsion, to drink.
Loss of control – The inability to stop drinking once a person has begun. Physical Dependence – The occurrence of psychological and physical withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. These symptoms are usually relieved by drinking alcohol or by taking another sedative drug. Psychological Addiction – This could include, among other things, anger, anxiety, depression, stealing or lying to support the addiction, using in secret, etc.5 Increased Tolerance – When the alcohol or other substance loses its potency with repeated use, so that you need increasing amounts get “high.”
Reverse Tolerance – Reverse tolerance often happens in the late stages of alcoholism, when the liver has become damaged from prolonged use of alcohol, and can no longer break down, or metabolize, the alcohol. When this happens, there is “reverse tolerance,” where the drinker becomes intoxicated on less alcohol.
Overdose6 This may seem pretty obvious – an overdose is more than the recommended or generally taken amount, and a fatal overdose is when too much causes death. What is not obvious, is what to do when this happens! An alcohol overdose is called “alcohol poisoning,” but overdoses can also involve alcohol and barbiturates, benzodiazapines, or other drugs. A combination of alcohol with other drugs (and that includes LEGAL drugs, like your prescription drugs) is estimated to account for one-third of all drug overdoses.
5 Right Diagnosis: “Symptoms of Psychological Addiction.” Last updated on February 1, 2012. Accessed on August 22, 2012. http://www.rightdiagnosis.com/p/psychological_addiction/symptoms.htm. 6 Alcoholism Information: “Alcohol Poisoning Symptoms.” Last updated on February 1, 2012. Accessed on November 15, 2012. http://alcoholism-information.com/Alcohol_Poisoning_Symptoms.html. and Mayo Clinic: “Alcohol Poisoning: Symptoms.” Accessed on November 15, 2012. http://www.mayoclinic.com/health/alcohol-poisoning/DS00861/DSECTION=symptoms.
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The signs of an alcohol overdose – either alcohol alone, or alcohol with other drugs, could include some of the following: Being dazed and confused
Breathing that is slower than average (less than 8 breaths a minute) Shallow or irregular breathing
Not having reflexes or a reaction to pain Cold, clammy skin
Slow heartbeat Seizures Vomiting
Low body temperature Pale or Bluish skin and lips
Unconscious, unable to be aroused, or in a coma These signs could mean that your drinker is at risk of dying! According to the Mayo Clinic, if your drinker is— unconscious;
breathing less than eight times a minute; or has repeated, uncontrolled vomiting —you need to get them to a hospital as quickly and safely as possible, or, if a phone is accessible, call 911 and tell the operator that your drinker has overdosed and you need an ambulance. Be prepared to tell the hospital staff when, what kind, and how much alcohol was consumed. If they are UNCONSCIOUS: Put them on their side and make sure their breathing passages are clear, and that they don’t choke on or inhale vomit, which could be fatal.
Do NOT try to force them to vomit, as this could also be dangerous. If they’re not breathing, give them CPR.
Do not leave them alone If they are CONSCIOUS:
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Keep them awake, standing and walking as much as possible, and keep talking to them.
Call 1-800-222-1222 to reach the poison control center. These calls are confidential, and they will tell you what to do, and whether or not you need to take your drinker to the hospital. NEVER assume that they will sleep it off, because alcohol continues to be released into the bloodstream after a person falls asleep or becomes unconscious. You may not want your drinker to be angry with you later for doing this, but – if his life is at stake? It’s better to be safe than sorry! An estimated 50,000 cases of alcohol poisoning are reported each year, and about once a week, someone dies from alcohol poisoning. And remember that this doesn’t happen just with alcoholics; many times, this happens when someone is drinking heavily or binge drinking.
Withdrawal If your drinker survives having had too much alcohol, or alcohol and drugs, the next hurdle is withdrawal, which is when your drinker is coming off of the alcohol and/or drugs. For alcohol, some of the signs of withdrawal are: Irritability, jumpiness, mood swings, or nightmares
Shakiness or tremors
Sweating or clammy skin Headaches or insomnia
Rapid heart rate Loss of appetite Nausea or vomiting Delirium tremens, or DT’s, is a severe form of withdrawal that can include uncontrollable trembling, hallucinations, severe anxiety, sweating, and sudden terror. Sometimes this is also called autonomic hyperactivity, or AH. The degree or intensity of withdrawal is one of the parameters used to determine the degree of dependence on alcohol, and we’ll talk more about this later.
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Alcohol alone, and alcohol used in combination with sedative drugs such as barbiturates (for example, Seconal, Amytal, and Nembutal) and benzodiazapines (for example, Valium and Ativan) are high on the list of drugs having serious withdrawal risks – so it’s critical to know that withdrawal symptoms can be so severe that the drinker can die from withdrawal! I will repeat that: withdrawal can be so severe that a drinker could die from it! This is why it is so important to recognize and monitor the signs of withdrawal. For benzodiazapines (Xanax, Valium, Ativan, etc.), signs of withdrawal are: Discomfort or restlessness
Anxiety, fear, or panic
Appearing disconnected Perceptual disturbances Sensory disturbances, such as hyper-sensitive hearing
Muscle pain or spasms Shaking, convulsions, or seizures So you can see that, although symptoms vary from drug to drug, there are also many symptoms that are shared among these drugs. And you can also see that there is a continuum of severity for withdrawal, and that you need to watch for these signs to determine if your drinker needs medical help and a medication-assisted withdrawal. Withdrawal can be hard on the body, and with long-term substance abuse, either with alcohol alone or alcohol with other drugs, if a person has multiple withdrawals over time, there is also a condition called “kindling,” which means that, with each successive withdrawal, there are increasingly severe withdrawal symptoms.7 Overdose and withdrawal, especially when they involve multiple drugs, can be very complicated and very dangerous (and remember that alcohol is a drug, so I am referring to alcohol, also). So if there is any doubt that the drinker is in extreme distress, you need to get them to a hospital, where a doctor can hopefully make a professional assessment and determine what is needed. It would help doctors for you to be as calm and knowledgeable as
7 Wikipedia, “Kindling (sedative-hypnotic withdrawal).” Last updated June 13, 2012. Accessed August 22, 2012. http://en.wikipedia.org/wiki/Kindling_(sedative-hypnotic_withdrawal).
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possible, and if you can take bottles or remnants of the drugs that were taken, that would probably help a lot. Sometimes doctors will use assessments that help determine the severity of withdrawal, such as the CIWA-Ar for alcoholism, the CSSA for cocaine withdrawal, and the SOWS or OOWS. I’m not sure how long it would take to become addicted to barbiturates – I have read that an addiction can develop “quickly.” But with benzodiazapines, I have read that you should not take them for longer than 4 weeks. There is also a specific vitamin protocol for alcohol withdrawal, using high doses of Vitamin B3, administered intraveneously, and Vitamin C. It’s described on page 22 of the 2009 book, The Vitamin Cure for Alcoholism. This protocol was developed in the 1950’s, and one of the authors, who is a medical doctor, reports that it was very effective.
The Disease Model8 Is alcoholism a disease? Yes. It is often referred to as a chronic, progressive, and terminal disease. Chronic – because it is persistent, with remissions in between (chronic, meaning the periods of time when an alcoholic drinks; and remissions, meaning the periods when he is sober).
Progressive – Because it gets worse over time; and Terminal – because, without treatment, it results in death. Now, there is something in the field of medicine called the “disease model.” This is defined by three things: organ, defect, and symptom: An organ has a defect, and the organ defect will exhibit certain symptoms. In addiction, the disease model is widely accepted as applying to alcoholism. Alcoholism is considered to be a disease of the midbrain, where the midbrain, which governs impulsive behavior, overrides the frontal cortex, which governs interpretations of meaningfulness, a sense of right and wrong, and self- monitoring behavior. So we have a defect, in an organ, which is the midbrain, and the symptoms are craving, loss of the ability to stop drinking, and a physical reaction to withdrawal that, if not properly managed, could be fatal.
8 Kevin T. McCauley, M.D. CD Series, “Disease 1.” Institute for Addiction Study, instituteforaddictionstudy.com.
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And, at this point, there seems to be little argument that alcoholism is a brain disease. Dr. Kevin McCauley states that “The overwhelming preponderance of evidence is on the disease side of the equation.” So, to answer the question of, “Why can’t they just stop?” addiction counselor and author Debra Jay, in her book, Love First, states that ”Willpower is not an effective therapy for this disease, any more than it would be for cancer, diabetes, or heart disease” and goes on to quote an 1877 issue of Scientific American, which states: Science …. draws a broad distinction between drunkenness as a vice and drunkenness as a disease. The man who drinks for pleasure, it holds, may look for benefit in the counsels of others or in his own strength of will; but he who drinks because he cannot help it, being led by an irresistible impulse, is a sick man, and needs not a temperance pledge but a physician.” Isn’t it interesting how, after over 150 years of ignorance, addiction professionals seem to be coming to the same conclusion? Now, here’s an extremely important distinction when it comes to comparing alcoholism with diseases like cancer or diabetes. You may have noticed Debra Jay saying that willpower is no more useful a therapy than it is for cancer, diabetes, and heart disease. And you might be thinking, “Well, that’s not right because cancer, diabetes, heart disease – all of those diseases are often controlled with willpower.“ I would agree in the sense that people can control their diets and lifestyles to improve these diseases. But here’s the rub with alcoholism: the organ defect in those other diseases does not involve the very organ that controls discipline, self-monitoring, and a sense of right and wrong. With these other diseases, a person can self-monitor and say, “This is a good food and this is a bad food, I can eat this, but I can’t eat that, I can do this but I can’t do that.” With alcoholism, the defect involves the very organ that controls that kind of self-monitoring and self-controlling behavior. We are NOT recommending that the drinker ignore discipline in his or her life. Of COURSE, anything that helps to mitigate a destructive behavior or condition is GOOD, and DISCIPLINE is GOOD. But to understand that what we could call the “self-monitoring, self-control, and discernment” organ, is the very organ that is damaged, is to understand HOW MUCH HARDER it is for the drinker to “exercise discipline” or “get with the program,” so to speak. Another value of the disease model is that it makes alcohol a disease that qualifies to be treated medically. We will talk about health insurance, and some of the pluses and minuses of this, later. But for now, let me just say that
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you will want to get health insurance BEFORE you get a medical diagnosis – IF you can do this SAFELY.
Is Alcohol a Gateway to Other Drugs? This naturally leads to the question, “Is alcohol a gateway to other drugs?” Now that you know what parts of the brain are suppressed or damaged with alcohol abuse and alcoholism, it’s not too hard to figure out that the answer to this question is, “Yes.” It is also believed that alcohol plays into suicide, because it lowers the defenses that would normally discourage a person from suicide. In fact, alcoholism is the primary diagnosis in 25% of those who commit suicide. Because alcohol abuse often does lead to other drug-taking, we will address some other drug-related matters, as well.
Types of Alcoholics
Functional and Non-Functional Alcoholics Sometimes the distinction between “functional” and “non-functional” alcoholics can be a sort of smoke-and-mirrors way of deluding the drinker into thinking he is OK. “I’m successful, I have a great job or lots of money, so I’m fine.” Well, the functioning alcoholic is NOT fine. In the book, Understanding the High-Functioning Alcoholic, Sarah Benton states that “Having outside accomplishments led me and others to excuse my drinking and avoid categorizing me as an alcoholic. My success was the mask that disguised the underlying demon and fed my denial.”9 Worse yet, if the functioning alcoholic is a role model to someone, and that someone is having a problem with drinking, that someone might be inclined to say to himself, “Well, Mom-Dad-Brother-Cousin-Uncle are doing fine, and they drink a lot – so I can’t blame my problems on alcohol!” Here we have some widespread denial that more than just one person needs to face.
Sober Alcoholic Alcoholism is generally thought of as something that does not have a cure, so the term, “sober alcoholic,” is someone who is not drinking, but would like to drink if he could drink without consequences. AAers have a saying, “Once a pickle, always a pickle,” and they do not believe that an alcoholic will ever
9 Jane Brody, “High Functioning, but Still Alcoholics.” New York Times: Personal Health (May 4, 2009). Accessed January 30, 2011. http://www.nytimes.com/2009/05/05/health/05brod.html?_r=1&ref=health.
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again be able to drink moderately. I, personally, question the belief that there are no cured alcoholics, because I believe that a cured alcoholic would be someone who does not crave alcohol, and I have read reports of alcoholics who have become that way. But because the majority of alcoholics are not that way, I believe it’s a valid term.
Dry Alcoholic or “Dry Drunk” The terms “Dry Alcoholic” or “Dry Drunk” are used to describe someone who is a sober alcoholic, that is, an alcoholic who does not drink, but who is plagued with problems that may include irresponsibility, anger, resentment, and the same psychological and emotional patterns or baggage that were creating problems while he was drinking.10 This just shows that the problems don’t necessarily stop when the drinker stops drinking, and that some of these other problems were probably contributing to his drinking when he did drink. So it’s important to know that an alcoholic doesn’t just shuffle through a “treatment factory” and come out clean. Instead, expect that life may be even more difficult for him, because he won’t have alcohol as a soother. This is where you will need to be patient, continue to put into practice some of the communication techniques in this book, and just understand that this process doesn’t happen overnight.
Recovering Alcoholic A recovering alcoholic is someone who is working on recovery and sobriety.
Addiction Transfer Addiction transfer is when you swap one form of addiction for another form of addiction. Two types of addiction transfer are cross-addiction and switched addiction.
Cross Addiction Cross Addiction is when someone in recovery takes a doctor’s prescription for sleep, pain, anxiety, or other condition, and this leads to a new addiction, or more likely back to the original substance of abuse. This can happen with Vicodin, Oxycontin, Ultram, Xanax, Valium, Ativan, Ambien, amphetamine-
10 Carole Bennett, M.A., “Do You Have a ‘Dry Drunk’ in Your Life?” Huff Post Addiction and Recovery: The Blog, May 27, 2010. Accessed July 22, 2012. http://www.huffingtonpost.com/news/addiction-recovery.
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type stimulants for ADD,11 and other medications.12 Especially if the patient is in desperate and immediate need to relieve pain or some other severe medical condition, he may not consider whether or not a prescription medication could lead to a new addiction or back to the old addiction, and doctors are not trained to watch out for this, either. It’s best to consult an addiction specialist for medication alternatives that will reduce the possibility of this happening, and we will talk about addiction specialists next week. Maybe the drinker could get a list of these “approved” types of medications beforehand, so that he could have them on hand in an emergency. I don’t know if doctors or addiction specialists do this, but it might be worth a try, because it would be a shame for the drinker to be completely derailed in his recovery, just because he was in an emergency situation and was given a medical prescription that led to a cross-addiction.
Switched Addiction A Switched Addiction, on the other hand, is when an addict who is not abusing switches his addictive behavior to another obsession, such as work, religion, 12-Step meetings,13 food, sex, gambling, or spending. These are sometimes called “process addictions,”14 and while some may be more problematic than others, the common thread is the obsession and lack of balance, and the avoidance and lack of resolution of the same denial, powerlessness, emotional pain, self-defeating patterns, or other problems that plagued the addict when he was abusing, and that now keep him from finding some happiness in recovery.
11 Robert M. Leath, MD, “Cross Addiction: When Good Medicine Yields Bad Results for People with Chemical Dependency Problems.” In Recovery Today Online. Accessed July 30, 2012. http://www.recoverytoday.net/articles/142-cross-addiction. 12 Meghan Vivo , “Understanding Addiction Transfer and Cross Addiction.” In Drug Addiction Center: Featured Articles. Updated July 30, 2012. Accessed July 30, 2012. http://www.drugaddictioncenter.org/drug_addiction_center/understanding-addiction-transfer-and-cross- addiction.php. 13 Tony L., “16. Crossed and Switched Addiction.” In Addiction Recovery. Accessed July 30, 2012. http://integrated-recovery.blogspot.com/2006/01/16-crossed-and-switched-addiction.html. 14 Floyd P. Garrett, M.D. “The Addictive Process.” In Psychiatry and Wellness. Accessed July 30, 2012. http://www.bma-wellness.com/addictions/addictions.html.
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Self-Medication This is when someone uses alcohol to reduce psychological or psychiatric disorders such as depression, schizophrenia, or panic disorder, because alcohol does provide sedative, anti-anxiety, and anti-depressant effects. So sometimes the person will then suffer from addiction AND a psychiatric disorder, and this is sometimes referred to as “dual diagnosis.” Now this was an area of confusion for me, because you’ll hear some people say that, while in recovery, a substance abuser should not take ANYTHING, no matter what! But it’s actually not that simple. According to addiction researchers Hester and Miller, medications that reduce the effects of these disorders can actually REDUCE the need for alcohol.15 But proper diagnosis and receiving the right medications are very important, because getting the wrong ones can just lead to more problems and more addiction. Sometimes the drinker can abuse or get addicted to the psychiatric medication, and sometimes alcohol can negate the effects of the medication and make the psychiatric disorder worse.16 I, personally, feel that if there are medications that really help a drinker to relieve depression, anxiety, and other medical conditions, that should be available to him. But as to what and how, it can be tricky and should probably be decided by both a psychiatrist and an addiction specialist, a doctor who is licensed and certified in these areas, or a doctor who has knowledge of these things, and knows what to do.
Polydrug Use This is when you abuse two or more drugs at the same time, or within a short period of time, to achieve a particular effect, such as coming down from the first drug or stepping up the effects of the first drug. Often it involves a primary drug of choice, in combination with, or followed by, another drug or drugs. This can lead to some unpredictable and dangerous results. For example, taking any combination of alcohol, heroin, tranquilizers, or methadone could be fatal.17 Some tipoffs are as follows:
15 Reid K Hester and William Miller, Handbook of Alcoholism Treatment Approaches, p. 261. Boston: Allyn and Bacon, 2003. 16 Drug and Alcohol Rehab Helpline: “Addiction and Psychiatric Medication Treatment.” Accessed July 30, 2012. http://www.recoveryconnection.org/addiction-psychiatric-medication-treatment. 17 Fitzroy Legal Services, Inc., “Polydrug Use.” Accessed November 12, 2012. http://www.vicdrugguide.org.au/handbook/ch01s05s06.php.
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If pupils are wide open – could be from the use of stimulants or psychedelics
If pupils are small – could be from opiate use. If eyes are bloodshot – could be marijuana.
Stages Now let’s move on to stages. One of the critical parts to defining alcoholism is stages. This is something that you don’t hear much about, but it is one of the foundations upon which this program is built, because it gives you milestones, or markers, so that the worst nightmares of alcoholism don’t creep up on you, unannounced. (And you might be thinking, “How could this creep up on you?” Well, like the old story of frogs in a pot of warm water who don’t notice that the heat is being turned up, sometimes we get used to so many “new normals,” that we don’t go into response mode until close to the boiling point, and at that point, the challenges can be overwhelming. The stages I’m about to describe are drawn from some research done by E. Morton Jellinek, a professor at Stanford University in the early 1960’s. According to Wikipedia, he “coined the expression, ‘the disease concept of alcoholism,’ and significantly accelerated the movement towards the medicalization of drunkenness and alcohol habituation.”18 [http://en.wikipedia.org/wiki/E._Morton_Jellinek ] Jellinek was criticized for basing his research on too small a sample, but I see tremendous value in this chart, because it basically provides these milestones along the way from mild to severe stages, and also helps you to consider where, along the line, your drinker may be, and how this may modify your response. I would argue, and will argue throughout this teleconference, that you do not respond to your drinker in the early stages, in the same way that you would respond in the later stages. For example, in the early stages, your drinker may be more self-monitoring, and may be thinking about his own alcohol intake; in the later stages, he may be less capable of self-monitoring and taking responsibility, and may need more assistance in getting help. I have abbreviated and modified this chart in the following ways: I have named and color-coded the stages Green, Yellow, Orange, and Red, and across from each stage, I have a second part that describes what you, the loved one, might be going through. (This 2nd part is based on my own
18 Wikipedia: “E. Morton Jellinek.” Last updated November 14, 2012. Accessed November 15, 2012. http://en.wikipedia.org/wiki/E._Morton_Jellinek.
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understanding, observation, and experience; I did not draw from research for it.)
Stages of Alcoholism Critical Timeline Stages For Drinkers19 for Supporters of Drinkers Green Stage Typically lasts several months to 2 years. There may be a few red flags on the horizon, but you doubt that there is any real, persistent problem. Socially motivated drinking transitions to drinking for psychological relief. Signs and symptoms . . . aren’t noticeable . . . [and even] the best addiction specialists have difficulty The drinker seeks out drinking occasions. diagnosing the problem.20 Drinking becomes a standard means of handling At this stage, you have some time to step back and stress. reflect, and your drinker is also in the best position – physically, socially, and psychologically – to The drinker’s tolerance to alcohol increases. determine if there is a problem, and to understand and accept ways of addressing it. This is the best time to get educated and to observe your drinker – because, if things get worse, you will need to know how to identify what’s wrong, and how to intervene. Yellow Stage The drinker drinks more heavily and more often than Time may seem to be speeding up, possibly because his friends. your drinker is accumulating more than his share of problems, and you are both “fighting fires” on a “Getting wasted” becomes a habit. fairly continual basis. Physical exhaustion, impaired The drinker may develop a “Big Shot” complex, judgment, diminished social skills, and depression or recklessly spend money, boast of real or imagined hopelessness may be entering into the picture, and accomplishments, etc. your drinker may be getting more difficult to reason with. Blackouts (temporary loss of memory) become more frequent and develop into a pattern.* At this stage, you may be wondering if your drinker is an alcoholic, or someone else may have posed the The drinker engages in “sneak” drinking, before or possibility of it to you. It may also be more difficult during a party (while the drinker thinks no one is for your drinker to demonstrate sound reasoning, looking), to maintain a level of euphoria. acknowledge that there is a problem, and take action. The drinker feels guilty and avoids the topic of The Green and Yellow stages are the best times to drinking. determine if there is a problem, and if there is, to take steps to address it. Chronic, “morning after” hangovers become more frequent and more painful. There is greater reliance on alcohol as a shock
19 “Jellinek Phases: The Progressive Symptoms of Alcoholism,” accessed December 28, 2010, http://www.readytotest.com/NewJersey06/JELLINEK_PHASES.pdf. 20 Debra Jay, No More Letting Go: The Spirituality of Taking Action Against Alcoholism and Drug Addiction (New York: Random House, Inc., 2006), 18.
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Stages of Alcoholism Critical Timeline Stages For Drinkers19 for Supporters of Drinkers absorber to daily living. *With a blackout, the individual may forget what he said or did during the period of intoxication, or for longer periods. This is different from “passing out,” which is a loss of consciousness. A social drinker can have a blackout, but for prospective alcoholics, blackouts are more frequent and may develop into a pattern.
Orange Stage More rapid development of addiction symptoms. At this stage, you may have become exhausted from continually “fighting fires” or arguing with your Loss of Control – A psychological habit has become a drinker. Alcohol-related diseases, such as liver physical addiction. A single drink is likely to trigger a disease, heart disease, or depression, may have also chain reaction until a state of complete intoxication is entered into the picture, along with several traffic reached. accidents and/or DUI’s and periodic trips to the Elaborate system of reasons or excuses for drinking. Emergency Room. Eye-Openers – A morning drink to “start the day By now, if you have not learned how to identify right” (This first drink could happen at any time of the what’s wrong and intervene, you may have been day or night, to ease jangled nerves, minor trembling, told, instead, that you need to “practice detachment a hangover, feelings of remorse, etc.). with love,” “wait until they hit rock bottom,” or “wait until they ask for help.” Tired and perhaps “Changing the Pattern” – Trying to correct (or mask) even disgusted, and being unaware that experts in the problem by setting rules as to what they will drink this field do NOT advise the above, you may have (for ex., beer instead of hard liquor) and when they given up on, or even abandoned, your drinker. will drink (for ex., weekends or holidays only). But Ironically, the very time you may decide to give up, one sip of alcohol still triggers the chain reaction. is the critical time for jumping in! An Drinking alone, or only with other alcoholics who EMERGENCY RESPONSE is required, because if “understand” them. one is not offered, it may be the last time you will ever be able to help your drinker. Brooding over imagined wrongs. The less you know and the longer you delay, the Thinking people are staring at or talking about them. more severe and unmanageable the problems may become. Being highly critical of others. May become violent or destructive. Loss of friends, family, or job Physical and mental erosion causes them to seek help from doctors, hospitals, psychiatrists, etc. Failure to level with health professionals about the drinking, or to follow doctor’s instructions.
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Stages of Alcoholism Critical Timeline Stages For Drinkers19 for Supporters of Drinkers Red Stage Without help, the signposts of this phase point to In the red zone, you may still have options, but these custodial care or death. options may carry enormous and overwhelming The drinker has no choice, and must drink. burdens for both you and your drinker. Many things could happen at this point, but none of them is likely Benders – Getting blindly and helplessly drunk for to be completely reversible, if at all. days at a time. For example, your drinker may need a liver Disregarding everything – family, food, job, even transplant, but may not have a matching donor or shelter. may be too ill to sustain transplant surgery. Or he may require extensive rehabilitation and custodial The D.T.’s (Delerium Tremens) – When abstaining care to function on even a limited basis. Or you may from alcohol, a combination of “the shakes” (a serious be suddenly informed of the shocking news that your nervous condition that wracks the whole body) and drinker has died in a traffic or boating accident, by hallucinations. This is often fatal if medical help is suicide, or from some other tragedy. It’s also not close at hand. possible that your drinker may have killed Swearing off alcohol forever, then coming back for someone—in a traffic accident, through negligence, more of the same. or in a drunken rage. Hiding bottles and ensuring a supply of alcohol, even Your stress and distress levels will be off the charts, if it means spending their last cent. and, if you care about your drinker, the sadness and heartbreak will be overwhelming. Unreasonable resentments or hostility toward others. At this stage, you may have to say goodbye to your Intangible fears, anxieties, and nervousness that drinker. If he ends up in a hospice (sometimes called underscore the compulsion to drink. These could be “palliative care”) situation, you will be able to spend the result of auditory or visual hallucinations. some time with him, and you, family, and friends will be able to say your goodbyes. Alibis no longer work, and are preposterous to others, Without the right prior knowledge and intervention, and even to the drinker. this stage can emerge very rapidly and seemingly Physical damage may result in: without warning. Extensive and irreversible brain damage, or some Residential treatment centers (for alcoholism) form of alcoholic psychosis; probably will NOT take alcoholics who are at this stage or worse. Amnesia and confabulation (false recollection) of Karsakoff's syndrome; Convulsions and comas of Wernicke's disease. Death may result from: Advanced cirrhosis of the liver; Pancreatitis; Ruptured blood vessels of the esophagus; or Suicide, the rate of which, in alcoholics, is three
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Stages of Alcoholism Critical Timeline Stages For Drinkers19 for Supporters of Drinkers times the normal rate.
Steps and Stages Now that we’ve looked at the steps that we can take, and we’ve also looked at Jellinek’s stages of alcoholism, let’s look at how the stages can affect the steps. What I mean by this is that, if you take the first step, “Learn about Types and Stages of Drinking,” you may treat that differently if your drinker is in the Green stage, than if he is in the Red stage. Let’sl look at a hypothetical example. This is an example of how the stages – NOT “do always,” but rather “MAY sometimes” affect the steps. So it’s just a hypothetical example of how two stages – the Green and Red stages – could affect the steps. Drinkers and their loved ones are unique, so every situation will be unique. And the order of the steps may vary also, depending on what’s going on in your lives.
STEPS IMPACT OF THE STAGE ON THE STEP 1. LEARN ABOUT THE DEFINITIONS, STAGES, Green – A this stage, it might be difficult to apply a AND STEPS OF DRINKING. DON’T do type or stage of drinking to your drinker. You may anything yet – just learn and observe. be wondering if this is a just a phase or a little bit of Think about what types and stages of irresponsible or immature behavior, perhaps age- related, or situational (a difficult or traumatic drinking may apply to your drinker. situation has temporarily caused an excessive amount of drinking). Red – This is an emergency stage, and you won’t have time to study or think. The immediate imperative will be to reverse the physical damage of the disease so that your drinker can survive the next day to even think about sobriety. Because there is little time and the stage of your drinker is obvious, you might skip over Step 1 and go directly to Step 2, Risk Factors and Health Insurance, because your drinker may need extensive care now or in the immediate future.
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STEPS IMPACT OF THE STAGE ON THE STEP
2. KNOW ABOUT THE RISK FACTORS, Green – At this stage, your drinker may be healthy. COMPLICATIONS, HEALTH INSURANCE, However, one instance of heavy drinking could AND LASTLYASSESSMENTS FOR result in serious injury in other ways at this stage – DRINKING. Understand risk factors, and from alcohol poisoning, a car accident, an accident which ones apply to your drinker. Find out due to carelessness, etc. If alcohol abuse is evident, if your drinker has health insurance. you will want to make sure that your drinker has health insurance. . If he owns a business, you may want to make sure he has liability insurance and a NOTE: If your drinker gets a medical business entity that protects his personal assets. evaluation or diagnosis of alcoholism BEFORE getting health insurance, this could disqualify him from health Red – At this stage, health care – sometimes very insurance, due to having the “pre-existing expensive health care – may be critical to the illness” of alcoholism or an associated survival of your drinker. However, your drinker may illness. have already been disqualified from health insurance due to a “pre-existing illness” (diagnosis of alcoholism or another of the illnesses that alcoholics are at greater risk for). If possible, it’s important to have health insurance before any diagnosis is made; but if your drinker is already disqualified, there are other options for treatment. 3. INTERACT AND COMMUNICATE Green – At this stage, your drinker may be healthy DIFFERENTLY. Analyze how you are and independent, and It may be easier to impacting your drinker’s drinking habits, communicate with him, or to reach agreement on and how his drinking is impacting his better ways to communicate. relationship with you. How are enabling and co-dependence affecting your Red – At this stage, it is possible that your drinker relationship? may be experiencing memory lapses and irrational thinking that make communication difficult. Your drinker has a serious disease – perhaps combined with other diseases associated with alcoholism – and living has become a matter of survival. Don’t confuse “help” with “enabling” at this stage. “Helping” means that you are helping your drinker to live by making sure he doesn’t die of liver disease, commit suicide, freeze to death under a bridge, etc. “Enabling” means that you are helping your drinker to die by making it easy for him to drink.
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4. BE PREPARED FOR CRISIS SITUATIONS. Be Green – Crisis situations could occur at any stage, aware of crisis situations that could and are so varied that it is difficult to determine how develop with your drinker, and be the stage would affect a given crisis; however, in this prepared to implement solutions that have stage, the drinker may be more resilient and capable of analyzing and responding to what is happening or worked for other people in similar what has happened. situations. [In any crisis at any stage, the imperative is to shift focus to all of those who are affected, to ensure the safety or recovery of everyone involved.] Red – In this stage, due to the progression of the disease, it may be difficult for your drinker to analyze and respond to what is happening or what has happened. Blackouts may be involved. However, depending on the nature of the crisis, it’s also possible that there may be very little, if any, difference between these two stages. 5. TAILOR INTERVENTION AND TREATMENT- Green – At this stage, intervention may consist only PART I. Learn about detoxification, of you – or someone else whom your drinker likes, intervention models, and treatment trusts, and connects with – having a personal models. conversation with him about your concerns.
Red – There are different types of intervention, some of which are more subtle, and some of which “sneak up from behind” and shock the drinker. In the Red stage, the drinker may be very ill and in a state of extreme denial, and may need a more aggressive approach with rapid results, such as the Johnson method of intervention. 6. TAILOR INTERVENTION AND TREATMENT- Green – At this stage, further observation may be PART II. Investigate what treatments and warranted, and a consideration of treatment treatment programs are available. This methods will probably be unnecessary or could involve one, or a combination of, premature. inpatient treatment, outpatient treatment, anti-craving medications, alternative Red – What often distinguishes this stage is the lack (holistic or wellness) approaches, etc. of time to plan. You may have to spring into action, and may not have much time to evaluate different treatment methods. In addition to treatment for alcoholism, the drinker may also need treatment for illnesses associated with alcoholism. If the drinker has already been in treatment one or several times,
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maybe anti-craving or other medications should be investigated. 7. DISCOVER AND USE SUPPORT SYSTEMS. Green – Even if your drinker never needs formal “Support Systems” refer to support intervention or treatment, it might be a good idea to systems for both you and your drinker, do a quick study and review of treatments, before, during, and after treatment – intervention, and support systems, so that you will be a little ahead of the eight ball if the necessity organizations like AA, AL-ANON, and ACA. arises later on. Red – If your drinker is seriously ill, he may not be accepted into treatment. If he is accepted and you want him to survive, it will be critical for you to play an active role in what happens after treatment. Understanding the support systems that are available to both of you after treatment may be critical to a successful outcome. 8. CARE FOR THE CRITICALLY ILL DRINKER Green – Most likely this will not apply to the Green stage, unless, due to alcohol abuse, there is a serious accident or the drinker’s life is threatened by alcohol poisoning. Red – Red stage drinkers may have very special and complex needs. While they may be ill from the effects of alcohol, they may also be ill from other illnesses that Red stage drinkers are at high risk for. Other kinds of substance abuse may be involved (although this may be true for the other stages, as well). They may need a liver transplant or other surgery. They may need a special environment for long-term recovery, home care, or hospice care. Brain damage and physical or mental disability may require special rehabilitation, physical therapy, and/or occupational therapy.
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9. SUPPORT YOUR DRINKER DURING AND Green – See Step 10, “Create Your Action Plan.” It AFTER TREATMENT. Isn’t this where the doesn’t hurt to create an Action Plan, even a short rubber meets the road? Post-treatment one, at the Green stage. If you create an Action Plan can be a very tough time for the drinker, and follow it, then hopefully the shifts that you create will be enough to avoid all of the other stuff and he needs all the support he can get. that could happen if you don’t. Red – The criticality of this step – at this stage, but also at the Yellow and Orange stages – hopefully goes without saying. Your drinker’s life may depend on it. With this step, it’s good to remember the definition of the disease: Chronic – A chronic disease comes back “now and then.” Progressive – When your drinker relapses, the disease progresses. Fatal – If the disease progresses too much, it becomes terminal or fatal. 10. CREATE YOUR ACTION PLAN. Create an Green –Because heavy drinking can lead to alcohol Intervene Action Plan for supporting your abuse, and alcohol abuse can lead to alcoholism, the drinker. thrust of your action plan will most likely be preventive - shifting emphasis from situations and activities that trigger heavy drinking, to situations and activities that create a space for average and responsible drinking. Red – At this stage, the thrust of the Action plan is more likely to be on making sure your drinker survives and gets sober and healthy. The focus can then switch to relapse prevention, or sustaining the benefits that have been achieved.
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Wrap-up Even in this first chapter, we’ve covered a lot: Definitions of heavy drinking, alcohol abuse, and alcoholism;
What a functional alcoholic and a sober alcoholic is; Why alcoholism is a disease; Why this is an emergency guide;
What the Green, Yellow, Orange, and Red stages are; Steps that you can take to help your drinker; and
How these Steps are related to the Stages. Next , we will be looking at Risk Factors, Health Complications, Health Insurance, and Assessments for Alcohol Abuse and Alcoholism, including: What factors put a person at greater risk for having problems with alcohol.
How alcohol is related to certain health complications, including physical and psychological illness, and why this is so important.
How alcoholism is identified, who should or should not be involved in that, and for what reasons. Why it is important to AVOID a diagnosis of alcoholism BEFORE you find out if the drinker has health insurance (if you can do so, SAFELY).
How we can avoid the landmines of health insurance, and use it to work to our benefit.
And what you can do if the drinker needs help and has no insurance.
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