Episode 20 – The Reality Of Relapse
Dr. Ashish Bhatt ❘
Relapse is oftentimes part of the recovery process. Dr. Bhatt, MD explains why it happens and what you should do if it does.
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Hayley: Welcome to another episode of Straight Talk With The Doc. My name is Hayley and I’m joined by addiction medicine specialist, Dr. Bhatt.
Dr. Bhatt: Hi Hayley, how are you doing today?
Hayley: I’m good. Today we’re going to be talking about a term that has been floating around recently in the media, although it’s not exactly a new idea. That idea is being “California sober.” Some define California sober as being sober, but still using alcohol and marijuana. What does it mean to you, Dr. Bhatt?
Dr. Bhatt: California sober is a term that’s been around for a short period of time, and I think it’s created a level of controversy in the addiction recovery community because it’s hard to define. It seems to be interpreted differently by different people, maybe by a different group of people. But from my understanding of it’s intention is, is those who consider themselves California sober are claiming to not be using the substances that they considered the hardcore addictive substances that they struggled with in their life. And now are using what might be considered more benign or those that are legal more like alcohol or those places where cannabis is legalized. Those that simply might have less initial harm, although we know that alcohol and cannabis can cause destruction in many people’s lives, but at least perceived harm. Often, I think California sober includes other uses of other psychedelics or hallucinogens that don’t really alter too much of a sensorium the same way that other drugs could. I believe it’s a term used for those that stopped using the drug that they considered themselves addicted to and using a perceived less harmful or more moderate consumption of other potentially more acceptable substances. It’s definitely a hard thing to define.
Hayley: Right, but just because something is legal doesn’t mean that it’s good or better. Take alcohol for example.
Dr. Bhatt: For sure, I mean, cigarettes are legal and alcohol’s legal and, in many places, cannabis is legal. That does not mean people are not getting intoxicated or having negative consequences. I think that can get distorted in that definition and that’s why I think people have an issue with it because it’s a slippery slope. People who are pursuing something that gets them high and have even used the same substance while getting intoxicated with their “addicted” substances, if you can call it in some way different. It’s very hard to say where something starts and where something ends and where that overlap can create risk for that harmful behavior returning again.
Hayley: I think it’s the level of harm though that people use as an argument. If someone recovers from heroin addiction, but still has a glass of wine on occasion. I guess that’s better. It is better, but can they call themselves sober?
Dr. Bhatt: I think that perspective really depends on what school of thought you’re coming from. I think people in recovery define things differently. There is an abstinence based perspective for many people. If they are using or were addicted to a certain substance or multiple substances, that in their mind recovery or sobriety only is defined when you don’t use any other mind-altering substances. Some go so far as to not even include prescribed medications, but we know from the medical community we don’t look at it that way. We understand that addiction is defined as a brain disease. It can be treated with other medications that are FDA approved. Those medications often are needed in order to prevent further harm to stop being addicted to their illicit substances and to live healthier lives. That’s one extreme again. Using illicit substances and then being in recovery from those and then if somebody’s having a drink or smoking cannabis, yes. Can that be looked at as a harm reduction perspective and if their quality of life improves and they’re functioning in a healthy way? Does it look any different from someone who never suffered from an addiction in the first place? I think that’s really what that outlook is comparing. Is that if they are functioning like someone who never suffered with an addiction? Why can’t we then continue to use substances in a way that doesn’t cause us consistent harm or negative consequences? That might be something also looked at in different areas of the world. I think different areas of the world define and look at addiction a little differently than we do here in the United States.
Hayley: That’s true. You mentioned, obviously people take prescription medications when they are in recovery, but it’s really about that intent of why somebody is taking any type of substance.
Dr. Bhatt: We’ve spoken about that before. I think that’s really a great word and I know we’ve talked about it. Intent- what is the intention? If your intention is to get high and have an altered state of mind, and in that altered state of mind it’s causing you to behave and feel differently to the extent that it causes all of these negative consequences that define addiction. But the problem here is that using alcohol and cannabis often is, or was, co-existing at this time that people were using those other illicit substances. And for many people, those are the gateway of how they use those illicit substances in the first place. I think where the risk lies is how is the brain teasing itself out from the high or the altered sense of emotion, and feeling, and sensations caused by alcohol and cannabis or other psychedelics not somehow hitting similar neurotransmitters and neurobiological receptor sites, that can then kindle, or unmask, or crave the other illicit substances. It’s a very difficult thing to tease out, and it’s hard to measure it in terms of scientifically and on a personal level. I believe as a medical doctor, that it’s a risky thing for those people that are addicted or suffer from addiction to Heroin, Cocaine, Methamphetamine, whatever, to think that this is the approach to take. I’m not saying that it can’t happen, I think each individual situation is a case by case basis. There are many people that have used other substances and then have been able to drink alcohol and live successfully without relapsing on other things, but that might not work for everybody. This approach is not a one size fits all approach. It has to be customized. It has to be done while working with somebody professionally or with an intact recovery environment, whether it’s personal family, friends, whatever, but it’s definitely not for everybody.
Hayley: Can you elaborate on the risks you mentioned, the dangers of attempting to be California sober?
Dr. Bhatt: The danger is going back to using the substances that you think was your harmful substance. If somebody used cannabis and alcohol and segued into using harder drugs, and those are the things that they consider themselves addicted to, well, everything- the mind, it’s related. Triggers, whether it’s environmental, it’s behavioral, it’s biological, there is an association between that memory and that motivation that led to certain drug seeking behaviors. A lot of these reward mechanisms are the common pathway. The harder drugs that they were addicted to, and I think that’s what people are concerned about with that term or with that behavior. Nobody wants anybody to relapse because they thought they were doing the right thing, or healthier thing, by using alcohol or weed or psychedelics and then go back to using heroin.
Hayley: For those who may be listening who, I guess in quotation marks, have had “success” with this, they stopped using heroin, but they still drink or use marijuana. Why do people get addicted to certain substances but don’t have the same reaction to others?
Dr. Bhatt: Well, everybody’s different, addiction is a multifactorial disorder. It’s a multifactorial disease. Whichever one you want to call it, but there’s so many different things that influence somebody’s pathway to becoming addicted or not. Not everybody’s going to have the same outcome. Nobody knows beforehand what relationship they’re really going to have with drugs or alcohol until it actually starts to transpire. You can’t base yourself off of what somebody else is doing. What might work for you or what might work for somebody else, might not work for you and vice versa. Again, it goes back to my previous statement that California sobriety recovery. It’s an individualized situation. How somebody looks at sobriety can be defined differently. Ultimately, we want the goal of people to live healthy lives, to be functional, to take care of themselves, to take care of their family, whatever obligations that they have, to be happy. And if that happened while using substances, then, obviously nobody wants it to be in a destructive manner. That’s really what the help that’s out there is trying to provide, but, an individual needs to really gage what’s healthy for them. It has to be based on certain measurements and how it affects the people around them. If they can live that healthy quality of life and if the quality of life is good, if somebody who was previously addicted to a certain drug now can somehow manage themselves with things that might be perceived as not in recovery by others but they’re living healthy. That might be an option for certain individuals and I think that those who are seeking or using the words California sobriety are ultimately trying to say, “We’re trying to live healthy lives and not go back to those things that caused us such destruction”. And if it means to drink or to smoke marijuana and not go back and live that way, this is our way to live a healthy life. I don’t want to speak on their behalf or anyone’s behalf, but this is what I think they’re trying to say
Dr. Bhatt: We see that all the time. With the common pathway of reward going through the brain, certain areas of the brain, certain chemicals that are implicated in causing certain feelings. If the behaviors somehow can mimic those things, you will see that shift from that substance use to a behavioral addiction, let’s call it that, that can also cause harm. When that reward is so outweighing the risk in somebody’s mind, and again, not necessarily in reality, because if the risk is more significant, but yet somebody keeps pursuing that behavior because in their mind or their body the reward is there, we will see behavioral addictions start to take place. But again, it’s still ultimately behaviors that now are causing destructive consequences and are being pursued in an overzealous manner, despite things going well in somebody’s life. We see that all the time whether it comes to eating, it comes to gambling, or maybe involving sex, even exercise. When things are in their extreme form and they’re self-destructive and destructive to people around them, unfortunately we see that happen a lot. And it can happen with people who suffer from pre-existing addiction issues, and from people who don’t, but they are developing a new addiction. So, yes, we see it happen, and it’s unfortunate but it’s there. It’s an unfortunate part of addiction as a whole.
Hayley: Would you say that those behavioral addictions are more difficult to treat, or not really?
Dr. Bhatt: I don’t know if the word difficult is correct, but they have a different type of intervention. There are similarities in treating addiction as a whole. It depends on who the person is. Those people that are professionals that are out there focus on certain behavioral addictions and they become more astute at doing so. The bottom line is behavioral addictions are a different type of addiction, but don’t necessarily have total separate concepts in terms of the treatment. There are therapies. There are medications. There are interventions that exist that mimic and are similar to those that treat other substance addictions. Not necessarily more difficult, it just often incorporates a different type of therapeutics.
Hayley: You brought this up in the beginning of this episode. I want to talk about the origin of the abstinence only model. Why is that the goal of many support groups and treatment plans?
Dr. Bhatt: Because many people who sought sobriety years ago, and we do have a very popular and successful model with the 12 steps and that has helped millions of people across the world. For many, abstinence has been the ultimate goal or factor. Let me use that word, factor, to obtain the goal of not living that destructive life that being addicted causes. They saw that because of the relationship with things that go together with the multiple substances that often can create relapse, that abstinence achieved sobriety and recovery in a clearer path. Because our mind is so easily affected by other substances, that is was difficult and is difficult for many people to tease that out. And that’s part of the disease of addiction because the pathway is common. The high that’s achieved is often through similar neurochemicals, and neurobiological pathways, that put one into the brain. The brain has a difficult time often teasing out one from the other. Abstinence in its entirety can clear the brain of the confusing messages that getting high off of one substance doesn’t look like getting high off of another. That’s why many people who are seeking recovery and trying to achieve sobriety have to stay away from all of it, because with it comes so many other behaviors. And the same drug seeking behavior that happened often with cocaine pursual, or alcohol, or sex, these things all went together. It’s a life styling changing approach that often incorporates clearing the path and clearing the brain from all of these similarly influencing agents. And abstinence was not just the goal, like I said, it was a factor that helped achieve the goal of living a healthy life of recovery.
Dr. Bhatt: Hopefully that made sense- I know that was a little bit-
Hayley: It does, it does. And the 12 steps, they have been around for a very long time.
Dr. Bhatt: The 12 steps have been around for a long time and they’ve been successful for so many people. If it has been successful for so many people and many people that I know personally, that’s the way they live, they’re living proof that it works with that approach. It’s an abstinence based approach for them and they’re living healthy lives. They couldn’t see themselves doing it any other way and they’ve tried it. For many people who live an abstinence based approach, it’s because they’ve realized that using other substances in so called moderation for them, did not work. They tried it. They tried to stop using alcohol, but were using cannabis. Yet, once they used cannabis, ultimately it didn’t change their ultimate behaviors. Again, I’m not saying that this is the path for everyone. This may be the path just for some people, but ultimately, people need to develop and learn their own recovery plan that works for them. And being that more people have become open to this harm reduction model, I don’t even want to use the words California sober model, but whatever, the model that they’re able to stay away from other substances, and use legal substances without being detrimental to them. Well I think the quality of life is the ultimate outcome we want to have for individuals. As long as they’re not doing anything illegal, or things of moral turpitude, or things that are destructive to their lives. Ultimately, they’re judged by themselves and by those around them that love them. As long as they’re living healthy lives for themselves, I think that’s the ultimate outcome that they’re trying to achieve. So, it’s difficult, abstinence works for some people, and now we see that many people are looking into alternate pathways to improve their quality of life.
Hayley: Okay. For those who are attempting to try the California sober method, do you think that there are some of them who are just basically replacing one substance with another?
Dr. Bhatt: I mean, I don’t think it’s just the California sober seeking people. I think many people who are not ready to achieve sobriety and to live a life of recovery are not going to take the proper steps necessary to do that. And addiction is a game of deception, the drug deceives us. I often say, it’s not us who abuse drugs, it’s the drugs that abuse us. I’ve said that multiple times to many patients. Drugs abuse us. They change the way we think. They change the way we feel. They hijack us. When they change that so much, we also change the way we think even when we’re not on drugs. And people look for ways to rationalize behaviors, and I don’t want to use the word excuse. I want to use the word that people who whatever means they need to rationalize what they want to do. For example, cannabis is legal in so many places and recreational cannabis is available. People who might like to smoke marijuana are going to say that this helps me, if it facilitates their purpose of continuing to use, so they don’t do something else. But can that be, sure, it could be an excuse, a rationalization, or whatever you want to call it to continue to use things. But again, what are we ultimately trying to achieve? If these people use it and they aren’t using it in a destructive way and they’re not getting high behind the wheel. They’re not abusing themselves or their family members and they continue to live successful lives and they’re contributing to society, well then it might work for them. What’s the intent? It’s hard to determine what people’s intentions are if we take things at face value. If psychologically we look into the subconscious reasons why people do anything, we’re opening up a huge discussion here. I’m trying to take things at face value, that it could be somebody’s subconscious intentions to continue to get high, but, how can you tell that?
Hayley: That’s interesting what you said about the subconscious intentions and how drugs change the way that we think and make us rationalize the use, That’s important to be aware of. With that in mind, how can someone know if being California sober will work for them, or if it’s going to cause them to spiral?
Dr. Bhatt: We have to look at certain risk factors. What other drugs they have been using in the past, has there been any degree of sobriety while using something else, you have to look at those things. Some people might have been able to correlate certain behaviors, other substances uses with periods of sobriety. I think that’s a variable to look at. I don’t think anybody can be completely aware of what will work for them, until they try it or attempt it, but definitely looking at the supportive factors within somebody’s life. Looking at what kind of therapeutic frame that they try to put together with somebody who’s willing to monitor them. If they’re putting effort into creating other protective mechanisms in their social life or personal life, maybe getting a sponsor that is going to be there to help them in the event things start to spiral out of control. There are multiple factors that people use. Regardless if they are going to be California sober seeking or if they’re going to seek sobriety in a different way, the point is the more protective things that you put in place. The more historical things that you look at from an environmental, psychological, social perspective that open risk factors in the first place. You start to eliminate them and put protective factors in place, the more successful you’re going to be ultimately to reduce harm and go back to those risky behaviors. I think that would be the approach, but it would be customized to each individual. And if there’s a professional helping them, that professional can help them look at those variables to see if that’s something that they should consider or not. I think the short answer for many people is try to eliminate things that you know can cause you to relapse and substances tend to go together. I think in my experiences, I haven’t found too many people that are able to do those things early on. It often takes a period where they do need to watch out a little bit and clear themselves from illicit substances. But, I think now that there’s a philosophical change that’s happening around the country. You might start to see more attempts at it and then we might see different outcomes as a result. A lot is going to be left to be seen.
Hayley: That’s true. It’s an interesting topic and we’ll see how it unfolds. At the end of the day, if substances are causing problems in your life, it’s probably best to steer clear of them. If you find yourself wanting to stop but you’re unable to, that’s a sign of addiction. You should do some research and consider getting professional help. It can be very difficult and sometimes dangerous to try and quit on your own, so seeking out professional help with detox can make the process easier and increase your chances of success. You can learn more about that at addictioncenter.com and also check out some other podcast episodes there. Thank you, Dr. Bhatt. Thank you to everyone who listened to Straight Talk With The Doc.
Dr. Ashish Bhatt
Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.