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

November 8, 2014


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First, let’s look at the results of a meta-analysis of 26 published and unpublished studies with 70 hypothesis tests representing a sample of 9,504 participants.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



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:

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:


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Complexity: The Comprehensive Bio-Psycho-Social-Spiritual-Cultural-Economic-Political Profile

September 1, 2014

thBy Terence T. Gorski, Author
President, The CENAPS Corporation

Gorski’s Book, Straight Talk About Addiction,
further explains the implications of the distinction between
the brain and the mind in addiction recovery.

Please view this blog as a work in a progress. See it as a passing glance through a partially opened window of my brain/mind, Forgive me, for the room you are glancing into is still cluttered and poorly organized, yet you will see some interesting things emerge from  this superficial examination of the clutter.  As I said, I have not yet fully explored and organized these ideas. I started this blog with a simple idea and became possessed by something newer and for more complex.
I started to write a simple blog asserting that I believe we have both a physical brain and a nonphysical mind and that both are equally important. I wanted to lash out at the flat-landers who would smash human experience into the single dimension of nerve cells  firing as they rub up against each other and band into the environment. My argument was going to be simple: the brain is an important thing, but it is not the only thing.

The paradigm of the BRAIN-MIND is emerging to explain how the physical brain, connects with and is sensitive to the nonphysical actions of the mind. THE BRAIN is the physical structure that supports the nonphysical actions of the THE MIND. We, as human being, are sentient beings with a neuroplastic brain is capable of reprogramming itself based upon experience throughout the entire human life span.The ability to self-regulate the brain-mind assigns meaning to life experiences which can become culturally based beliefs that cause the development complex shared beliefs and personalities that influences our behavior, relationships, and social structures. This can lead to stress, conflict, violence, pain, trauma, stress-related illness, , addiction, and mental health problems. The Brain-Mind takes note and moves to correct the problems.

Medicines can certainly save lives and ease suffering, but so can our interactions with other people who care about us and have well-developed helping characteristics.  The environment in which we live has a lot to do with health and illness. It is incredibly important in terms of alcoholism and drug abuse. Certain kinds of neighborhoods become the incubators of drugs dealers, crime, and violence. Where we live, who we live with, and the nature of our relationship with those we live with has a lot to do with getting addicted, getting clean and sober, staying clean and sober, or relapsing. All these things have a lot do with addition, mental health, and lifestyle-related chronic illness.
As I thought about it, the environment also has a lot to do with illness injury and accident. Some of the greatest improvement in public health did not come from medicine, that came from improved sanitation, safer cars, and the awareness of and elimination of toxic substances in our homes and workplaces. Medicine, of course, base a place in the treatment of heart disease, but so does nutritional science, stress management, and motivational counseling to keep people going with the big changes demanded of heart-healthy living. The lifestyle and stress-related illnesses are among the most difficulty  to treating and the most relapse-prone..
Chronic Life-style-related Illness
Is the Most Difficult To Treat
And the Most Relapse Prone.
In my opinion, the future direction for improving our ability to treat chronic addiction and other lifestyle-related illness will not come from a revolutionary new treatment for these lifestyle-related problems. I would celebrate if that were to happen, I just don’t believe that it will. The next big breakthrough that I see coming in the treatment of addiction and other lifestyle-related illness will not be revolutionary. It will be evolutionary and it is slowly unfolding before out eyes right now.
Brain-Mind Cascade

The Brain-Mind Cascade

There are evolutionary changes pushing us inevitably toward conquering addiction and other lifestyle-related diseases. The evolution involves examining everything we have ever done that helped out clients. It also involves bring all these success stories, no matter how small, together. We view each little success story as a piece in the puzzle to a complicated life-long chronic disease management process.    Then we put them into a big pile (the big pile is actually a high power computer) and start looking for similarities and complimentary components. (The computer actually does most of the looking. We push a button and let the computer do the hard number crunching in the cyber-space world of correlations and algorithms.)

This will allow us to dramatically increase the amount of data that get analyzed and integrated our current knowledge-base of addictive, mental, and stress-related  illness.  This future direction that I believe holds the most promise. We integrate what we already know and look for new combinations and insights. We do this by  organizing the mountain of data into a new grid. I believe that if we could pull off this comprehensive BIOPSYCHOSOCIAL AND ENVIRONMENTAL synthesis of what we have already know, we will be able to find ways of matching patients to treatments and to prevention strategies that could reduce stress-related and life-style related illness by up to 75% in ten years.  It is possible, but it would take a major effort. The necessary funding would require financial reorganization that would probably fail to gain any political traction.
We would need to bring together everything we have learned that helps people to recover across all areas of study. This would mean mapping out a … well a …  Heck, there is no name for the type of map we would be creating. It would be as big a deal as mapping out the human genome, but at least the genome has a name. I can’t think of a good name for dynamic ever-growing map of the human condition so I will call it a comprehensive human bio-psycho-social-spiritual-cultural-ecnomic-political profile. (This name sounds simple and easy to remember, does it not?)
This task is as challenging, perhaps more challenging than mapping the human genome. It would involve getting dozens of different professionals, working in different areas of speciality expertise, who operate in different profession cultures, who use different specialty language, who compete for the same funds, and who usually dislike communicating  across the professional and specialty lines because they don’t really respect what the other professionals are doing. We need to get several million of these professionals to become committed to a collaboration that could change on multiple levels the health of billions of people and the planet they live on.
This collaboration could change on multiple levels
the health of billions of people and the planet they live on.
All specialties would be important. Collaboration and the willing to learn across disciplines would be the cultural organizing theme.  Since each speciality tends to have it own unique professional jargon, it would mean creating a new common-sense language tha could be understood across disciplines and by the common folk who suffer from the illnesses being studied.. It would involve many cross-walks between different ways of thinking: people doing pure science would have t cross-walk their ideas with people doing clinical work.
The people suffering from the human condition, which is nearly every human being alive at some pint in his or her life, needs to be invited to participate. They would be invited to log  onto smart social networking bulletin boards. These smart bulletin boards will allow people to tell the story of their disease and recovery, to describe their symptoms and related issues, and to report what they found helpful, not helpful, and harmful. There would be social networks linking people together to exchange information.
This would require big computer power — and we have that already. It needs to be designed for easy use by ordinary people who can easily enter their experiences with their disease or conditions. This probably means both key-board and voice-activated input — and we have those already.  The computer will organize the information into a big number analysis. The most difficult part of the model is that a wide variety of social, cultural, spiritual, religious, and political factors which affect the health or illness generating capacity of the environment must be included.
The next big breakthrough in the treatment of
addiction and other lifestyle-related illness
will not be revolutionary. It will be evolutionary and
its is slowly unfolding before our eyes right now.
It it were possible to build  this comprehensive multidimensional map of human existence, interesting links and new approaches to cross-disciplinary treatment would begin to emerge.  The technology s here right now. I am sure I am not the only on generating this idea or some variation, so the idea is coming of age.  The financial resources are there, but would need to be redirected which would force a cultural change in values. So what s missing? The only missing element is an army of willing of professionals who are wiling ton take up the challenge. People don’t like change and most people don;t like to take risks. The fear of launching into a new comprehensive paradigm of total  a comprehensive human bio-psycho-social-spiritual-cultural-ecnomic-political profile could open up a whole new environment paradigm and a new way of doing medicine.
This vision is emerging from studying the trends presented by Jeremy Rifkin in his books The end of Work, The Third Industrial Revolution, and the Zero Marginal Cost Society. tThe world is well into the information age that allows us to do things that seemed impossible just two decades ago.  
It is interesting to see the emerging correlations between brain function and such diverse areas as behavior, stress, personality, addiction, violence, interpersonal communication, individual and collective problem solving, and mental health disorders. Looking at these relationships  raise a very old question: does the physical brain or the non-physical mind determine our ability to control our behavior or does behavioral control result from the proper use of the non-physical mind?
There is another factor pushing the process in the information age. Health care is becoming patient driven as the internet provides readily available and scientifically valid descriptions of symptoms, illnesses, medications, and other treatment modalities. The mutual support groups starting with 12-Step programs are expanding through the internet to include high level patient collaboration and even patient initiated studies. Relatively inexpensive websites with smart bulletin boards organizes and sort information into categories to give a bigger picture that could have ever been seen before.

The answer, of course, is yes! At different times the survival responses of the brain (fight, flight, freeze) plus our deeply conditioned habits take over control and we do things we either are not aware of that, in spite of our awareness, we would prefer not to do. (Have you ever had your mouth take on a life of its own during an argument?). At other times we make conscious rational choices governed by the lifestyle we live and the people places and things we choose to associate with.

Today we are coming to the end of a failed paradigm that the physical brain is all that there is. All of the accomplishments and tragedies of mankind ia causes  by a clump of cells that accidentally at some point became self-aware.  Everything is pointing to a non-physical mind that inhabits and works with the physical brain to allow human beings to survive, thrive, maintain health, manage illness and keep moving forward with courage in to an uncertain future.



Using Stress Management In Relapse Prevention Therapy (RPT)

August 3, 2014

thBy Terence T. Gorski, Author

This blog is an excerpt from the book:

Starting Recovery With Relapse Prevention
by Terence T. Gorski. 

November 10 -14, 2014 at the Hyatt Regency Pier Sixty Six

2301 SE 17th Street Causeway, Fort Lauderdale, FL 3331
Iinformation: Tresa Watson: 352-596-8000,
Course Description:

Stress management is a critical key to staying away from alcohol and other drugs[i] [ii]during the critical first two weeks of recovery.[iii] It is important for people in recovery to learn how to recognize their stress levels and use immediate relaxation techniques to lower their stress. [iv] [v]

Recovering people are especially vulnerable to stress.[vi] There is a growing body of evidence that many addicted people have brain chemistry imbalances that make it difficult for them to manage stress in early recovery. The regular and heavy use of alcohol and other drugs can cause toxic effects on the brain that create symptoms that cause additional stress and interfere with effective stress management.

Stress Self-Monitoring and Relapse ,
The CENAPS Model and Mindfulness in Relapse Prevention,  and
Mindfulness Made Simple.

Many people who are in recovery from addiction have serious problems with Post Acute Withdrawal (PAW). PAW is a bio-psychosocial syndrome that results from the combination of brain dysfunction caused by addictive alcohol or drug use, and the stress of coping with life without drugs or alcohol. PAW is caused by brain chemistry imbalances that are related to addiction. PAW disrupts the ability to think clearly, manage feelings and emotions, manage stress, and self-regulate behavior.

PAW is stress sensitive. Getting into recovery causes a great deal of stress. Many recovering people never learn to manage stress without using alcohol or other drugs. Stress makes the brain dysfunction in early recovery get worse. As the level of stress goes up, the severity of PAW symptoms increase. As PAW symptoms get worse, recovering people start losing their ability to effectively manage their stress. As a result, they are locked into constant states of high stress that cause them to go between emotional numbness and emotional overreaction. Since high stress is linked to getting relief by self-medicating stress with alcohol or other drugs, high stress gets linked with the craving for alcohol or other drugs. So one of the first steps in managing craving is to learn how to relax and lower stress without using alcohol or other drugs.

The severity of PAW depends upon two things: the severity of brain dysfunction caused by addiction and the amount of stress experienced in recovery. The first two weeks of recovery is the period of highest stress in recovery. This high stress occurs before you have a chance to learn how to manage it in a sober and responsible way. Since you cannot remove yourself from all stressful situations, you need to prepare yourself to handle them when they occur. It is not the situation that causes stress; it is your reaction to the situation.

According to the National Institute on Drug Abuse, exposure to stress is one of the most powerful triggers for relapse to substance abuse in addicted persons, even after long periods of abstinence. Stress can cause a problem drinker to drink more, a person using prescription medication to use more than prescribed, and an illicit drug user to get more deeply involved in the drug culture than they could ever imagine. The high stress of the first two weeks of recovery can activate powerful cravings that make people want to start self-medicating with alcohol or other drugs in spite of their commitment to stop and stay stopped.

There is a simple tool called The Stress Thermometer that can help you to learn how monitor your stress. There is a simple immediate relaxation technique called Relaxed Breathing that can help you noticeably lower you stress in two to three minutes. First, let’s talk about the Stress Thermometer.

The Stress Thermometer

The Stress Thermometer is a self-monitoring tool that teaches people to become aware of their current stress levels, notice increases and decreases in stress at different times, and encourages the use of immediate relaxation techniques to lower stress as soon stress levels begin to rise. The Stress Thermometer makes it possible to manage stress before craving for alcohol or other drugs is activated. Lowering stress can also lower cravings. Lowering cravings can help you to turn off denial and addictive thinking. (More about this later).

The concept of using a stress thermometer came from thinking about how we use a temperature thermometer to measure our body temperature. When we take our body temperature we use a thermometer to tell us accurately and objectively what our body temperature is. When we use a stress thermometer, we use a system for self-monitoring our stress levels that can tell us accurately and objectively how high our stress levels are.

The stress thermometer is divided into four color-coded regions: blue – relaxation, green – functional, yellow – acute stress reaction, and red – trauma reaction.

What the Stress Levels Mean

Low Stress/Relaxation: Stress levels 1, 2, and 3. These stress levels are coded blue because they are cool and relaxing.

  • Stress Level 1: Deeply Relaxed/Nearly Asleep: At Stress Level 1 you are in a state of deep relaxation and nearly asleep. Your mind is not focused on anything in particular and you feel like you are waking up in the morning to a day off and can just let your mind drift in the deeply relaxed state.
  • Stress Level 2: Deeply Relaxed/Not Focused: As you come back from a state of deep relaxation you enter Level 2, during which you stay very relaxed, but begin to notice where you’re at, what is going on around you. You can stay in that state and just be aware and deeply relaxed. Eventually we will either go back down to Level 1 and then perhaps falls asleep or else you will move up to Stress Level 3.
  • Stress Level 3: Deeply Relaxed/Focused:At stress level 3 you get focused and start to think about getting yourself back into gear and getting going. In other words, you are getting ready to “kick-start your brain” so you can move into a functional stress level to begin getting things done.

By practicing the Relaxed Breathing Technique (this will be explained on page 19) most people can learn to put themselves in a relaxed state (Stress Level 1, 2, or 3), stay there for a few minutes, and then come back feeling refreshed and relaxed. It is important to remember that this will take time and practice. In our culture people are taught to work hard and burn themselves out. People don’t get much training on how to relax. People who get a euphoric effect from using alcohol or other drugs don’t need to. When they get the “right amount” in their system they shut down their stress chemistry, turn on the pleasure chemistry, and feel relaxed.

It is important to practice relaxation four times per day. I recommend linking it to meals: Take five minutes in the morning before breakfast, five minutes at lunch, five minutes at dinner, and five minutes to relax before going to sleep. Taking these stress breaks will make it easier for you to stay at a functional stress level and bounce back quickly from high stress situations.

With that in mind, let’s look at the “Functional Stress levels.”

Functional Stress: Stress levels 4, 5 & 6 designate the zone of functional stress. They are coded green because green is a color that represents “go”.  At stress levels 4, 5, and 6 we are experiencing stress levels that are high enough to give us the energy to get started, keep going, and get things done. The stress, however, is not so high that in interferes with what we are doing.

  • Stress Level 4: With effort we get Focused and Active.
  • Stress Level 5: We operate at high performance, a state of free flow with little or no effort.
  • Stress level 6: We can keep on going but it takes effort and we notice we are getting tired. It’s called free flow with effort. This is a good time to take a short break if you can to get your stress level back down to a level five.

Acute Stress Reaction: Stress levels 7, 8, and 9 are coded yellow. The color yellow represents caution. At stress levels 7, 8, and 9 we are experiencing an acute stress reaction. The word “acute” means immediate and severe. The good thing about acute stress is that if we notice it early and know how to relax, by taking a short break and using a relaxed breathing technique for example, we can lower our stress and get back into the functional zone. When we enter stress level 7 it means that our immediate levels of stress have gotten so high that we can’t consistently function normally. We’re in danger.

  • Stress level 7: Space Out: at a stress level 7 we space out. Our mind goes somewhere else and we don’t even know we were gone until our mind comes back on task.
  • Stress level 8: Driven and Defensive: at stress level eight we are driven and defensive. Our stress chemical has been activated and we are running on an adrenaline rush that is keeping us compulsively on task. The problem is that if someone or something interrupts us we become defensive and can easily move into stress level 9.
  • Stress level 9: Overreaction/Survival Behavior: at stress level 9 our automatic survival behavior takes over. The three basic survival behaviors that everyone has are: fight (irritated, angry, agitated); flight (anxious, fearful, panicked); and freeze (we feel an agitated sense of depression and indecision. We freeze up and can’t make a decision or move.) On top of these three core survival behaviors we learn more sophisticated survival behaviors from our family of origin, life experiences, education or special training in stress management, emergency management, martial arts, or combat. For that training to automatically come into play, we must have practiced it over-and-over again until it became habitual. In sports, emergency services, police work, and military operations these are called trained response. When our stress hits level ten our brain won’t allow us to rise to the situation. The emergency brain response will always lower us to the level of our training. In an emergency, all we can rely on are our automatic responses that we learned to perform on cue without having to think about it.

Traumatic Stress Reaction: Stress levels 10, 15, and 20 are coded red. Red is for stop. At this point our stress levels are so high that our brains and minds are at risk of shutting down. There are three levels of stress that can occur in the red zone of traumatic stress.

  • Stress level 10: Loss of Control: We automatically start using our survival behavior and we can’t control it. We are on automatic pilot and we will go through our learned survival responses one-by-one. This means we will cycle through stages of extreme anger (fight), extreme fear (flight, and extreme inner conflict or ambivalence (freeze). It is important to remember that all people with serious alcohol and drug problems have conditioned themselves with a survival behavior called “seek and use drugs to handle this.” So it is not unusual for a person at a stress level ten to get into drug seeking behavior and start using alcohol or other drugs.
  • Stress level 15: Traumatic Stress: At level 15 our high stress overloads the brain and we mentally disconnect from what is happening to us. Our stress is so high that we can’t stay consciously connected with out bodies. We may go into a state of daze, shock, and dissociation. Our mind can start to play tricks on us and things around us may seem bigger, or closer or farther away than they really are. We may start feeling confused and disoriented. It may seem like we are moving in slow motion. Some people feel like they have floated out of their bodies and it seems like they are watching themselves go through the experience.
  • Stress level 20: Collapse/Psychosis: When our stress levels hit a level 20 our brains can’t take the high level of stress and fatigue. We may collapse, enter an exhausted state of stupor or restless sleep, move into a vivid fantasy world or a world of memories or dreams, or become unconscious.

Any time people experience a “level 10 plus” state of stress; it will take a while after the stress stops for our brain to start functioning normally. When this is a short-term period of adjustment it is called an “acute trauma reaction.” When in it is a longer-term reaction it is called post traumatic stress disorder.

If you have ever experienced a “level 10 plus” stress experience – which can happen when you are the victim of crime, accidents, caught in a burning house, participating in combat, having been assaulted, etc. – it is important to discuss these experiences with your doctor or therapist. This is especially important if the high stress experience you had causes problems that you did not have before it occurred.

The Stress Thermometer

Developed By Terence T. Gorski (© Terence T. Gorski, 2011);;

Level 20: Dissociation/Unconsciousness: I get dissociated and feel like I am floating out of my body. Things seem unreal, and I eventual pass out.
Level 15: Traumatic Stress: Stress overloads the brain and we go into a state of daze, shock or dissociation. We may feel like we are floating out of our bodies and watching ourselves go through the experience.
Level 10: Lose Control: Fight = Anger-based, Flee = Fear-based, Freeze = Depression-based.
——————————–The Brain Shift Gears ——————————–
Level 9: Overreact: Anger, fear, or compulsion get out control & starts running our intellect.
Level 8: Get Defensive: Automatic defenses are used; we start acting out compulsively. The ability to think becomes a servant to hidden fear, anger, & depression. Strong craving and urges to fight, run, hide, find a rescuer, blame others, or lose motivation & hope.
Level 7: Space Out: My brain can’t handle the stress, turns off for a second, and I gone blank and don’t even realize it until my brain turns back on a few seconds later.
——————————– The Brain Shift Gears ——————————–
Level 6: Free Flow Activity With Effort I’m getting tired and have to push myself to keep going.
Level 5: Free Flow Activity With No Effort: I’m totally into what I’m doing and get lost in the process. I’m on automatic pilot.
Level 4: Become Focused and Active With Effort: I make a decision to dig in and get to work. It takes an effort to get started.
——————————– The Brain Shift Gears ——————————–
Level 3: Relaxed – Aware But Not Focused: I’m relaxed and aware of what’s going on around me. I’m beginning to realize that I need to get going.
Level 2: Very Relaxed – Not Aware & Not Focused: I’m so relaxed that I’m not aware of what’s going on around me. I’m disconnected and don’t want to notice anything.
Level 1: Deeply Relaxed – Nearly Asleep: I’m so deeply relaxed that I’m drifting in and out of a dreamy type of sleep state filled with active fantasy or daydreaming.
The Most Important Stress Management Tool is
The Conscious Awareness of the Rise and Fall of Your Stress Levels.
This is Achieved Through Self-monitoring.


Measuring Levels of Stress

Notice that you are measuring your personal perception of stress, which is a combination of three things: (1) the intensity of the stressor (the situation activating stress); (2) your ability to cope with or handle the stressor; and (3) your level of awareness while you are experiencing the stress.

It is possible for you to score yourself very low on the stress thermometer even when your stress is very high. This can happen because: (1) you are distracted and involved in something else (like managing the crisis causing your stress); (2) your stress is so high that you are emotionally numb and don’t know what you are feeling; (3) if you have lived with such high stress for such a long time that you consider it normal; and (4) you have trained yourself to ignore your stress.

The first step in learning how to manage your stress is to learn how to recognize and evaluate your level of stress and by learning how to quickly get back into a low stress level by using a Relaxed Breathing Technique. Let’s start by looking at how you can improve your stress awareness.


Improving Stress Awareness

The best way to learn to be aware of your stress level is to get in the habit of consciously monitoring your stress level. You can do this by using a mental tool called The Stress Thermometer, (page 17). The first step is to imagine that you have an internal stress thermometer that starts in the pit of your stomach and ends in your throat. The lowest reading on the stress thermometer is zero and represents a deep sense of relaxation that is so complete that you want to fall asleep. At a stress level seven or eight, your stress becomes so intense that you start shutting down, getting defensive, or avoiding the issue that is causing the stress. If you can’t manage or get away from the stressful situation, at a level ten you lose control and start believing that you can’t handle the situation and that you or someone you love may be hurt or killed. These extreme feelings of stress are called trauma.

When most people hit a stress level of seven or higher they are not able to respond to constructive criticism or to make sense out of their emotional experiences. At stress levels between seven and nine most people start acting compulsively, overreact to things going on around them, and start using automatic habitual survival behaviors that may or may not solve the problem and lower stress.

This is why it is so important for you to learn to recognize your stress levels when they start hitting a level seven and learn how to quickly lower them. You can do this by using an immediate relaxation response technique called Relaxed Breathing any time you notice your stress hitting a level seven or above. So you have four goals in this exercise:

(1)        To learn how to get into the habit of noticing when your stress is getting up to a level seven or eight;

(2)        To learn how to quickly lower your stress by using the Relaxed Breathing Technique;

(3)        To figure out what is happening and how you are thinking and feeling about what is happening that is causing your stress to go up; and

(4)        Manage the stressful situation by responsibly getting out of the situation or learning how to manage your thoughts, feelings, and behaviors that will allow you to stay cool and relaxed even tough you are in a tough situation.

Monitoring Your Stress – Body Awareness

Body awareness is a technique that allows you to recognize how your body physically reacts to stress. It can be a powerful skill to use in stress management because as you notice the stress in different parts of your body, you will start to relax the part of the body you are noticing. With enough practice your body will automatically start identifying and releasing stress before you become consciously aware of it. Muscle tension is the primary way your body let’s you know that you are experiencing stress. Consciously using a systematic body awareness technique whenever you think about it and at least four times per day will start you on the road to teaching your body to automatically recognize and release stress. Here’s how the technique works:

Begin by closing your eyes. You will concentrate on one muscle group at a time, tensing and releasing and being aware of how tight the muscle is as you focus on it. If the muscle feels tight as you begin, this may indicate you store stress in this muscle. Begin with focusing on your toes and slowly move up your body. Tighten your toes and release, flex your calves and release, tighten your thighs and release, tighten your stomach muscles and release, fist your hands and release, tense your shoulders and release, clench you jaw and release, squint your eyes and scrunch your face and release. Any time you encounter tension in a muscle, record that muscle tension and be aware that you are holding stress there. This will help you in developing a personal stress reduction plan and using exercises and techniques to release pent-up tension.

Reducing Your Stress – Relaxed Breathing

There are a number of different relaxation methods. For the purpose of this workbook I am going to teach the easiest and most effective. It is called Relaxed Breathing. It is so effective that military, police and firefighters are taught to use it to lower their stress when responding to emergencies. Here’s how it works:

Relaxed Breathing, often called combat breathing in the military or tactical breath by police and emergency responders, is designed for both before and during stressful times to calm you down and help you relax. In terms of the stress thermometer, relaxed breathing is used before a stressful situation to calm you down and get you ready to be at your best. It is used during a stressful situation to keep your stress from going above that critical Level 7, where your brain turns off and automatic defensive behavior and cravings kick in.

Early in recovery, thinking about and talking about your use of alcohol or other drugs will cause some of your highest stress. The catch 22 is this – if you don’t talk about it, the thoughts will keep coming back like a ghost in the night that haunts moments that should be quiet and restful. Each time you expel the ghost by refusing to think and talk about the “real problems” the ghost goes away for a little while and comes back stronger. Your denial and resistance is strengthened, the intensity of your craving goes up, and your ability to think rationality about what you need to do goes down. As a result the voice of this “stress ghost” grows into a full-blown “stress monster” that can literally take your brain hostage and make you believe that self-medication with alcohol or other drugs is the best or only way to get back in control of yourself and your life.

Step 1: The first thing you need to do is to convince yourself that you can manage and reduce stress without having to self-medicate. There is another way. That way involves learning how to control your breathing.

Step 2: Practice relaxed breathing in a safe environment when you are not stressed. Just go through the steps and get used to them.

Step 3: Get used to rating your stress level. Initially you may need to use the stress thermometer, but with a few times of practice (four times per day for three or more days) the use of the scale will be an automatic tool that you will use whenever you check out you stress level.

Step 4: Take control of the process by stressing yourself out and then relaxing yourself using the relaxed breathing technique.

Sit in a quiet place where you will not be disturbed for ten or fifteen minutes. Take a deep breath and do a quick body checks. Then on a sheet of paper write the word START and underneath or next to it rate your stress level.

For example, I would do a body check and write: START = 6. I am still relaxed and able to think and respond, but I am tired and on the edge of spacing out.

Step 5: Stress yourself out! Your heard what I said. Think about the things you usually think about that raise your stress. Be sure to beat yourself up about your drinking and drugging, how stupid you were, the problems it has caused and how you will never-ever be able to repair the damage you have done to your life. Stop the process before your stress hits a level 9 or 10 and you go running out of the room. Then write the words: AFTER STRESS and rate your stress level. Most people find it easy to raise their stress.

For example, after beating myself up for about 60 seconds I would write: AFTER STRESS = 8. I feel myself driving myself and notice the thoughts start to take on a life of their own. If someone interrupts me at this moment I could easily over-react.

Step 6: Relax yourself! You heard me. Do what you need to do to relax. This is the problem for many people, especially people who use alcohol, prescribed medication, or other drugs regularly and heavily. They can stress themselves out easily enough, but other than self-medication they have no way to calm themselves down. So try this:

Take a deep breath and hold it for a moment until your lungs feel just a little uncomfortable, hold your breath for a moment, and then exhale all the way out. Hold your breath for a moment with your lungs empty and then slowly inhale again. Start to breath a slow rhythmic count of four: “INHALE– two- three – four; HOLD – two – three – four; EXHALE – two – three – four; HOLD – two – three – four. Then start the cycle over by inhaling to the count of four. Repeat the cycle five times. Imagine the stress gathering in your lungs as you inhale and hold. Imagine the stress releasing from your mouth as you exhale and hold. That’s it.

Now rate your stress again. Look at the stress thermometer and see what happened. Then write the words: AFTER followed by your stress rating.

For example I would write: AFTER RELAXING = 4 (remember I’ve been practicing a long time). So the record of my session looks like this:


Don’t force yourself to relax, just do the relaxed breathing, and focus on counting and imaging the stress leaving your body ever time you exhale.

Practice four times per day, at breakfast, lunch, dinner, and before bed. Keep track of your progress. Use relaxed breathing if you notice your stress going up during any of the following exercises.


[i] Stress and increased Relapse Risk: Stress is an important factor known to increase alcohol and drug relapse risk. This paper examines the stress-related processes that influence addiction relapse. First, individual patient vignettes of stress- and cue-related situations that increase drug seeking and relapse susceptibility are presented. Next, empirical findings from human laboratory and brain-imaging studies that are consistent with clinical observations and support the specific role of stress processes in the drug-craving state are reviewed. Recent findings on differences in stress responsivity in addicted versus matched community social drinkers are reviewed to demonstrate alterations in stress pathways that could explain the significant contribution of stress-related mechanisms on craving and relapse susceptibility. Finally, significant implications of these findings for clinical practice are discussed, with a specific focus on the development of novel interventions that target stress processes and drug craving to improve addiction relapse outcomes.

  • Reference: The role of stress in addiction relapse. Curr Psychiatry Rep.  2007; 9(5):388-95 (ISSN: 1523-3812) Sinha R. Department of Psychiatry, Yale University School of Medicine, 34 Park Street, Room S110, New Haven, CT 06519, USA
  • Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of theses factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal

[ii] Stress Identification and Management: Stress as verified by clinical observations, patient self-reports, and subjective and behavioral measures have been correlated depressive symptoms, stress, and drug craving during withdrawal. All of these factors predict future relapse risk. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

[iii] The Role of Stress In Addiction: Both animal and human studies demonstrate that stress plays a major role in the process of alcohol and drug addiction and that a variety of stressors can increase both self-reported stress and measures of biological stress. Among neural measures, brain atrophy in the medial frontal regions and hyperreactivity of the anterior cingulate during withdrawal were identified as important in drug withdrawal and relapse risk. This study suggests that stress management would be helpful in preventing relapse especially during the period of withdrawal.

Reference: New findings on biological factors predicting addiction relapse vulnerability. Curr Psychiatry Rep.  2011; 13(5):398-405 (ISSN: 1535-1645) INTERNET:

[iv] Stress and Addiction: Stress plays a major role in the process of drug addiction and various stressors are known to increase measures of craving in drug dependent human laboratory subjects. Animal models of stress-induced reinstatement of drug-seeking have also been developed in order to determine the neuropharmacological and neurobiological features of stress-induced relapse.

  • Reference: Pharmacologically-induced stress: a cross-species probe for translational research in drug addiction and relapse. Am J Transl Res.  2010; 3(1):81-9 (ISSN: 1991) See RE; Waters RP. Department of Neurosciences, Medical University of South Carolina, Charleston SC USA.

[v] Stress-Induced Craving and Cognitive Behavioral Therapy: The Division of Clinical Neuroscience, Medical University of South Carolina, Charleston, South Carolina 29425, USA. ( has found that stress-induced craving and stress reactivity may influence risk for substance use or relapse to use. Interventions designed to manage stress-induced craving and stress reactivity may serve as excellent adjuncts to more comprehensive treatment programs. The purpose of this study was to (1) tailor an existing, manualized, cognitive-behavioral stress management (CBSM) intervention for use in individuals with substance use disorders and (2) preliminarily evaluate the effects of the intervention using an experimental stress-induction paradigm. Twenty individuals were interviewed and then completed a psychological stress task, the Mental Arithmetic Task (MAT). After this, participants were assigned to either the CBSM intervention group or a non-treatment comparison group. Approximately 3 weeks later, participants completed a second MAT. In contrast to the comparison group, the CBSM group demonstrated significantly less stress-induced craving (p<.04) and stress (p<.02), and reported greater ability to resist urges to use (p<.02) after the second MAT. These findings are among the first to report on the use of an intervention to attenuate craving and stress reactivity among individuals with substance use disorders. Although preliminary, the findings suggest that systematic investigation of interventions specifically targeting stress management in individuals with substance use disorders should be undertaken.

  • Reference: Source: Back SE, Gentilin S, Brady KT. Cognitive-behavioral stress management for individuals with substance use disorders: a pilot study J Nerv Ment Dis. 2007 Aug;195(8):662-8

[vi] Research Society On Alcoholism: This report of the proceedings of a symposium presented at the 2004 Research Society on Alcoholism Meeting provides evidence linking stress during sobriety to craving that increases the risk for relapse. The initial presentation by Rajita Sinha summarized clinical evidence for the hypothesis that there is an increased sensitivity to stress-induced craving in alcoholics. During early abstinence, alcoholics who were confronted with stressful circumstances showed increased susceptibility for relapse. George Breese presented data demonstrating that stress could substitute for repeated withdrawals from chronic ethanol to induce anxiety-like behavior. This persistent adaptive change induced by multiple withdrawals allowed stress to induce an anxiety-like response that was absent in animals that were not previously exposed to chronic ethanol. Subsequently, Amanda Roberts reviewed evidence that increased drinking induced by stress was dependent on corticotrophin-releasing factor (CRF). In addition, rats that were stressed during protracted abstinence exhibited anxiety-like behavior that was also dependent on CRF. Christopher Dayas indicated that stress increases the reinstatement of an alcohol-related cue. Moreover, this effect was enhanced by previous alcohol dependence. These interactive effects between stress and alcohol-related environmental stimuli depended on concurrent activation of endogenous opioid and CRF systems. A.D. Lê covered information that indicated that stress facilitated reinstatement to alcohol responding and summarized the influence of multiple deprivations on this interaction. David Overstreet provided evidence that restraint stress during repeated alcohol deprivations increases voluntary drinking in alcohol-preferring (P) rats that result in withdrawal-induced anxiety that is not observed in the absence of stress. Testing of drugs on the stress-induced voluntary drinking implicated serotonin and CRF involvement in the sensitized response. Collectively, the presentations provided convincing support for an involvement of stress in the cause of relapse and continuing alcohol abuse and suggested novel pharmacological approaches for treating relapse induced by stress.

  • Reference: George R. Breese, Kathleen Chu, Christopher V. Dayas, Douglas Funk, Darin J. Knapp, George F. Koob, Dzung Anh Lê, Laura E. O’Dell, David H. Overstreet, Amanda J. Roberts, Rajita Sinha, Glenn R. Valdez, and Friedbert Weiss. Stress Enhancement of Craving During Sobriety: A Risk for Relapse, Alcohol Clin Exp Res. 2005 February; 29(2): 185–195.

See the related blog: Stress Self-Monitoring and Relapse

Stress Management Is Used In The Gorski Relapse Prevention Certification School (RPCS)

Relaxation Training and Mindfulness Meditation are a big part of Relapse Prevention Therapy (RPT). When patients are under high levels of stress, their ability to understand, integrate, and use new skills is diminished. Gorski RPT teaches therapists how to use a form of immediate relaxation training to keep clien’s stress low during the session. It also teaches them to use relaxation methods in the moment so they are more likely to use them in real-life events. For an overview of how relaxation training and a simple tool called the stress thermometer can be used with RPT check out Terry Gorski’s Blog:

November 10 -14, 2014 at the Hyatt Regency Pier Sixty Six

2301 SE 17th Street Causeway, Fort Lauderdale, FL 33316
For further information: Tresa Watson: 352-596-8000, 

Stress Self-Monitoring and Relapse ,
The CENAPS Model and Mindfulness in Relapse Prevention,  and
Mindfulness Made Simple.

Hitting Bottom and Detaching With Love

April 30, 2014
Up From Mud

Drowning In The Mud Of Addiction

By Terence T. Gorski, Author

People tend to get sober in their own time and in their own way. The world is loaded with codependents who destroyed their lives trying to get the addict they loved into recovery. Despite decades of perfecting the technique, professional interventions only result in the addict entering treatment in 80% of the cases. Sometimes the attempted intervention has the reverse effect, driving the addict farther away and deeper intone their addictive lifestyle.

Much of what we call “hitting bottom” or “getting sick and tired of being sick and tired” results from a chance convergence of immediate undeniable problems coupled with the offer of hope and a concrete opportunity to recover.

This doesn’t mean that you should not attempt to intervene with addicts you love. It just means that it is best to view intervention as an ongoing process of honest communication. These honest talks need to come from a posit of detached love. Active addicts are expert at detecting and thwarting the efforts of codependent who try, with the best of intentions, to control and manipulate them.

The most important rules in dealing with someone who is addicted are these:

  • Ÿ Get clear about what you will and will not tolerate and then set limits.
  • Ÿ Never make promises or threats that you are not willing or able to do.

Here are some more ideas to think about if someone you know and love is actively addicted: Keep loving them.

1. Keep loving them.

2. Remember their addiction is not about you.

3. Every addict has “teachable moments” but they are few and far between.

4. Choose carefully when you try to talk about getting help. In the aftermath of undeniable consequences when the person is sober and feeling remorseful is often the best time.

5. Work your anger out with your own therapist. Getting made at an addict just gives them the excuse to not take you seriously.

6. Detach with love. This means keep loving an caring but stop giving them resources that allow them to keep drinking and drugging.

7. Give them information about addiction and treatment/recovery resources.

8. Tell the truth and set clear boundaries calmly and firmly.

9. Remember, getting well is and always will be their choice. You can just make the choice easier by removing any support for their addiction and refusing to accept or enable any unacceptable behavior.

10. Loving an addicted family member is hard. It can make you a sick and codependent. Put yourself first. If you allow the addict to destroy you, it will make you part of the problem instead of being part of the solution.

The most important rules in dealing with someone who is addicted are these:

  • Ÿ Get clear about what you will and will not tolerate and then set limits.
  • Ÿ Never make promises or threats that you are not willing or able to do.

Ÿ Be consistent. Your behavior needs to be the stable point on the map of sober and responsible living.

These three rules are easy to understand buy incredibly difficult to put into action. So learn to be gentle with yourself. You wont be able to do it perfectly and you don’t need to.

Living with an addict is painful. So is setting boundaries and following through no matter what. Most of us need help and support to figure out what to do and to stand firm in the face of the out-of-control addiction of someone you love. It will take time and emotional work on your part to get prepared to detach with love while pointing the addict toward treatment/recovery resources. Don’t worry. The addiction probably won’t go away while you are learning to deal with it in ore effective ways.

It is hard detaching from an actively addicted person. There will come a point, however, when they will use any action you take as a part of their rationalization to keep using. Don’t take it personally. It is just what addicts do to everyone and anyone who tries to help.

Addicts do recover. They usually do it in their own time when the perfect storm of consequences start sinking their ship and the only rescue helicopter in sight is a recovery program.

This is a very difficult disease to have and just as difficult to live with.

If you are in recovery, don’t abandon those you love. When you get sober, please be aware that your friends and family may need not just your amends, but your help to get their health and their lives back.

Recovery is not just about the addict. It is about everyone who is affected by the addiction.

Check out Alanon and find a therapist knowledgeable in codependency.


Gorski Books

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 or


Getting Love Right – Learning The Choices Of Healthy Intimacy

January 5, 2014

We Can Learn The Choices
Of Healthy Intimacy

By Terence T. Gorski, Author
September 10, 2003

Men, Women and the Search For Wholeness

According to ancient Greek mythology, human beings were originally created with each individual have both sexes, male and female, combined in one person.  They were whole and complete within themselves and lived in a fulfilled state of perfect union.  All human beings were able to meet their own needs without the help of anyone else.

Then humanity angered the gods.  The gods punished humanity by cutting each person in half. One-half became male and the other half became female.  The gods then cursed human beings for the rest of their existence to try to become whole again by putting themselves back together .

On a fundamental level, relationships represent a search for that wholeness, a search for completeness and the ability to feel as one with another human being.  In many ways, this striving for unity with another person is a fool’s game.  Ultimately, it is impossible to merge and stay merged with another human being.  At best, we can find moments of completion, moments of closeness and oneness.  But then what happens?  We always come back to the reality that I am me and you are you–that we are two separate individuals.

Yet, like all myths, there is a measure of truth to this one, too.  When we get love right, the me and the you together become us, an entity that makes the two of us together stronger than we ever could be alone.  The me and the you still remain as separate entities, however, side by side with us.

The Three Players In Intimate Relationships – Me, You, and Us

So the question becomes, given the reality that I am me and you are you, how can we come together and build a relationship that creates this better us?  How do we go about developing relationships that can meet our needs for wholeness and fulfillment?  It is not simple, but it can be done.  We can learn to share our life with another person in a way that enhances rather than diminishes who we are.  It is possible to get love right.

This book will demonstrate the step-by-step process involved in building and maintaining a healthy relationship.  It will enable you to understand the origins of your relationship patterns, show you how to analyze them and identify alternative behaviors so you can replace dysfunctional patterns with healthy patterns.

If you are single, Getting Love Right will help you learn how to develop into the kind of person who is capable of a healthy relationship; how to select an appropriate partner who can meet your needs; and how to guide your relationship through different levels and stages.

If you are currently in a relationship, Getting Love Right will teach you how to transform that relationship.  It will provide information and assessment tools that will enable you to evaluate your present relationship and identify areas for growth. It will give you the techniques to problem solve in a productive way and undertake a fundamental relationship renegotiation with your partner.

Deciding on Healthy Love

Many people experience problems in relationships because they hold mistaken beliefs about the fundamental nature of love. We have been taught since childhood to believe that love is a mysterious phenomenon beyond our control.  Just look at the way we talk about it.  We “fall” in love, sometimes “head-over-heels.”  We say she “stole his heart,” or “he lost his heart” to her.  Cupid shoots his arrow and we are powerless to resist.  All these are ways in which love and relationships have traditionally been mythologized.  These myths tell us that love comes into our lives suddenly through little or no choice of our own.  No wonder we are confused about how to achieve a lasting, fulfilling relationship.

Love is a decision we make
based on essential choices about
ourselves, our partner, and
our relationship.

        Healthy love is not an accident.  Nor is it a temporary feeling that comes and goes.  Love is a decision we make based on essential choices about ourselves, our partner, and our relationship.  While healthy love is often profound and passionate, we can build it into our lives step by step, one choice at a time.

To get love right, therefore, we need to revise our concept of love as some romanticized ideal and understand a relationship for what it is:  an agreement between two people to meet each other’s needs and to have their own needs met in return.

Three Relationship Errors

1.  Expecting too much from a relationship

2.  Expecting too little from a relationship

3.  Expecting a relationship to remain unchanged

Some people expect too much from a relationship.  They hold onto the belief that the right partner or the right relationship can magically fix them and free them from taking responsibility for their lives.  They expect a partner to have the ability to instantly make them feel better on demand.  As a result, they are constantly disappointed.  They experience cycles of intense highs, when the relationship seems to be going well, and intense lows, when it fails to meet their unrealistic expectations.

Other people expect too little from a relationship. They are so sure they can never feel whole and complete with another human being that they never give themselves the chance to have their needs for love and intimacy met.  They equate intimacy with pain and do everything they can to insulate and protect themselves from it.  They do not know that there are two kinds of pain: pathological pain that comes from dysfunctional, unsafe relationships and the healthy pain of growth in normal intimate relationships.

Still others may have found a satisfying relationship, but then make the mistake of expecting it to stay the same year after year.  They don’t realize that relationships are not a one-time event, but an ongoing process.  As time goes on, both partners need to continue to talk and problem solve together, and, when necessary, renegotiate the terms of the relationship so that it stays current with their needs.

Healthy Relationships:  Passion and Safety

Healthy relationships meet our needs for both passion and safety.  Dysfunctional relationships, by contrast, represent extremes in which only one or the other exists.  People who expect too much from relationships seek passion.  Unfortunately, they almost always give up safety in the process and end up being hurt.  People who expect too little from relationships choose safety over passion.  They often lose the chance to have their needs for intimacy and passion met.

Healthy partners know that passion and safety can coexist in healthy relationships, because these relationships are rational, flexible, and safe.

Healthy relationships
Are rational, flexible, and safe.

Healthy relationships are rational because you choose them. You choose the type of relationship you’re ready for.  Then you choose to become a person capable of being in a healthy relationship.  You select your partner on the basis of a variety of characteristics and choose the rate at which the relationship develops.  Ultimately, you and your partner choose whether to continue the relationship or to end it.

Built in this way, a relationship becomes a series of choices, all of which have logical consequences.  If you choose as a partner someone who is incapable of meeting your needs, the logical consequence is that your partner and the relationship will not give you what you want.  If you choose a dangerous partner, you can expect to have a dangerous relationship.  If you choose a healthy, compatible partner who is capable and willing to meet your needs, it is logical to expect that you will have a compatible relationship in which your needs are met.

Healthy relationships are also flexible.  They operate on a variety of levels, depending upon the needs of the partners. Sometimes they may be very exciting and intense.  Other times they will be very relaxed and comfortable, even boring.  Such relationships allow each partner to be flexible:  You can be together as a couple or alone as individuals, according to the situation and your preference.  You are not forced to be strong all the time; you are not forbidden to be strong.  The flows of give and take enables you to be both strong and weak, to be yourself.  This flexibility means you can be accepted as a fallible person who will make mistakes and who, in turn, is willing to accept the mistakes of your partner.

Finally, healthy relationships are safe.  No matter how committed you are to the relationship, no matter how much you love your partner, you do not abandon who you are and your partner does not abandon who he/she is.  You don’t lose yourself in your partner or in the relationship.  To stay in the relationship, you may make compromises if necessary, but not at the expense of your own safety or well-being.  Healthy partners do not tolerate abuse and will do whatever is necessary for their own safety, even at the expense of the relationship.

Many people prize spontaneity in their relationships.  They fear that by becoming conscious of the choices they make, going through a rational decision-making process, they will lose the spontaneity and passion that make love exciting.  Fortunately, that is not true.  Choosing safety and making sound choices allow you even greater freedom in your relationships.  Once you know your partner is safe, you are free to give in to your passion and spontaneous desires.  When you are able to communicate openly and honestly about who you are without fear of guilt or retribution, you don’t have to hide from your partner or pretend to be something you are not.  You are free to be yourself and know deep down that your partner will love and accept you.

Becoming a Choice Maker

Once you understand what healthy relationships are, you can work to create them in your life by becoming a choice maker.  If you come from a dysfunctional family, you may have been taught that choices are all or nothing, yes or no, black or white.  As a result, you may not have learned basic decision-making skills, which include thinking through a number of options and selecting the best on the basis of what you want.  If so, you may find it useful to think of decision-making as a three-step process, outlined in the following questions.

1.         What choices do I have?  First, you need to identify the options you have to choose from and the likely consequences of each.  This will help you see that, in most cases, your choices are not black and white, but include a range of options. In examining the likely consequences of a particular option, you may discover that what feels good now may not, in the long run, be in your best interest.

2.         What do I need/want?  You need to know yourself well enough to assess your particular needs and wants at this time in your life.  It includes knowing what you’re thinking, what you’re feeling, and what is motivating you to think, feel, and act that way.

3.         Which option is best for me right now?  On the basis of your answers to the first two questions, you can select the option that promises to best meet your unique needs and wants at the present time, knowing that these needs and wants may change over time.

The more you practice this three-step process the more experience you will gain as a choice maker.  The more you apply it to your relationship choices, the more able you will be to get love right.

Decision Making Questions
1.   What choices do I have?
2.  What do I need/want?
3.   Which option is best for me right now?

             In each chapter I’ve identified the principal choices to be considered in that particular area of relationship preparation, building or development.  Chapter discussions will identify various options and give you the information about each to help you choose among them.  As you consider the options available to you, keep in mind the following:

 Most choices are not perfect.  We can rarely get 100% of what we want.  Many times we are afraid to make a decision because we fear making the wrong choice or having to give up one thing for another.  It is important to remember that choices typically involve a tradeoff.  All we can do is strive to make the best choice among the options we have, based on what we know or believe to be true.

Mistakes are unavoidable.  As fallible human beings, we can’t always choose the best option.  Once you accept the fact that you will make mistakes, you can choose to learn from them to make better and better decisions in the future.

Choices are not forever.  Choice making is an ongoing process.  The best option one day may be very different the next. We change, and our needs and wants change, too.  We need to be prepared to reevaluate and, when necessary, renegotiate and alter our decisions.

If you have had relationship problems in the past, healthy change is possible.  It may be, however, that before you can begin to make healthy choices, you need to alter some fundamental aspects of the way in which you go about your relationships. Change is not easy, especially when it requires us to alter deeply ingrained patterns learned in childhood from our parents.

Facts about Relationships
1. Most choices are not perfect
2. Mistakes are unavoidable
3. Choices are not forever

            This book is designed to help you make those changes by giving you the tools you need to alter the way you conduct your relationships and to become a person capable of healthy love. The chapters in this book are designed to give you the concepts and models you need to answer the question, “What are my choices?” 

You can then apply this information to your situation and relationship goals by completing the self-assessment questionnaires in each chapter.  As you evaluate your relationships and the patterns you’ve followed in the past, you can decide what you want to do differently.  The assessments are not designed to tell you what to do, but rather to serve as a mirror to help you understand what is going on in your relationships.  They will give you the information to implement the changes you want on the basis of your options and preferences.  They will help you answer the question:  what do I need and want?

In understanding what this book can do to help you get love right, it is important to discuss what it will not do.  This book will not teach you how to have a perfect relationship.  It will not teach you how to find Mr. or Ms. Right who is going to magically fix you and make all your pain and problems go away. It is not going to teach you how to transform your present relationship into some romanticized soap-opera ideal of love–because ideal love does not exist.  This book is not going to give you an effective relationship overnight–because healthy love is achieved by slow stages.

What it can show you are the processes and the steps involved in finding a healthy partner and building a healthy relationship capable of meeting your realistic needs and wants. It will act as a road map to show you the choice points and options you have that can take you where you want.

Another thing this book will not do is to save you from the responsibility of thinking for yourself or making up your own mind.  You need to decide what kind of relationship you should have to be happy.  There are many choices available.  All this book can do is to show you the skills involved in becoming a healthy choice maker and point out some of the options available, along with the logical consequences that some of those options may have.

This book will not teach you how to have a problem-free relationship, because relationships have problems.  Partners are fallible human beings, and, no matter how much they love one another, they will encounter problems.  What this book can do is to demonstrate concrete skills so that you can effectively practice problem solving with your partner.

Finally, this book will not save you from the pain of loving another human being.  Being in love means you’re going to be hurt.  If you don’t want to get bruised, you don’t want to play football; if you don’t want to fall down, you don’t want to ski. The same is true for relationships:  If you don’t want to get emotionally hurt, you don’t want to be in love.  Why?  Because you’re going to love another fallible human being who is going to make mistakes, who is going to have faults, and who is going to inadvertently hurt you.  You, too, are a fallible human being and you’re going to make mistakes.  You are going to do things that hurt your partner, even if you don’t want or mean to.

What this book can do is to show you how to build a relationship in which pain and disappointment are the exception, not the rule.  It can show you how you can build relationships in which support, love, and mutual respect are the everyday reality, not just the dream.

Healthy relationships are possible.  Through knowing the processes and steps involved in relationship building, learning to make choices, solving problems with your partner, you can replace painful, dysfunctional relationships with healthy relationships in which both passion and safety coexist.  You can learn how to get love right.


Getting Love Right By Terence T. Gorski



Craving & Relapse

December 30, 2013

Craving Hurts

by Terence T. Gorski, Author
December 31, 2013


Addicts often relapse because they are overwhelmed by a powerful sense of craving.  The physiological craving is powerful and, as a result, the issue of craving needs to become a primary concern in preventing relapse—especially during the first 90 to 120 days of recovery.  To responsibly focus upon the issue of craving requires a comprehensive bio-psychosocial model that will help us understand the craving process.

In 1990, I developed a three-stage model for managing craving.  The three stages of craving are:

Stage 1: Set-up behaviors: Ways of thinking, managing feelings, and behaving that increase the risk of having a relapse

Stage 2: Trigger Events:  Events that activate the physiological brain responses associated with craving.

Stage 3: The Craving Cycle:  A series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.

It is important to note that craving is the last step of a three-stage process.  It is self-defeating to focus on the end result, craving, without focusing on the factors that cause the craving.

Recovering people unconsciously set themselves to experience cravings.  The set-up behaviors lower their resistance to craving.  When their resistance is down, they’re vulnerable to trigger events that cause the actual feeling of craving to start.  Once they feel the urge to use, they start using habitual behaviors that amplify or make the craving worse.  This is the craving cycle.  Fortunately, there are prevention and intervention techniques available in this high time of need.

Stage One Set-Up Behaviors

Set-up behaviors are a combination of physical, psychological, and social factors that lower resistance to craving.

Physical Set-ups For Craving

There are five common physical set ups for craving.

1. Brain Dysfunction From Drug Use:  Mind altering drugs damage the brain and leaves recovering addicts physically set up to experience powerful cravings.  The result of this physical predisposition to experience craving is if recovering addicts don’t do special things to avoid craving, they will experience craving.

2. Poor Diet: Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.  Many have coexisting eating disorders that lead to binges on junk food and/or starving for days at a time to deal with the result of weight gain.

3. Excessive Use Of Caffeine And Nicotine: Both caffeine and nicotine of these are low-grade stimulant drugs and increase the likelihood of having a craving.

4. Lack Of Exercise: Aerobic exercise reduces the intensity of craving.  Regular aerobic exercise is a protective factor against craving, especially in the first six to nine months of recovery.  Not doing aerobic exercise on a regular basis sets the stage for craving.

5. Poor Stress Management: When recovering people don’t manage stress appropriately in recovery, they increase their risk of having craving by becoming stress sensitive.  Regular stress management activities such as meditation, relaxation exercises, taking regular breaks and rest periods are all protective factors against craving.

Psychological Set-Ups For Craving

There are five major psychological ways that recovering addicts set themselves up to experience craving.

1. Euphoric Recall: Euphoric recall is a way in which addicts “romance the high” by remembering and exaggerating the pleasurable experiences of past use, while blocking out painful and unpleasant aspects of the memory.

2. Awfulizing Abstinence: When addicts “awfulize” abstinence, they notice all of the negatives and exaggerate them while blocking out all of the positive aspects of recovery.  This leads the recovering addict to feel deprived in recovery and to believe that being sober is not nearly as good as using the drug.

3. Magical Thinking About Use: Magical thinking about use is the belief that using will solve all of their problems.  This magical thinking is brought about by the euphoric recall (“Remember how good it was!”), and the “awfulizing” of sobriety (“Look at how awful it is that I can’t use it.”).

4. Empowering The Compulsion: They exaggerate the power of the compulsion by telling themselves that they can’t stand not having the drug and telling themselves that there is no way to resist the craving.

5.  Denial and Evasion: The final psychological set-up is denial and evasion. Addiction is a disease of denial.  This denial does not go away simply because they are not using the drug.  Many addicts deny their need for a recovery program to reduce the likelihood of craving.  They also deny that they are setting themselves up to have craving for the drug.   Because this denial is an unconscious process, many addicts believe they are doing the best they can in recovery when, in fact, they are not.

Social Set-Ups For Craving

There are three major social ways that addicts set themselves up to experience craving.

1. Lack Of Communication:  Addicts stop talking about their experiences in recovery and, as a result, they get into trouble.  They replace rigorous honesty with superficial communication.  This isolates them and prevents them from doing a sanity check on their recovery experiences.

2. Social Conflict: Out of isolation and a refusal to communicate comes a tendency to get into arguments and disagreements with other people.  This social conflict prompts the recovering addict to avoid sober social situations and isolate themselves from others, spending more time alone.

3. Socializing With Other Drug-Using Friends:  Out of loneliness and desire to be with people who understand them, many recovering addicts decide to associate with people who they used to drink and drug with.  This puts them in the proximity of the drug and sets them up to have a craving.

Stage 2: Trigger Events For Craving

There are four primary types of triggers that activate immediate craving.  These triggers include thoughts, feelings, behaviors, and situations that activate craving. Once these triggers are activated, a powerful craving to use emerges.

1. Thought Triggers:  Thought triggers arise out of addictive thinking or an addictive mind-set that creates thoughts about the role that alcohol or other drugs play in a person’s life.

2. Feeling Triggers:  Feeling triggers come from sensory cues – seeing, hearing, touching, tasting, or smelling something that reminds them of drug of choice.  It also results from experiencing feelings or emotions that were normally medicated by use.

3. Behavioral Triggers: The behavioral triggers deal with drug-seeking behaviors and rituals that activate a craving.

4. Situational Triggers:  Situational triggers include any stressful relationships or situations that used to be engaged in on a regular basis while using.

Stage 3: The Craving Cycle

The third and final stage of craving is the actual craving cycle.  This cycle is marked by obsession, compulsion, physical craving, and drug-seeking behavior. This cycle can be prevented and there are helpful intervention techniques when it arises.

1. Obsession:  When the obsession is activated, the person has out-of-control thinking about using.  Intrusive thoughts invade their mind and they can’t turn them off.  The obsession quickly turns into a compulsion.

2. Compulsion:  When compulsion is activated the person begins experiencing an overwhelming urge to use the drug even though they consciously know that it is dangerous to do so.

3. Craving:  The obsession and compulsion merge into full-blown physical craving.  Physical craving is marked by a strong desire to use the drug, rapid heart beat, shortness of breath, perspiration, and at times the actual sense of tasting, smelling, or feeling the drug of choice.  Physical craving is very powerful.

4. Drug Seeking Behavior:  In an effort to manage the obsession, compulsion, and physical craving, many addicts activate drug-seeking, ritual behavior.  They begin to cruse old neighborhoods, talk with old drug using friends, and go to bars and other places where a drug of choice is available.  This exposes the person to more triggers–which intensify the craving cycle.  Eventually, the person becomes overwhelmed with a compulsion that they cannot control and they return to drug use.

Preventing Craving

Craving can be prevented by following a number of simple guidelines.

1. Recovery Program: Develop a structured recovery program that puts you in continuous daily contact with other recovering people.

2. Know Your Triggers: Identify the things that activate the craving and learn how to cope with those triggers.

3. Know & Avoid And Set-up Behaviors:  Know your set-up behaviors and learn how to avoid or cope with those set-up behaviors.  If you don’t set yourself up for craving, when you do have a craving they will be less severe and last for a shorter length of time.

4. Dismantle Euphoric Recall:  Carefully examine past pleasant memories about using and search for the hidden negatives in the experience.  Most people find that they had no purely positive experiences while using their drug of choice.  There were always hidden negatives.

5. Stop Magical Thinking:  It is also important to stop magical thinking about future use and to stop “awfulizing” your current sobriety.  This will allow you to deal with the physical set-ups and let you know what to do to stop a craving.

Intervening On An Episode Of Craving

Since craving is a normal and natural symptom of addiction that follows the addict into recovery, it is important for addicts to learn how to deal with craving in recovery.  This is done by learning and practicing a number of steps.

1. Recognize Craving:  Addicts must learn how to recognize a craving while it is happening. Many addicts fail to identify mild cravings as problematic and wait until they are in a full-blown, severe craving before taking action.

2. Accept Craving As Normal:  Many people experience a craving, panic, and believe there is something wrong with their recovery or that they are condemned to return to their drug of choice.  This is not true.

3. Go Somewhere Else: The craving was probably activated by an environmental trigger, so get out of the setting you’re in and get into an environment that supports sobriety.

4. Talk It Through: If you talk it through, you don’t have to act it out.  Addicts need to talk about their cravings as soon as they occur to discharge the urge to use.

5. Aerobic Exercise:  This stimulates brain chemistry and reduces the physiology of craving.

6. Eat A Healthy Meal: Eat a healthy meals in order to nourish the brain.  Consume some lean fish or meat for protein and eat some whole wheat bread or baked, potatoes or brown rice for complex carbohydrates.  It also helps to take some vitamins and amino acids to help stabilize brain chemistry imbalances.

7. Meditation And Relaxation:  Cravings are worse when a person is under high stress.  The more a person can relax, the lower the intensity of the craving. See a related blog on Mindfulness Meditation:

8. Distraction:  divert attention from the craving by engaging in other activities that productively distract the person from their feelings.

9. Remember Cravings Are Time-limited: The ninth step is to remember that most craving is time limited to two or three hours.  If you can use the previous eight steps to get yourself fatigued enough to fall asleep, most people wake up and the craving is gone.

It is possible to understand drug craving and to learn how to manage craving without returning to use. A model that allows people to identify set-up behaviors, trigger events, and the cycle of craving itself, and intervening upon this process has proven effective in reducing relapse among addicts.


Gorski, Terence T., Addiction & Recovery Magazine, April 10, 1991

Gorski, Terence T., Managing Cocaine Craving, Hazelden, Center City, June 1990

About the Author

Terence T. Gorski is the President of the CENAPS Corporation a training and consultation firm specializing in relapse prevention, addictive relationships and treating chemically dependent ACA’s.  He holds a B.A. degree in psychology and sociology from Northeastern Illinois University and an M.A. from Webster’s College in St. Louis, Missouri.  He is a Senior Certified Addiction Counselor In Illinois.  He also contributes articles and interviews to major magazines, acts as a consultant to the health care industry, and conducts workshops in the U.S., Canada, and Europe.

Some of his books include Passages Through Recovery, Staying Sober: and Relapse Prevention for African Americans. These and many more are provided in our Recovery Bookstore under the heading “Relapse Prevention. For more information about his leading techniques used by some of the nation’s top rehabilitation facilities or to  enroll in one of his training programs, you may also visit his site directly at 






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