Part I
By Bob Tyler, BA, LAADC-CA, SAP, ACRPS
Greetings! Welcome to the Craving and Relapse Prevention series. In a broad sense, most of what we do with our patients can be considered relapse prevention. However, the information in this series covers what most in our profession would consider specific relapse prevention tools. Giving credit where credit’s due, this course is based on the Terence Gorski (CENAPS) Model of relapse prevention. As I am drafting this version of Craving and Relapse Prevention, many of us who have been in the profession for a while have been mourning this recovery pioneer who passed away a few months ago (July 2020). He left an indelible mark on the work that we do, and I am honored to be able to forward his legacy by presenting this information to you.
This course, while providing these relapse prevention principles, also includes much practical application. I believe this lends to the learning experience and demonstrates how it is utilized both professionally by us as we treat our patients and how, in turn, our clients might specifically use it in their recovery. This practical application takes the form of examples of how I’ve used the information working with patients over the past 30 years, and how I’ve used it in my own recovery of 32 years sober. You will notice that many paragraphs in the series are italicized. I have done this for ease of reading as I switch from teaching relapse prevention principles (normal type) to demonstrating how many of these principles were effective in saving my own life and the lives of others (italics). Let’s get into it!
When I was approximately 30 days sober, I read an article that changed the course of my recovery. It was called “Cocaine Craving and Relapse” and was printed in Sober Times: The Recovery Magazine in early 1989. The article was written by one of the most renowned and knowledgeable relapse preventionists in the world – Terence Gorski. I benefited from this article as much as any information I received while in treatment a few months earlier. The insight and knowledge I gained has compelled me to pass it on to patients and colleagues ever since. Don’t allow the title of the article to sway your attention – it is just as applicable to any drug of choice.
In the fall of 1999, I had the honor of meeting Mr. Gorski when he spoke at the annual conference of CAADAC (California Association of Alcoholism and Drug Abuse Counselors). I was awed at the opportunity of hearing one of my mentors speak in person. I shook his hand at the end of the talk and shared with him what an impact his information has had on my life and career.
Later that night, I was heading for my hotel room across the street, and there came Mr. Gorski walking down the street. Once again, I extended my hand to him and elaborated on the influence he has had on me. I shared about my relapse prevention lecture series, which is largely based on his information that was published a decade prior. He appeared genuinely thrilled that someone was using his information in this way. We talked about many other issues in recovery as well. The next thing we knew, an hour and a half had passed as we spoke under stars at that Sacramento intersection. It was truly one of the thrills of my life. It also gave me great pleasure to have him validate what I was doing (Tyler, 2005). To the late, great, Mr. Gorski, I am eternally grateful.
So, now it is time for me to pass it on to you. This series will, most assuredly, increase your ability to help patients deal with craving and minimize its occurrence. The information that follows is based on the article mentioned above and, as stated previously, some of my own personal and professional experience with it is included.
Craving and Relapse
We will start by exploring “The Craving Cycle” as outlined by Terence Gorski. It consists of:
- Obsession
- Compulsion
- Physical Craving
- Drug Seeking Behavior (Gorski, 1989)
As a craving “cycle,” it typically starts with obsession, moves into compulsion and, finally, into physical craving and drug-seeking behavior. As you will see below, each stage in the craving cycle moves the person increasingly closer to relapse. A brief definition of each of these elements of the craving cycle follows:
Obsession
Obsession is “the inability to stop thinking about the alcohol and drug use.” Such a thought is very strong and persistent (Gorski, 1988). It usually starts as a mild thought of using and, if left to run its course, becomes all-encompassing and is characterized by the inability to think about anything else. Therefore, it is very important to intervene on an obsessive thought of using or it will “quickly turn into a compulsion” (Gorski, 2001).
Compulsion
While obsession is a thinking state, “a compulsion is an emotional state that is marked by an urge or desire to use alcohol or drugs” (Gorski, 1988). “When compulsion is activated the person begins experiencing an overwhelming urge to use the drug…” (Gorski, 2001). Since it is an emotional state, people are unable to think rationally. Have you ever made a decision based on emotion that didn’t turn out so well? This is what a compulsion causes you to do. The person is so emotionally involved that using actually appears to be a good decision. Once a compulsion hits, they are usually unable to make rational sense of it without the assistance of another recovering addict. As with obsession, it is important for our patients to intervene on a compulsion before it gets too strong because they will eventually be rendered unable to use the tools of recovery to deal with it.
Once a compulsion hits, they are usually unable to make rational sense of it without the assistance of another recovering addict.
Physical Craving
If a compulsion is left uninterrupted, it will eventually “merge into full blown physical craving” (Gorski, 2001). In physical craving, the body is actually asking for the drug of choice. “It is a physical need or tissue hunger for a drug that is caused by brain chemistry imbalances” (Gorski, 1988). In my disease, when a physical craving became extremely strong, I would actually lose control of bodily functions and would often have to run to the restroom. It is as if my brain was preparing my body for the incoming drugs or alcohol.
Physical craving also occurs in early sobriety independent of the cycle of craving. When people use drugs or alcohol, they are actually pumping poison into their bodies. The body compensates for the presence of this poison by actually changing into a transformed state. The more drugs and alcohol used, the more the body must change to survive. When using stops, the body cannot survive in this transformed state without the poison, so it must adjust back to its normal state in order to survive. The problem is that the process of changing from its transformed state to its normal state is painful. Therefore, the body begs for more drugs so it can stay comfortable and avoid the pain of changing back to normal. As you are well aware, this process of the body changing back to normal is known as acute withdrawal.
Another of Gorski’s many contributions to our profession is the phenomenon of Post-Acute Withdrawal Syndrome (PAWS). “Post-acute withdrawal means symptoms that occur after acute withdrawal.” Symptoms include: lack of mental clarity; memory issues; emotional instability; insomnia; lack of coordination; and high stress (Gorski, 1986). It is very important to educate our patients regarding PAWS as they might think that life with these symptoms is their “new normal.” They might think: “if this is what sobriety is going to be like, I don’t want any part of it!” We need to let them know that PAWS is temporary, and the symptoms will subside over time. You can read more about PAWS in, Staying Sober: A Guide for Relapse Prevention (1986), abook he co-authored with Marlene Miller.
Drug Seeking Behavior
Eventually, if left untouched, the craving will arrive at this final and most dangerous stage. Drug seeking behavior is just that – it is the action our patients take to seek out their drug of choice. They “begin to cruise old neighborhoods, talk with old drug-using friends, and go to bars and other places where (alcohol or drugs are) used” (Gorski, 2001). It is important to realize that it is typically “ritualized, habitual behavior” (Gorski, 1988). People often don’t even realize they are doing it. They might have a very good reason in their heads to go visit George, but George was a using buddy. They might also have rationalized why they are driving down a certain street, but that is where their drug dealer hung out. They might think it’s a good idea to go see some old friend at a bar, but it was their favorite watering hole. The reality is that these are all drug-seeking behaviors that often lead to relapse.
More About the Craving Cycle
There are two things our patients need to know about the craving cycle. First, it occurs at some point for all alcoholics and addicts. No matter how much people got their butts kicked by the disease before they began pursuing sobriety, they will at some point experience craving. Often times, it does not occur right away. People might think this is a good thing, however, it can be quite dangerous. It can lull them into a false sense of security, and they might be unprepared when craving strikes. In fact, if they are having many cravings in early sobriety, they will actually have an advantage if they can stay sober through it. The experience of utilizing the tools of recovery to successfully deal with cravings prepares them for the next time the phenomenon hits.
The other thing that is known about craving is that it always precedes relapse. People don’t find themselves walking down the street, tripping over the curb, with a bottle dropping from the sky into their mouths. They will first stop at the craving cycle by thinking about it, becoming emotional about it, their bodies will start asking for it, and they will eventually seek it out. The fact that craving happens to all alcoholics/addicts, and that it always precedes relapse, should tell us that the craving cycle is a very dangerous place that should be avoided as much as possible.
In many alcohol and drug treatment centers, our primary focus is on teaching patients what to do when craving hits. Unfortunately, many centers neglect to teach them how to avoid falling into the craving cycle in the first place. Over the next several weeks, we will do just that – learn how to help our patients minimize the frequency of entering the craving cycle. We will accomplish this by focusing on what are called set-up behaviors and trigger events, two criteria that contribute to the craving cycle. By utilizing this information, our patients can significantly reduce the frequency of entering it. The fewer set-up behaviors they have, the less often they will end up in the craving cycle. Likewise, if they are aware of their relapse triggers, they will be able to avoid many of them and experience the craving cycle less frequently. This information will also help in identifying the cause of their entrance into the craving cycle so they can deal with it more effectively.
(In part 2 of this 6-part series, we will explore the physical and psychological set-up behaviors that lead to the craving cycle)
References
Gorski, Terence T. (Speaker). (1988). Cocaine craving and relapse: A comparison between alcohol and cocaine (Cassette Recording No. 17 – 0157). Independence, Mo: Herald House/Independence Press.
Gorski, Terence T. (1989, April). Cocaine craving and relapse. Sober Times: The Recovery Magazine, 3 (4), pp. 6, 29.
Gorski, Terence T. (2001). Cocaine, craving, and relapse. [On-line].
Available Internet: http://www.tgorski.com/gorski_articles/cocaine%20craving%20&%20relapse%20010523.htm.
Gorski, Terence T., and Merlene Miller. (1986). Staying Sober: A Guide for Relapse Prevention. Independence, Mo: Herald House/Independence Press.
Tyler, Bob. (2005). Enough Already!: A Guide to Recovery from Alcohol and Drug Addiction. Humble House Publishing: Long Beach.
Bob Tyler, BA, LAADC-CA, ACRPS, SAP
While working in Inpatient, Residential, and Intensive Outpatient levels of care, Bob Tyler has been working in recovery since 1990. He serves as Compliance Officer at L.A. CADA, is owner of Bob Tyler Recovery Services (consulting, CD private practice, public speaking), is Past President of CAADAC, and is on faculty at LMU Extension in the Alcohol and Drug Studies Program. He authored the EVVY Award-winning book, Enough Already! A Guide to Recovery from Alcohol and Drug Addiction and has produced several educational DVD’s shown in over 1000 treatment centers across the country, including Craving and Relapse. Please visit our website at www.bobtyler.net.