Abstinence

The primary goal in the treatment of drug addiction is abstinence. After the patient acknowledges the need for treatment and shows at least a preliminary commitment to treatment, the counselor and patient must begin to work on abstinence issues.

These include:

1. Recognizing the medical and psychological aspects of drug withdrawal.
2. Identifying triggers to drug use and developing techniques for avoiding these triggers.
3. Learning how to handle drug craving without relapsing.

The counselor should encourage the patient to establish a drug-free lifestyle that involves participating in self-help groups to aid in one's recovery, avoiding social contact with drug associates, and replacing drug-related activities with healthy recreational activities. This period of treatment lasts from the preliminary establishment of motivation toward abstinence to approximately 3 months or longer into recovery period, assuming the patient has reasonable success.

The topics described here are particularly relevant to the needs of the patient at this point in treatment. The order in which they are presented is generally the order in which they often emerge as treatment issues. But, the counselor should use discretion and address these issues as they seem appropriate for each individual patient.

Discussions of these topics may be repeated as needed. The counselor should base the relative emphasis placed on each topic on the patient's specific needs in recovery. No more than two topics should be introduced to the patient in a session. However, in reviewing topics previously introduced, the counselor can address all appropriate topics. Although the order in which they are presented and the relative emphasis are flexible, all the issues identified here should be addressed in the counseling sessions.

1. Teach the addict to recognize and avoid the environmental triggers that lead to drug use.
2. Teach the addict to engage in alternative behaviors when he or she experiences craving.
3. Help the patient to achieve and sustain abstinence from all drugs.
4. Urge the patient to participate in healthy activities.
5. Encourage participation in self-help groups.

1. Addiction and the associated symptoms
2. People, places, and things
3. Structuring one's time
4. Drug Craving
5. High-risk situations
6. Social pressures to use drugs
7. Compulsive sexual behavior
8. Withdrawal symptoms
9. Use of other drugs
10. addiction treatment participation

Addiction and the Associated Symptoms

The counselor should review with the patient the concept of drug addiction and the behavioral and medical/physiological symptoms of the problem. When discussing symptoms, the counselor should focus on the primary drug abused but can include other drugs as appropriate.

The concept of drug addiction is that the behavior, or use of something, becomes compulsive, leaving the addict no control over the behavior. Because the addict has no control over this behavior, he or she will continue to use the drug despite the resulting impairment to physical and emotional health, social and occupational functioning, and intimate relationships.

The behavioral symptoms of drug addiction include narrowing of one's behavioral repertoire, predominance of the drug in the person's daily life, spending time achieving or recovering from drug effects, and continuing to use in spite of the severe problems associated with use. The counselor will review with the patient the specific symptoms of drug addiction that he or she has demonstrated. The counselor will focus primarily on the life-overwhelming nature of addiction and the importance of avoiding abusable substances in order to provide the best chance for preventing a relapse.

The medical/physiological symptoms also should be reviewed with the patient. They can include increased pulse and blood pressure, anxiety, paranoia, hallucinations, seizures, cardiac arrhythmias, cardiac arrest, and cerebrovascular incidents (strokes). The relative risks for each of these adverse effects will be reviewed. For example, anxiety and paranoia are much more common than seizures or cardiac arrest. The drug withdrawal symptoms of depression, low energy, and insomnia will be described, along with the fact that these symptoms do not occur in all cases.

If the patient's route of administration of any drug used has included injection, and/or the patient has engaged in unsafe sexual behavior, perhaps impulsively when using cocaine, then infection with the HIV virus is a medical condition that may co-occur with cocaine addiction. The topic of HIV infection should be introduced here. The counselor must assess the patient's level of knowledge and sophistication about the topic and present information at an appropriate level. If the patient has engaged in high-risk behavior, or the counselor believes the patient may have engaged in high-risk behavior even though he or she denies it, then the patient's risk factors or potential risk factors should be identified, and behavioral changes to reduce risk should be encouraged at this point.

The medical effects of other abused substances, including alcohol, also should be reviewed if the patient has or has had problems with these drugs.

People, Places, and Things

People, places, and things are a way of designating the external triggers that initiate craving or the urge for a drug. The patient must learn how to deal with these triggers in order to achieve continued abstinence. This topic is central to addiction counseling and usually requires repeated discussion throughout treatment. First, the counselor should help the patient to identify the people, places, and things that will trigger or lead to a cocaine craving or urge. Then the counselor should point out that the patient must avoid the people, places, and things that trigger craving and have the patient discuss how he or she can avoid the triggers. The patient should be encouraged to avoid those triggers that are possible to avoid easily (for example, having one's paycheck deposited directly or taking public transportation to and from work rather than drive through a risky area). The patient and counselor should collaborate to develop strategies to help the patient avoid or manage those things that are more difficult to stay away from (for example, a drug-using partner or spouse or a crack house on the block where one lives).

During an individual's drug addiction, he or she has learned to associate drug use with people, including one's dealer or other users; places, like a particular crack house or corner; and things, especially money and drug paraphernalia. The counselor should strongly encourage the patient to avoid those people, places, and things that were previously associated with drug use and assist the patient in developing strategies for avoiding these triggers. These strategies may include having someone the addict trusts handle his or her money, cutting up his or her automatic teller machine card, getting rid of drug "works," i.e., paraphernalia (preferably with someone else's help); staying away from certain neighborhoods, blocks, or areas of his or her community; and avoiding drug-using friends and family members. Triggers that cannot be avoided altogether can sometimes be faced more safely in the company of another, non-using person, such as one's sponsor or one's spouse or child.