Craving & Relapse Prevention - Part 4

In part 3 of the series, we finished up with the set-up behaviors that lead to the craving cycle.  In part 4, we will define relapse triggers and explore common trigger events which lead to entering the craving cycle.  Remember that, despite its danger, many alcohol and drug treatment centers focus merely on teaching the tools of recovery to utilize once craving hits, rather than on how to avoid falling into the craving cycle in the first place.  In this series, we are doing just that – demonstrating how to help our patients minimize the frequency of entering the craving cycle.  We are accomplishing this by focusing on set-up behaviors and trigger events, two primary criteria that contribute to the craving cycle.  By utilizing this information, patients can significantly reduce its frequency. 

Trigger Events

Terence Gorski defines a trigger event as “any internal or external occurrence that activates a craving (obsession, compulsion, physical craving, and drug-seeking behavior)” (Gorski, 1988).   In breaking down this definition, “internal” occurrences are thoughts or feelings, and “external” occurrences involve the five senses: sight, sound, smell, taste, and touch.  In order for it to be a trigger, such an event must be connected in some way to the using.  The event must also happen just before, or simultaneous to, the actual use (Gorski, 1988).

A simple way of explaining this is by relating it to classical (or Pavlovian) conditioning.  Ivan Pavlov was a Russian scientist who won the Nobel Peace Prize in 1904 for his research in digestive processes.  While studying the relationship between salivation and digestive processes in dogs, he would show the dog some meat powder causing it to salivate and then measured the salivation level. One day, Dr. Pavlov noticed that the dogs were starting to salivate as soon as he entered the room.  It appeared that there was some relationship created between him and the meat powder.  To study this phenomenon, he rang a bell just prior to showing the dog the meat powder and would again measure the salivation level.  He did this repeatedly: bell  meat powder  salivation, bell  meat powder  salivation, etc.  He eventually found that he could ring the bell, not present the meat powder, and the dog would still salivate.  Thus, there was a connection made for the dog between the bell and the meat powder that prompted the salivation (PageWise, 2002).  For our purposes, the bell was the event (trigger) that occurred just before, or simultaneous to, the presentation of the meat powder, which caused the dog to salivate, or crave, the meat powder.  The challenge for our clients is to identify the bells (triggers) that cause them to salivate (crave) their drug of choice.  This will allow them to avoid or manage such triggers.  We will now explore, in more detail, the different types of triggers that Gorski identifies as being strongly associated with craving.

Thinking Triggers

Thinking about using becomes a trigger when it is repeatedly followed by actual use. I often share with my brethren in recovery: “I don’t know about you, but when I thought about using, I used.  I never thought about using and said to myself, ‘That doesn’t sound like a very good idea, I don’t think I’ll do that.’  I then proceeded to use – like every time!”   So, there was a strong connection made between my thinking about using and my using.  Thus, thinking about using was a trigger. 

Gorski warns against repressing such thoughts when they arise because they simply get stored away and come back stronger later (Gorski, 1988).  This usually happens when our patients are in a weak emotional place. After all, if they repress such thoughts, aren’t they really doing the same thing they were doing when out there using?  They have an uncomfortable thought or feeling and shove it down with drugs or alcohol so they can pretend it isn’t there.  Such repression is very common because, when they begin thinking of using, their first instinct is to avoid the thought as they are in recovery and don’t want to relapse.

Gorski suggests processing thoughts of using in a controlled setting with a counselor (1988).  Processing can also be done by calling a sponsor (or another member of one’s sober support system) and talking about it.  Using this support, our clients can make some sense out of the using thought and, if done correctly, will come to the conclusion that using is not such a good idea after all.  Consequently, the using thought goes away because it then lacks merit.

Feeling Triggers

A feeling trigger is “any emotional state that was linked with the drug use” (Gorski, 1988).  Any feeling that is repeatedly followed by using drugs or alcohol becomes a feeling trigger.  A common feeling trigger is anger.  If, whenever our patients felt angry, they drank whiskey, there was a connection made between their anger and whiskey.  So, whenever they get angry in sobriety, it triggers them to want to drink whiskey.  Another example is the feeling of shame.  If their feelings of shame or embarrassment led to their taking pills, a connection is made between shame and taking pills.  Thus, shame would become a trigger for taking pills.  The feeling doesn’t necessarily need to be a negative feeling.  In fact, some of my biggest triggers were positive feelings, such as my propensity to use cocaine when I got excited, or to use marijuana when I felt accomplished or deserving of a reward.  I’ll never forget the first time I mowed the lawn in sobriety.  My craving for marijuana was overwhelming. 

Acting or Behavioral Triggers

Acting triggers are things that our patients do that are connected to their using, such as: going to bars, visiting using people, or going to their favorite liquor store (Gorski, 1988.)  They have some control over these triggers because they result from behavior.  Therefore, they can and should avoid these triggers right away.  Our patients have absolutely no business getting into drinking or using situations.  They need to avoid them at all cost.  This is especially true in early sobriety.  Eventually, they will be able to handle some such situations, but that will happen later in sobriety and we will explore this later in this course. 

Relating or Interactional Triggers

Relating or interactional triggers can involve certain relationships (Gorski, 1988.)  We can use this stereotypical example: If whenever people are around their in-laws they needed to have a drink, visiting their in-laws would then become a trigger for drinking.  Another relating trigger is using drugs other than the drug of choice (Gorski, 1988).  For example, if whenever people drank alcohol, they used cocaine, alcohol would become a trigger for cocaine use.  What could be a bigger trigger for a mind-altering substance than another mind-altering substance?

A little over two years before I got sober, I took a trip to Lake Nacimiento to go water-skiing over the Fourth of July weekend.  I was very much looking forward to water-skiing with my wife and friends.  However, I was so deep into my disease, I never once made it to the water.  We binged on cocaine literally the whole four days we were there.  Interestingly, the brother of a very close friend of ours who used to keep right up with us in the partying category didn’t hang out with us and went water-skiing all weekend.  I was very intrigued (and jealous) about this, so I approached him and asked what had happened.  He explained that he had been through rehab and how the 12-Step programs had helped him.  It all sounded doable to me except when he got to the part that I would have to quit drinking and smoking pot if I expected to stay off of cocaine.  My response, as I remember it, was something like this, “Wait a minute, I just have a little cocaine problem.  I don’t need to take it to that extreme.”  Well, it took me two more years of painful research in my disease to become willing to go to that extreme.  I now know that he was absolutely right and he eventually became my sponsor when I got sober.  I have not seen one person come into treatment and have success at stopping one drug while continuing to use the others for any extended period of time without eventually returning to his or her drug of choice.

Dreams of drinking or using are also triggers of significance.  These dreams are common in early recovery, seem very realistic, and can be scary.  I will distinguish between two types of using dreams.  The first, and most dangerous to the recovering addict, is the dream in which one is getting ready to drink or use and suddenly wakes up. My experience is that there is often an extreme level of disappointment when I wake up and realize that I can’t use. These dreams are so real that people actually experience the physical and emotional craving they felt just before using.  There may be no stronger trigger than waking up with these feelings.  This is an extremely dangerous place to be.  It is important, especially in our patients’ early recovery, to have someone in their sober support system whom they can call at any time day or night.  When waking up from such a dream, I highly recommend they call such a person immediately so they can talk their way through the craving.

The other type of dream is one in which people find themselves having already relapsed.  Again, the dreams are so real that they experience all the emotions they would if a relapse actually occurred, including sadness, shame, and remorse.  Very often the thoughts that are running through their heads in such a dream include rationalization and minimization, i.e., “That wasn’t a relapse because it wasn’t my drug of choice.”  Other thoughts often include wondering if they are going to be honest about the relapse and evaluating what the consequences of the relapse will be.  When they awaken from the dream, they are typically very relieved that it was only a dream.  I remember rejoicing in such a situation.  This type of dream can be very therapeutic because the person actually experiences the uncomfortable feelings associated with relapse, without actually relapsing.

I can remember only one time where I was actually using in my dream.  The whole dream was the preparation for a hit of crack cocaine.  In the dream, I finally took the hit.  As I reached my maximum lung capacity, I suddenly woke up.  This dream was so real that I woke up with my lungs completely full of air and actually holding my breath.  I remember looking at Robin sleeping next to me and turning my head quickly away from her and exhaling!  I even had a small placebo effect as I actually got a little rush when I exhaled! 

Finally, I want to share with you one final item in regard to using dreams.  There was a time in my early recovery that I was having such dreams every night.  I was getting very tired of this and shared at every meeting about them.  One day a guy approached me after a meeting who stated that he had the same problem in his early recovery.  He stated that during one such dream he was offered cocaine and actually turned it down.  He very rarely had using dreams after that one.  He shared this with me hoping that I might have the same experience. I did! 

(In part 5 of this 6-part series, we will explore the little-known trigger recovery process.)

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/co

            caine%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.