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Strategies for Clients with Multiple Addictions
Probably the majority of addicted persons suffer from multiple substance and/or behavioral dependencies. It is often unrealistic or impractical to give all of them up at once, even if that is your goal. Sometimes, it is even medically unwise to attempt this. On the other hand, it is often important to give up several of them at the same time. This section outlines some reasonable strategies or plans for attacking complex dependency problems. If inpatient treatment is available, more habits can be given up at the same time because the risk of relapse or an increase in one addiction when another is given up is greatly reduced. The bigger problems occur when inpatient treatment is not available, and so the following suggestions refer mostly to outpatient recovery attempts. We use the term outpatient recovery attempts to refer to the addict who is living at home and working as usual, but is, at the same time, going for one or another kind of help several times a week. This can include self-help groups, talking to your sponsor, or seeing some professional therapist of one ilk or another. Here are some principles to use in planning your total recovery program:
1. It is best for the addicted person to give up all addictive drugs, including alcohol, at the same time. This is because of the phenomenon of cross-addiction, which can cause a dramatic increase in the abuse of one substance when another is given up.
2. The use of alcohol, opiates, tranquilizers, or barbiturates complicates matters a great deal. These substances are both physically and psychologically addictive. Withdrawal from these substances might require medical supervision and a weaning-off period, temporarily using other addictive substances. Thus, the heroin/marijuana addict can stop using marijuana immediately (not physically addictive) or cold turkey, but might be better off substituting methadone for the heroin and then tapering off the methadone over a one- or two-month period. Similarly, the alcohol/cocaine addict can safely stop using cocaine "coldturkey," but might have to switch from alcohol to benzodiazepines and taper off those over the course of a week or two in order to prevent D.T.’s, seizures, or other severe consequences of withdrawal from severe alcohol abuse. The sleeping-pill-addicted compulsive gambler would likely do best to stop gambling altogether, but taper off the abuse of sleeping pills over a period of several weeks and with medical supervision. Cocaine is not physically addictive. The addiction is not supported by feeling physically "sick," only by feeling depressed. Only the downers (alcohol, opiates, benzodiazepines) are considered physically addictive. Interestingly, addicts who have experienced both psychologically addictive and physically addictive drugs find it harder to give up the former.
3. In general, drugs and behaviors best eliminated first are those that are: • most immediately medically dangerous • illegal • most costly • most heavily indulged in or abused
4. In general, drugs and behaviors that are already highly connected for you are best eliminated together. Common examples of this are: • alcohol and promiscuity when alcohol is used to reduce sexual inhibitions • alcohol and cocaine when drinking leads to cocaine use and/or is used to mellow out the effects of the cocaine • coffee (caffeine) and cigarettes (nicotine) if coffee is a major trigger for smoking • cocaine and gambling, if snorting or shooting or smoking produces unrealistic grandiosity, such as, "I can’t lose."
Heroin (and/or Other Opiates) and Marijuana
Unless your opiate use is very light, your withdrawal should be medically supervised. We are sure that you already know whether you experience withdrawal symptoms; if you do, then you are not in the very light category. The medical supervision would best be administered by a board-certified addictionologist. If you can’t find one, choose an internist or a psychiatrist well experienced with helping addicts go through withdrawal. With such help, there are a few options available. On an inpatient basis, there has been a fairly decent success rate for rapid medical detoxification. The speed of detoxification depends, somewhat, upon the length of use and the amounts used, but usually requires three days or more— possibly much more. There is an experimental program currently being conducted at several hospitals. It is a one-day detoxification program, wherein the addict is put to sleep via anesthesia and then given a cocktail of medications intended to rapidly strip the brain and body of the opiates. This method is controversial and is still being studied. Other methods available are methadone and cold turkey. If methadone treatment is chosen, the goal should be to rapidly taper off of the methadone. Here, again, support from a medical professional is vital. Medications to assist with the withdrawal symptoms are quite helpful in shortening the period of withdrawal from years to weeks for those committed to recovery. Switch from heroin to methadone and taper off of the methadone over a period of a few months. At the same time, the marijuana can be stopped immediately since there are no serious physical withdrawal effects. However, if this seems too stressful while undergoing opiate withdrawal, you could taper off the marijuana over the same period or, if both heroin and marijuana abuse have been very heavy, begin tapering off of the marijuana on the day following your last methadone dose. Schedule your last use of marijuana for one to two months after your last use of methadone. Be aware that the first alternative is by far the best due to the potential legal consequences of continuing to smoke marijuana. Also note that as you become more confident in your ability to give up heroin and methadone, you might develop greater confidence in your ability to give up marijuana since it is not physically addictive.
Heroin and Cocaine
This includes "speedballing," which is the combination of snorting, shooting (injecting), or smoking both of them together. Give up the cocaine cold turkey. Switch from heroin to methadone and taper off of the methadone. Cocaine has more immediately medically dangerous side effects, such as brain, vascular, and heart damage. Its withdrawal effects are, with medical assistance, mostly just a few days of depression and fatigue, followed by days or weeks of hunger, as the body tries to reverse the common weight-loss effect, The medical assistance during cocaine withdrawal is because the addict is likely to be quite debilitated and experiencing intense urges, and these conditions can be medically moderated. It is not, however, physically dangerous to go cold turkey. So there is little reason to delay giving it up, other than psychological reasons (the "rush" is terrific and, thus, beloved!). This is, however, a harder combination than heroin and marijuana to give up on an outpatient basis. If at first you don’t succeed, get your addicted butt to an inpatient detoxification program! Another word about methadone. There are alternative "cocktails" of medications to reduce the withdrawal pains from heroin. These require the expertise of an addictionologist, who is a physician with a specialty in addictive drug use and treatments. Also, if you want to recover fully, avoid methadone maintenance programs. They can, however, be useful if you are bound and determined to leave opiates as the last addiction from which to recover. We certainly do not recommend that for most addicts. While methadone is sometimes considered in the medical community a cure for heroin addiction, our program as well as the traditional twelve-step programs generally discourage the substitution of methadone for heroin. Many methadone maintenance patients have told us that they still use heroin in order to get high. They have also told us that it is much more difficult to withdraw from methadone than it is from heroin. (Medically, it takes longer and is more difficult because it has a longer half-life.) But it is up to you!
Heroin and Alcohol
Taper off the alcohol, with benzodiazepines if medically necessary, for the first week. Simultaneously, begin your methadone program, If your alcohol use is truly "social" or "controlled," you can get off of heroin/methadone first while continuing to drink. If your drinking stays at less than one or two drinks daily for three months after your last methadone dose, then you might choose to experiment with lifelong, "normal" drinking, at which most alcoholics fail. If the drinking starts to increase, you had better give up the booze, too! The chances are that it will start to increase due to the cross-addiction phenomenon. Remember, you are not so much addicted to heroin or alcohol as you are to getting high. Giving up the emotional need to get high is truly the way to recover. Also, it is pretty difficult to participate in AA, NA, CA, RR, SOS, SMART or most other self-help groups while you continue drinking!
Marijuana and Cocaine
If you cannot yet get yourself to give up both at once, give up the cocaine today and start tapering off of the marijuana over a period of one or two months. When you taper off of any drug or behavior, write out a schedule ahead of time and stick to it! If you cannot stick to the schedule, go cold turkey! Medical supervision can hasten the process, but is not an absolute necessity.
Marijuana and Alcohol
If you cannot yet get yourself to give up both at once, give up the marijuana today, and start tapering off of the alcohol over a period of one to two months. Again, when you taper off of any drug or behavior, write out a schedule, ahead of time, and stick to it! If you cannot stick to the schedule, medical supervision will be necessary.
Cocaine and Alcohol
Stop both now, switching from alcohol to the benzodiazepines as suggested previously. Again, if you have rated yourself as not addicted to alcohol, you can try to experiment with giving up one drug but continuing to control your use of another. If you choose that path, however, please do some Step 4 work on why you prefer that to total abstinence. Perhaps you are simply trying to find some way to continue to get high because you irrationally continue to believe that you cannot be happy without your high of choice, or that you are too weak to ever really recover.
- Peiser, K., & Martin, S. (2000). In The Universal 12-Step Program: How to Overcome Any Addiction and Win! Massachusetts: Adams Media Corporation.
What are the four principles to consider when planning a recovery program for multiple addictions?
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