Relapse Prevention Therapy (RPT) – An Affordable Evidence-based Practice

November 8, 2014

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By Terence T. Gorski, Author

 

Relapse Prevention Therapy (RPT) is an Evidence-based practiced that is recognized by both the National Registry of Evidence-based Programs and Practices (NREPP) and the National Institute of Drug Abuse. This is important because relapse following drug treatment is quite common and a collection of tools have been forged into a system for both preventing relapse and stopping it quickly should it occur. “RPT is a behavioral self-control program that teaches individuals how to anticipate and cope with the potential for relapse” (NREPP). In addition, RPT serves to normalize relapse as part of the overall recovery process, thus reducing the negative feelings and behaviors that result from a setback. RPT also provided relapse tools and techniques that patients learn early in treatment that can stop relapse quickly should it occur.

The GORSKI-CENAPS Model of RPT brings proven evidence-based practices to recovery and relapse prevention by providing effective and easy to use methods for identifying and managing early relapse warning signs and high risk situations. It also presents methods for planning to stop relapse quickly should it occur. All of the key practices of evidenced-based Relapse Prevention Therapy (RPT) are made available in practical and easy to use workbooks. Training is available to teach the most effective ways to make use the workbooks in individual and group therapy and in support groups. There is also an internationally registry of Certified Relapse Prevention Specialists (CRPS) that are trained to support RPT program implementation.

The Research Supporting RPT Effectiveness

Prevention (RP) is an evidence-based intervention. There is compelling evidence in the literature documenting its effectiveness.

First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants. (Irvin et al, 1999)

  • Relapse Prevention (RP) was found to be a widely adopted cognitive-behavioral treatment (CBT) for alcohol, smoking, and other substance use.
  • RP was generally effective, particularly for alcohol problems.
  • RP was most effective with alcohol or polysubstance use disorders combined with the adjunctive use of medication

Validation of Gorski’s Relapse Warning Signs

Though it has enjoyed widespread popularity, Gorski’s post-acute withdrawal syndrome (PAWS) model of relapse has been subjected to little scientific scrutiny. A scale to operationalize Gorski’s 37 warning signs was developed and tested in a larger prospective study of predictors of relapse. Of central interest were: (1) whether the warning signs hypothesized by Gorski are interrelated in a meaningful single factor and (2) whether the hypothesized syndrome would accurately predict subsequent relapses.

A sample of 122 individuals (84 men) entering treatment for alcohol problems was followed at 2-month intervals for 1 year. The Assessment of Warning-signs of Relapse (AWARE) scale was administered at each assessment point, and the occurrence of both slips (any drinking) and relapses (heavy drinking) was monitored during each subsequent 2-month interval. Principal factor analysis was used to study the factor structure of the warning signs.

The results showed that: (1) Of the 37 warning signs, 28 clustered as a robust single factor with excellent internal consistency (Cronbach’s alpha: 0.92-0.93); (2) A conservative evaluation of test-retest stability across 2-month intervals estimated reliability at r = 0.80. (3) After covarying for prior drinking status, clients’ AWARE scores significantly predicted subsequent slips and relapses. Relapse rates for clients with highest AWARE scores, as projected by regression equations, were 33 to 46 percentage points higher than those for clients with lowest AWARE scores, after taking into account prior drinking status.

The conclusion is that this scale of Gorski’s warning signs appears to be a reliable and valid predictor of alcohol relapses. (J. Stud. Alcohol 61: 759-765, 2000)

Relapse Prevention (RP): Controlled Clinical Trials (Carroll 1996)

(1) More than 24 randomized controlled trials have evaluated the effectiveness of cognitive-behavioral relapse prevention treatment on substance use outcomes among adult smokers, alcohol, cocaine, marijuana, and other types of substance abusers. Review of this body of literature suggests that, across substances of abuse but most strongly for smoking cessation,

(2) There is evidence for the effectiveness of relapse prevention compared with no-treatment controls across all drug categories.

(3) Relapse Prevention is most effective at:

  • Treating patients with long histories of chronic relapse after attempting recovery with other treatment methods.
  • Maintaining the positive effects of improvements made during treatment (enhanced durability of effects)
  • Reducing the length and severity of damage caused by relapse episodes when they occur;

(4)      The positive effects of RP are enhanced by patient-treatment matching.

(5) Patient-treatment matching improves outcomes for patients at higher levels of impairment along dimensions such as psychopathology or dependence severity.

Manualized Treatment

Manualized Treatment Improves Effectiveness of treatment (i.e. increases recovery rates, decreases relapse rates, and produces shorter less destructive relapse episodes. The results are achieved while reducing time in therapy.

The primary treatment manuals that help produce these outcomes are:

  1. Starting Recovery With Relapse Prevention Workbook: A workbook designed to integrate basic relapse prevention principles in to the first attempts at addiction recovery.
  2. Cognitive Restructuring for Addiction Workbook: A workbook designed to teach and apply the basic recovery skills of thought management, feeling management, behavior management, impulse control, the use of mental imagery, and a serious of relaxation methods, including mindfulness meditation, that has been proven to enhance the effectiveness of the cognitive component of relapse prevention. This work allows an easy application of RPT methods to a wide variety of additive and mental health problems.
  3. Relapse Prevention Counseling (RPC) Workbook: This is a guide for understanding and managing craving and high risk situations to avoid relapse during the critical first ninety days of recovery.
  4. Relapse Prevention Therapy (RPT) Workbook: This is a guide for helping recovering people with a stable recovery program to identify and manage the personality and lifestyle problems that can so must pain and dysfunction in recovery that self-medication seems like a positive choice. This workbook takes RPT to a deep psychotherapy level.
  5. Problem Solving Group Therapy (PSGT): There are two simple guidelines for using RPT in problem solving groups. There is a Participant Guide to prepare group members with easy to understand information on how to succeed at group therapy and a group leader guide giving in-depth instruction how to start, conduct, and manage common problems that occur in problem solving groups.

When these five practical tools are brought together into a well designed and comprehensive treatment program the quality of care, moral of the staff, and positive long-term outcomes of treatment tend to improve.

WORKBOOKS  USING RELAPSE PREVENTION THERAPY (RPT) – AN EVIDENCE-BASED PRACTICE  http://wp.me/p11fHz-7s

References

The CENAPS Model of Relapse Prevention was originally developed by Terence T. Gorski and continually updated to integrate new research findings. (Gorski 1990, )

Carroll, Kathleen M., Relapse prevention as a psychosocial treatment: A review of controlled clinical trials. Experimental and Clinical Psychopharmacology, Vol 4(1), Feb 1996, 46-54.

Gorski, Terence T., The CENAPS Model of Relapse Prevention: Basic Principles and Procedures, Journal of Psychoactive Drugs, Vol. 22, Issue 2, 1990, pages 125- 133, ON THE INTERNET: http://www.tandfonline.com/doi/abs/10.1080/02791072.1990.10472538

Irvin, Jennifer E.; Bowers, Clint A.; Dunn, Michael E.; Wang, Efficacy of relapse prevention: A meta-analytic review. Journal of Consulting and Clinical Psychology, Vol 67(4), Aug 1999, 563-570.

Miller, William R. and Harris, Richard J.  A Simple Scale of Gorski’s Warning Signs for Relapse, Journal of Studies on Alcohol and Drugs, Volume 61, 2000, Issue 5: September 2000 ON THE INTERNET: http://www.jsad.com/jsad/article/A_Simple_Scale_of_Gorskis_Warning_Signs_for_Relapse/814.html

 

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Addiction Can Be Understood and Treated

August 15, 2014

RECOVERY IS POSSIBLE
STRAIGHT TALK ABOUT ADDICTION

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Straight talk means giving clear, honest, and plain-English descriptions of important issues related to addiction, recovery, relapse prevention. Straight Talk means discussion the artistes for addiction — sobriety and responsible living.

This book tells it like it is without a great deal of concern for political correctness or the tentative guarded language that so often hides the truth about addiction, recovery, and relapse.

After 40 years of following the new research and treatment practices for addiction, Terry Gorski became frustrated at the misinformation about alcohol and other drug addictions and the narrow and incomplete approaches to treatment, recovery and relapse prevention.

In this book, Terry provides the best information on the current science-based upon an accurate understanding of what the core addiction syndrome is and what the an effective addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk of relapse.

This book is easy to read and loaded with useful information. The book can be quickly read from beginning to end, and then kept as a handy reference to find specific information that can be used as a guide to manage the problems and crises that are so often a part of the addiction and recovery process.

The message is simple: addiction is a biopsychosocial disease. science-based understanding of what the core addiction syndrome is and what the core addiction treatment process needs to look like if it is to increase the chances of recovery and decrease the risk. Here are some of the key ideas developed in depth with the book:

Addiction is a biopsychosocial disease. Bio means biological or of the body, Psycho means psychological or of the mind, Social means the relationships that develop among people and with the social and legal systems that are needed for responsible living.

Biologically, addiction is marked by brain dysfunction that disrupts the reward chemistry of the brain creating cycles of intense euphoria and powerful craving.

Psychologically addicted people slowly adjust their ways of thinking, feeling, acting that allows them to deny and rationalize the problems caused by the it addiction.

Gradually, over time, an addictive beliefs develops that create a powerful denial system. This denial blocks the ability to recognize the addiction, interferes with the ability to ask for and accept help, and creates a deadly spiral of progressively more severe relapse episodes.

Socially, addiction pushes away sober and responsible people while attracting and feeling attracted to addicted and irresponsible people. The result is a tragedy. The addict abuses, disregards, and destroys those who love and try to help them. Active addicts set themselves up to be exploited by other addicted people and are vulnerable to predators who use and abuse them.

Most importantly Straight Talk About Addiction provides hope. Addiction and be understood, recovery is possible, and relapse can be prevented it effectively managed should it occur.

This book is easy to read and understand. It is loaded with useful information. Many people read it from beginning to end to get a comprehensive understanding of addiction, recovery, relapse, and related problems. Many people keep the book handy so they can use it as an easy-access reference to find useful information that can be used to effectively manage addiction-related problems.

The message is clear: Recovery is possible. Relapse can be prevented or effectively managed should it occur. There is hope.

LIVE SOBER – BE RESPONSIBLE – LIVE FREE

Get The Book By Terence T. Gorski
STRAIGHT TALK ABOUT ADDICTION


Listening

July 25, 2014

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By Terence T. Gorski
Author
GORSKI BOOKS: www.relapse.org

People, regardless of gender, tend to hear what they want to hear. This tendency leads to many conflicts and a great deal of miscommunication.

Solving the problem begins with an honest self-exploration of our own willingness and ability to seek first to understand what others are saying before we seek to be understood.

Listen carefully and with your full attention. Check to make sure you have correctly understood by repeating what you heard and asking if you got it right.

Think before you speak. Be sure you have something worthwhile to say. Then say it clearly, calmly, compassionately, and with conviction.

Yelling makes you seem foolish even if you are right. People seem foolish when they are right at the top of their lungs. Breath deeply and become calm and centered when discussing important issues.

“Seek first to understand, then to be understood.” ~ Stephen Covey

If you want other people to take you seriously, you need to make others feel that they are listened to, understood, and taken seriously. This lead them to trust you and this increases the possibility that they will listen to, understand and take you seriously. Communication that starts with active empathetic listening skills tend to build a cycle of progressive openness and trust the deepens the process of feeling connected to others in recovery.

Trust is the foundation of all honest communication. To gain the trust of others we must me trustworthy within ourselves. Trust is built slowly, step-by-step by shared progressive self-disclosure.

GORSKI BOOKS: www.relapse.org

LIVE SOBER – BE RESPONSIBLE – LIVE FREE


Cognitive Restructuring: Why It Works With Addiction

June 8, 2014

Addictive ThinkingBy Terence T. GorskiAuthor

Abstract: This detailed blog by Terence T. Gorski explains the biopsychosocial factors in chemical and behavioral addictions; describes how cognitive restructuring can change addictive thoughts, feelings, and behaviors; and shows how the process can provide organization to the treatment/recovery process while improving the collaboration between the addiction professional and the recovering person. References are provided that show that Cognitive Behavioral Therapy (CBT), the core method upon which Cognitive Restructuring for Addiction is based, is an evidence-based practice.

COGNITIVE means information processing in the brain.

RESTRUCTURING means changing how information is processed by the brain.

ADDICTION, described in DSM IV as Substance Use disorders), is described in DSM 5 as addictive disorders and has been expanded to include: Chemical Addictions (alcohol and other mind altering drugs of abuse); and Behavioral Addictions (gambling and other forms of compulsive mood altering behaviors).

All addictive disorders share a common set of similarities which include:

  • Addictive Beliefs (Addictive use is an effective way to stop my pain and solve my problems);
  • Automatic repetitive addictive thinking patterns (often called addictive rumination) that is difficult to self-regulate;
  • Obsession (Out-of-control thinking about the addiction);
  • Compulsion (the strong irrational urge to engage in addiction seeking behavior and addictive use);
  • Craving (A powerful urge based in a psychobiological response to cues or triggers that activates a powerful urge ton use in order to normalize the uncomfortable feelings caused by the biological symptoms of the craving);
  • Loss of Control (A pattern of compulsive use making it difficult self regulate the quantity, frequency, or duration of addictive use episodes);
  • Secondary life and health problems caused by the loss of control. These tend to be related to the specific addictive release being used); and
  • Continuation of use in spite of adverse consequences and a subjective desire to stop and reduce the use.

Each specific addictive disorder that is organized around a specific drug of choice or behavior of choice has unique differences that need to be considered in treatment. An alcoholic who does not use prescription or illicit drugs will participate in a different addictive culture and have adaptations in their addictive thinking that accommodates the focus of their addiction. The same is true of Prescription drug Addicts who don;t use illicit drugs, illegal drug users also involved in criminal drug-centered culture, gamblers, compulsive over-eaters, etc.

As a result, the above symptoms of addiction are caused by:

  • A complex individualized (idiosyncratic) biopsychosocial responses in each addicted person;
  • The specific substance or behavior that is the primary source of addictive release;
  • The social and cultural reaction to the use, abuse, and addiction to the specific substance or behavior.
  • The degree of addictive brain dysfunction;  and
  • The unique information processing style of the  addict originating in the family of origin and influenced by social and cultural experiences.

These differences, however, are accompanied by a cognitive or information processing styles that are similar in all addicted people and create:

  • Addictive Beliefs/Automatic Thinking based upon the mistaken belief that “addictive use will take away my pain and solve my problems!”
  • Craving which is a strong irrational urge to use addictively in spite of good reasons not to. Cravings usually do not result from rational decision-making. They are usually activated by environmental cues or triggers. and
  • Habitual addiction-seeking behaviors, activated by the cue/trigger and acted out automatically and unconsciously. These addiction seeking behaviors are known as early relapse warning signs. Acting them out puts addicts into high-risk situations that surround then with people, places, and things that will encourage and support their use of alcohol and other drugs.

Cognitive restructuring is a proven method for:

1. Stopping addictive thinking and challenging addictive beliefs;

2. Managing craving;

3. Stopping or redirecting addiction-seeking behaviors;

4. Avoiding or effectively managing high risk situations;

5. Having a well-rehearsed emergency plan to stop addictive use should it begin; and

6. Using a debriefing process (sometimes called a relapse autopsy) to examine past relapse episodes and near-miss experiences in order to learn how to avoid or effectively manage similar situations in the future.

Cognitive restructuring for addiction, which is at the core of Relapse Prevention Therapy (RPT) is a core set of principles, practices, tools, and skills that can be used to enhance recovery and prevent relapse. When used effectively these principles and practices teach people:

  • How to change their thoughts, feelings, and behaviors in ways that eliminate or reduce craving and drug seeking behavior.
  • How to manage high risk situations;
  • How to find a sense of meaning and purpose in recovery that is note satisfying than acting out an addictive lifestyle.

The Cognitive Restructuring for Addiction Workbook contains a series of clear, simple, and effective exercises that can enhance recovery while breaking the cycle of relapse.

The exercises in the workbook can be applied to a wide variety of chemical and behavioural addictions as well as other problems involving the repetitive and habitual use of a specific self-defeating behavior.

The underlying cognitive restructuring process is the same. Additional information that is specific to unique addictive behaviors can increase effectiveness. The manual is based upon evidenced-based Cognitive Behavioral Therapy (CBT) principles and practices that are effective with addiction, depression, PTSD, and a wide variety of other disorders that are lifestyle-related and subject to periodic regression or relapse. (CBT and related therapies are documented as evidence-based practices by SAMHSA-NREPP.

A small investment in this inexpensive workbook can:

  • Organize and structure the recovery/therapy process;
  • Provide home-work assignments that increase progress; and
  • Demonstrate the use of evidence-based practices.

Most importantly, the proper use of the exercises in this workbook can literally make the difference between helping people to move forward in recovery, or to slide backwards into addictive use and the horrible damage than can be caused.

Click here to order: THE COGNITIVE RESTRUCTURING FOR ADDICTION WORKBOOK. This small investment could save you sobriety.

A Home Study that awards CEU’s for studying this workbook are available: email: tresa@cenaps.com or visit Gorski-CENAPS Home Studies 

 


Relapse Prevention Therapy (RPT) – The Clinical Process

May 31, 2014

20140531-010803-4083647.jpgBy Terence T. Gorski, Author

Relapse Prevention Therapy (RPT) is an in-depth clinical psychotherapy process that is designed to four outcomes – The development of a core issue list, a relapse warning sign list, warning sign management strategies, and a recovery plan.

1. Core Issue List:

Each person completing RPT develops a list of the core personality and lifestyle problems that create pain and dysfunction while attempting to maintain long-term sobriety and responsibility.

These core personality and lifestyle problems lead a person back into patterns of addictive and irresponsible thinking and behavior during times of high stress and problems. Since these patterns are automatic and unconscious and are activated by situational triggers, the individual can feel confused and powerless as they successfully avoid or cope with high risk situations only to find themselves acting out in other self-defeating ways for apparently no reason. As a result, the failure to identify and address these issues increases the risk of relapse after initial stabilization and return to normal functioning has been achieved.

The Core Issue List identifies the core or central system of irrational or mistaken beliefs about self, others, and the world that leads to feelings of deprivation and hopelessness when practicing habits of sober and responsible living.

These Core issues are based upon the general mistaken belief that “I can’t have the good life, and be sober and responsible at the same time.” The “good life” is subjectively defined by primary childhood experiences that cause the individual to perceive, think about and respond to the world using an automatic cycle of deeply habituated self-defeating behavior.

The core issue list is developed from a careful and systematic analysis of information gathered from three sources:

(1) the client’s original presenting problems,

(2) the client’s life and addiction history, and

(3) the client’s recovery and relapse history.

The goal of completing these three assessments is to guide the client in answering two basic questions:

(1) “What did you come to believe that alcohol, drugs, and irresponsibility could do for you that you could not do for yourself while being sober and responsible?”

(2) “What problems did you come to believe that alcohol, drugs, and irresponsibility could help you to cope with or escape from that you believed you couldn’t deal with while being sober and responsible?”

The client is taught:

(1) To recognize the basic core issues that increase the risk of relapse, and

(2) To write clear statements that describe the general mistaken beliefs and the automatic and unconscious patterns of thinking, managing feelings and acting that is used when that core issue is activated.

The goal is to teach the client to understand and describe the problems that lead to relapse on three levels in clear, simple, and concrete terms.

These three levels are:

(1) The mistaken beliefs or assumptions about self, others, and the world that limit choices in life planning and problem solving;

(2) The automatic and habitual self-defeating thoughts, painful unmanageable emotions, self-defeating behaviors that are activated by the structure of mistaken beliefs; and

(3) The dysfunctional professional and personal relationships that result from the habitual use of those self defeating behaviors.

This allows the client to unmask the big lie of addiction – the mistaken belief that alcohol, drugs and irresponsibility is good for me, can magically fix me and my problems, and can give me a better life.

Applications: The core issue list is designed to both prevent relapse and improve overall effectiveness by teaching the following skills:

(1) The ability to reflect upon past experiences, accurately assign meaning to those experiences, and avoid the thinking errors and self-defeating behaviors that are the logical consequences of mistaken beliefs;

(2) Mapping out the habitual patterns of thinking, feeling, and acting that are related to those mistaken beliefs; and

(3) Understanding how problems with professional and personal relationships are the logical extension of those core beliefs.

2. Relapse Warning Sign List

Each person completing RPT learns how to develop a Relapse Warning Sign List that describes the specific sequence of events and the related irrational thoughts, unmanageable feelings, self-destructive urges, and self defeating behaviors that are acted out when the core mistaken beliefs are activated.

This warning sign list allows the client to describe in concrete and specific terms the subtle changes in thinking, feeling, motivation, and behavior that set the stage for addictive thinking. It also allows significant others to recognize and assign meaning to the subtle changes in communication and behavior and to intervene appropriately before addictive thinking patterns become rigidly reestablished.

Applications: The relapse warning sign list is designed to prevent relapse and improve overall effectiveness by teaching the following skills:

(1) Developing a list of progressive personal problems and behaviors that lead back into a pattern of addictive and irresponsible thinking and behaviors;

(2) Isolating the warning signs that will interfere with performance by writing a Warning Sign List.

3. Warning Sign Management

Each person completing RPT learns how to identify key or critical warning signs and how to use specific skills or tools to manage those warning signs in a way that stops the progressive pattern of self-defeating thinking and behavior.

The coping strategies related to RPT go beyond the situational management strategies learned at the RPC level. They involve recognizing and intervening upon the more subtle patterns of thinking, emotional management and acting out that set the stage for gradually more destructive behaviors.

Applications: The relapse warning sign management strategies are designed to prevent relapse and improve overall effectiveness by teaching the following skills:

(1) Clearly identifying intervention points in the progressive pattern of irrational thinking and self-destructive behaviors that can impair performance and increase the risk of mismanaging critical situations in a way that could lead to relapse;

(2) Learning specific skills for identifying and challenging irrational and addictive thinking patterns;

(3) Learning specific skills for responsibly managing unpleasant feelings and emotions;

(4) Learning specific tools and skills for recognizing and changing subtle patterns of self-defeating behaviors that can lead to serious long-term problems and eventual relapse; and

(5) Learning how to proactively invite others to support patterns of sobriety and responsibility and to point out self-defeating behaviors or problems that clients may be unaware of.

4. Recovery Plan

Each person completing RPT develops a recovery plan consisting of regularly scheduled activities that clearly support the ability to challenge the mistaken beliefs that perpetuate a self-defeating style of living and working.

LIVE SOBER – BE RESPONSIBLE -LIVE FREE

GORSKI BOOKS: www.relapse.org


The Magic Triangle Relaxation Method

May 8, 2014

Magic Circle Relaxation 01by Terence T. Gorski, Author

Developed By Terence T. Gorski for use in Relapse Prevention Therapy (RPT) in 1995

Most relapse prone people have serious problems with stress that can lead to relapse. It is important to teach relaxation techniques that can be used to turn off or significantly reduce the immediate stress response when it occurs. Mindfulness mediation has become a popular evidence-based relaxation method, but there are other relaxation techniques that are also effective.

The Smorgasbord Approach To Relaxation Training

Relaxation training has been consistently integrated into the CENAPS® Model of Relapse Prevention since about 1985. Another blog with cover the seven core approaches to relaxation training and meditation used Certified Relapse Prevention Specialist (CRPS) and found to be helpful in their work.

The Magic Triangle Relaxation Technique is one specific application that integrates one application that has been used in the Relapse Prevention Certification School for many decades. It is not the only method that works, it is one of the methods.

Patients seem to do better when given a choice of relaxation techniques, and opportunity to experiment with the different core techniques, and the ability to choose what work best for them. Many Relapse Prevention Specialists have found that they can easily develop a personal relaxation exercise by combining the core approaches in a personalize script.

The Magic Triangle Relaxation Technique is one of the best techniques for teaching immediate relaxation response training because it involves a combination of deep breathing, guided imagery, and autosuggestion. The technique is called the Magic Triangle Relaxation Technique because it uses the focal image of a triangle to induce relaxation.

Self-Monitoring of Effectiveness

Self-monitoring is an evidence-based practice that is based upon the principle that regular self-evaluation of the effectiveness of a therapy technique tends to increase it’s effectiveness. Cognitive behavior therapists have found that using a simple subjective ten-point scale increases the effectiveness of self-monitoring.

The Stress Thermometer is simple stress scale for measuring the intensity of stress from patients on a self-report basis. The scale ranges from 1 -10 and allows easy measurement of four levels of stress:

  • Incapacitating Stress (Level 10),
  • High stress (Level 7-9),
  • Moderate stress (3-5) and
  • Low stress (1-3)

Before beginning and the end of each relaxation session ask the patient self-evaluate their current level of stress. At the end of the session, the therapist and patient compare the two scores and discuss which part of the relaxation training was most helpful. By keeping track of the scores and the technique used across sessions, patients can more accurately evaluate what works best for them as individuals. If patients do not perceive their stress level is decreased by the relaxation technique they are using, or if the technique actually raised their perceived stress, they rapidly lose the motivation build relaxation training into their recovery and healthy lifestyle plan.

The Magic Triangle Technique

Here is a detailed description of how to use the technique.

  1. Give a General Relaxation suggestion

“Take a deep breath and sit back in your chair. I am going to teach you an immediate relaxation response exercise called the Magic Triangle Relaxation Technique. Once you learn it, you will be able to use this technique to help you to turn off or significantly reduce stress whenever you become tense or agitated.”

  1. Give the Suggestion of Total Control and Safety

“You will be in total control of this relaxation process. If at any time you feel uncomfortable or frightened, all you need to do is to open your eyes, sit up, and look around the room and you will come back to the present.”

  1. Change Your Body Posture

“Change your body posture in the chair. Sit up straight, put your feet flat on the floor and look straight ahead. Find a spot on the wall or a spot in space in front of you. You can allow your eyes to close if it is comfortable, but you can also leave your eyes open and stare blankly in front of you as you let your mind relax and wander. You can do what feels best for you to do.”

  1. Body-awareness and Relaxation

“Notice your feet. Notice the pressure of your feet on the floor. Notice the feeling in your feet. Now say to yourself: ‘My feet are warm and comfortable. I feel a tingling sense of relaxation in my feet.’” (Repeat this suggestion three to five times)

“Now notice your legs. Notice the feelings in your lower and upper legs. Now say to yourself: ‘My legs are warm and comfortable. I feel a tingling sense of relaxation in my legs.’” (Repeat this suggestion three to five times)

“Now notice your lower body. Notice the feelings in your buttocks, lower back, and lower stomach. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My lower body is warm and comfortable. I feel a tingling sense of relaxation in my lower body.’” (Repeat this suggestion three to five times)

“Now notice your upper body. Notice the feelings in your chest and upper back. Feel the weight of your body pressing into your chair. As you are feeling the weight of your body say to yourself: ‘My upper body is warm and comfortable. I feel a tingling sense of relaxation in my upper body.’” (Repeat this suggestion three to five times)

“Now notice your arms and shoulders. Notice the feelings in your arms and shoulders. Feel the weight of your arms as they rest comfortably on your lap. Notice the feeling of your arms gently pulling down on your shoulders. Notice any tension in your arms and shoulders and, if it is comfortable to do so, adjust your arms and shoulders to release the tension and become more relaxed.”

“As you are feeling the feelings in your arms and shoulders, say to yourself: ‘My arms and shoulders are warm and comfortable. I feel a tingling sense of relaxation in my arms and shoulders.’” (Repeat this suggestion three to five times)

“Now notice your neck. Notice the feelings in your neck. Notice any tension in your neck and, if it is comfortable to do so, adjust your neck by rotating it gently to release the tension and become more relaxed.”

“As you are feeling the feelings in your neck, say to yourself: ‘My neck is warm and comfortable. I feel a tingling sense of relaxation in my neck.’” (Repeat this suggestion three to five times)

“Now notice your head and scalp. Notice the feelings in your head and scalp. Imaging your scalp tingling with a warm sense of relaxation.”

“As you are feeling the feelings in your head and scalp, say to yourself: ‘My head
and scalp is warm and comfortable. I feel a tingling sense of relaxation in my head and scalp.’” (Repeat this suggestion three to five times)

“Notice your face. Notice any tension in your face. Notice your jaw and allow it to relax. Feel how heavy your jaw is becoming and allow your jaw to relax. If it is comfortable to do so, adjust your jaw by rotating it gently to release the tension and become more relaxed. Notice the feelings around your eyes. If it is comfortable to do so, move the muscles around your eyes to release any tension.”

“As you are experiencing the feelings in your face, jaws, and eyes, say to yourself: ‘My face, jaws, and eyes are warm and comfortable. I feel a tingling sense of relaxation in my face, jaws, and eyes.’” (Repeat this suggestion three to five times)

  1. Deep Breathing

“Notice your breathing. Notice how your breath flows in and out of your body. Notice that you can regulate how quickly or slowly you breath. Take a deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. Take another deep breath, hold it for a moment until your lungs feel tense, then slowly exhale. One more time. Take another deep breath, hold it for a moment, slowly exhale.”

“Notice if you are breathing from high in your chest or low in the stomach. As you notice your breathing, lower the breathing deep into your stomach. Imagine your lower stomach going in and out with each breath you take.”

  1. Rhythmic Breathing

“Now, as you are listening to my voice and noticing yourself relax, slowly breath in to the count of four and out to the count of four. As you breath in allow your breathing to fill the lower part of your stomach. As you breath out feel the lower part of your stomach relax. Inhale … one, two, three, four .— exhale … one, two, three, four …hold it a moment.” (Repeat this for five to ten breaths)

  1. Visualizing the Triangle and Ball

“Now, visualize a black background before your eyes. See a bright red triangle, pointing up, with equal sides appearing on this deep black background. See the deepness of the red color within the triangle.”

“Now imagine a bright yellow ball at the bottom right hand side of the triangle. Imagine the ball rolling slowly up to the top of the triangle as you count slowly to four. Bring the ball up … one, two, three, four. Balance the ball at the top of the triangle. Bring the ball down … one, two, three, four.” (Practice this five to ten times).

  1. Combining Breathing and the Triangle and Ball

“Now, as you see the ball rising to the top of the triangle take a very slow and deep breath. As your lungs fill with air, imagine the ball balancing at the top of the triangle. As you slowly exhale, imagine the ball slowly moving down the other side of the triangle.”

Inhale … raise the ball to the top of the triangle … hold it for moment—exhale … lower the ball to the bottom of the triangle.” (Practice this five to ten times)

  1. Adding Relaxation Suggestions

“As you breath in and imagine the ball rolling to the top of the pyramid say to
yourself: ‘I am …’ as the ball rolls down the other side of the triangle say to yourself, ‘relaxing …’ ‘I am …’ Ball to the top. ‘Relaxing’ Ball to the bottom.” (Repeat five to ten times)

10. Waking Up From Relaxation

“Imagine that you are waking up in the morning from a deep and peaceful sleep. As you awaken you feel an urge to stretch and try to yawn. Take a deep, deep breath. Slowly come awake feeling the urge to stretch and yawn. Open your eyes, stretch your arms over your head. Come back fully awake feeling rested and alert.”

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Subutex and Suboxone: Questions and Answers By The FDA

February 17, 2014

Introduction By Terence T. Gorski: I have been receiving many questions about my opinion about the use of Suboxone and Subutex in the treatment of opiate addiction. I have mixed feelings, depending upon how it is used.

When Suboxone was originally developed as a joint effort between SAMHSA its subsidiary NIDA and Reckitt Benckiser Pharmaceuticals Inc. The motivations was to find a more effective maintenance medication for opiate addicts that could replace methadone maintenance and be administered and managed by physicians in their offices. Subutex and Suboxone are the first narcotic drugs available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed in a doctor’s office. This change will provide more patients the opportunity to access treatment.

Suboxone can be used as a part of multi-modality treatment, but it was developed to be a stand-alone treatment managed by physicians. With the implementation of the Affordable Care Act (ACA), Suboxone fits in perfectly with the government’s agenda to integrate addiction treatment into routine medical practice.

I am pleased that the government recognizes opiate addiction as a medical problem that requires treatment within the general health care system. I am disappointed that physicians are being trained to be the sole providers of Suboxone Treatment and that a comprehensive biopsychosocial assessment and multimodality treatment is not strongly recommended or required as part of the treatment.

I have heard many reports from opiate addicts that Suboxone has helped them because it reduces or eliminates craving and does not produce a state of euphoria if it more is taken the prescribed. I might add, that most opiate addicts recovering with only Suboxone that  have talked to have experimented on “bad days” to see if they can get high by taking ore than prescribed. Most report that they can’t. Some, however, have had a relapse when they went out and get some other drug to get them through the bad period.

Subutex and Suboxone are also used as opiate detox medications in some programs.

Suboxone can create a euphoric high and many people report tolerance with long-term use. As result it is an addictive drug of abuse that must be used cautiously. It has a street value and is showing up more frequently as a drug of abuse in people seeking treatment. 

I believe that any new medication that can help people addicted to opiates and other drugs is a good thing. It is short sighted, however, to build the use of any addiction medication around a purely medical model that does not encourage or require a brief course (about 90 days) of addiction counseling. This addiction-counseling program includes:

(1) A biopsychosocial evaluation determines the severity of addiction and related problems

(2) Develops a sober social support to help patients to develop a new set of sober and responsible friends.

(3) Teaches life, a recovery, and relapse prevention skills;

(4) Helps to rebuild relationships on the job, at home, with extended family members, and friends.

These addiction-counseling programs can be delivered flexibly on an outpatient basis. Many addiction professionals offer services n ear many Suboxone Doctors and they could form a valuable collaboration for the benefit of the patient. It is also possible for Suboxone Doctors you include addiction professionals in the practice. This would expand services, increases patient retention, and add an additional revenue stream.

With these comments in mind, here are some of the FAQ questions about Suboxone on Subutex developed by NIDA.

1. What are Suboxone and Subutex?

Subutex and Suboxone are medications approved for the treatment of opiate dependence. Both medicines contain the active ingredient, buprenorphine hydrochloride, which works to reduce the symptoms of opiate dependence.

2. Why did the FDA approve two medications?

Subutex contains only buprenorphine hydrochloride. This formulation was developed as the initial product. The second medication, Suboxone contains an additional ingredient called naloxone to guard against misuse.

Subutex is given during the first few days of treatment, while Suboxone is used during the maintenance phase of treatment.

3. Will most prescriptions be for the Suboxone formulation?

Yes, Suboxone is the formulation used in the majority of patients.

4. How are Subutex and Suboxone different from the current treatment options for opiate dependence such as methadone?

Currently opiate dependence treatments like methadone can be dispensed only in a limited number of clinics that specialize in addiction treatment. There are not enough addiction treatment centers to help all patients seeking treatment. Subutex and Suboxone are the first narcotic drugs available under the Drug Abuse Treatment Act (DATA) of 2000 for the treatment of opiate dependence that can be prescribed in a doctor’s office. This change will provide more patients the opportunity to access treatment.

5. What are some possible side effects of Subutex and Suboxone?

(This is NOT a complete list of side effects reported with Suboxone and Subutex. Refer to the package insert for a more complete list of side effects.)

The most common reported side effect of Subutex and Suboxone include:

  • cold or flu-like symptoms
  • headaches
  • sweating
  • sleeping difficulties
  • nausea
  • mood swings.

Like other opioids Subutex and Suboxone have been associated with respiratory depression (difficulty breathing) especially when combined with other depressants.

6. Are patients able to take home supplies of these medicines?

Yes. Subutex and Suboxone are less tightly controlled than methadone because they have a lower potential for abuse and are less dangerous in an overdose. As patients progress on therapy, their doctor may write a prescription for a take-home supply of the medication.

7. How will FDA know if these drugs are being misused, and what can be done if they are?

FDA has worked with the manufacturer, Reckitt-Benckiser, and other agencies to develop an in-depth risk-management plan. FDA will receive quarterly reports from the comprehensive surveillance program. This should permit early detection of any problems. Regulations can be enacted for tighter control of buprenorphine treatment if it is clear that it is being widely diverted and misused.

8. What are the key components of the risk-management plan?

The main components of the risk-management plan are preventive measures and surveillance.

Preventive Measures include:

  • education
  • tailored distribution
  • Schedule III control under the Controlled Substances Act (CSA)
  • child resistant packaging
  • supervised dose induction

The risk management plan uses many different surveillance approaches. Some active methods include plans to:

  • Conduct interviews with drug abusers entering treatment programs.
  • Monitor local drug markets and drug using network areas where these medicines are most likely to be used and possibly abused.
  • Examine web sites.

Additionally data collection sources can indicate whether Subutex and/or Suboxone are implicated in abuse or fatalities. These include:

  • DAWN—The Drug Abuse Warning Network. This is run by the Substance Abuse and Mental Health Services Administration (SAMHSA) which publishes a collection of data on emergency department episodes related to the use of illegal drugs or non-medical use of a legal drug.
  • CEWG—Community Epidemiology Working Group. This working group has agreed to monitor buprenorphine use.
  • NIDA—National Institute of Drug Abuse. NIDA will send a letter to their doctors telling them to be aware of the potential for abuse and to report it if necessary.

9. Who can prescribe Subutex and Suboxone?

Only qualified doctors with the necessary DEA (Drug Enforcement Agency) identification number are able to start in-office treatment and provide prescriptions for ongoing medication. CSAT (Center for Substance Abuse Treatment) will maintain a database to help patients locate qualified doctors.

10. How will Subutex and Suboxone be supplied?

Both medications come in 2 mg and 8 mg strengths as sublingual (placed under the tongue to dissolve) tablets.

11. Where can patients get Subutex and Suboxone?

These medications will be available in most commercial pharmacies. Qualified doctors with the necessary DEA identification numbers will be encouraged to help patients locate pharmacies that can fill prescriptions for Subutex and Suboxone.

12.      Where can I go for more information?

Go to the Subutex/Suboxone webpage

Contact the CSAT Buprenorphine Information Center at 866-BUP-CSAT, or via email atinfo@buprenorphine.samhsa.gov or http://buprenorphine.samhsa.gov/

 


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