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The Recovering Patient & the Primary Caregiver
Primary Care, Treatment Basics, Recovery Stages
Studies have shown that physician knowledge, support, and monitoring
of the recovering patient significantly improves long term treatment
outcome. The involvement of a primary caregiver in a patient’s ongoing
recovery is an extremely important source of support for the patient.
This article is an attempt to help aid the primary care physician in
dealing with the unique medical and psychological needs of the patient
recovering from drug or alcohol addiction. It is a resource to turn to
when questions arise, and an invitation for continued communication
and support from the addiction specialists who have cared for your
patient from the beginning of his or her recovery process.
Disease of Addiction
Since 1956, the American Medical Association has recognized and
defined alcohol addiction as a primary disease, not a secondary
symptom of an underlying psychological or medical illness. Since then,
this definition has been extended to define all chemical addictions as
"chronic, progressive diseases characterized by significant impairment
that is directly associated with persistent and excessive use of
psychoactive substances. Impairment may involve physiological,
psychological, or social dysfunction."
Research into the neurochemical basis of addiction points to the
dysfunction of one or more of six major neurotransmitter types as
being the basis of the symptoms of addiction, withdrawal, and drug
cravings. Studies have shown strong genetic predisposition to some
types of chemical dependency regardless of social environment.
The basic fact remains: the patient who has exhibited the symptoms of
chemical dependency functions physiologically and psychologically in a
way different from the general population. This is the reason
life-long abstinence from all psychoactive substances is the goal of
treatment for this patient.
The main thrust of the LMRC program is to assist the alcoholic or
addicted patient in recognizing that theirs is a primary,
progressive disease, rather than any manifestation of a moral
failing, character weakness, or psychological dysfunction. We
teach alcoholics and addicts to approach their disease as a treatable
condition with a high potential for lasting recovery.
The Basics of Treatment
The recovering patient you are caring for has most often started his
or her recovery by entering some type of "treatment." It is vital that
a patient’s physician realize that treatment is the beginning of recovery,
where the patient first obtains knowledge of the disease of addiction
and the behavioral tools needed to live life without drugs. Recovery is
a life long process of managing the chronic disease of addiction.
Several levels of initial treatment exist. The most intensive treatment is
inpatient treatment. This is often used for the patient needing
medical detoxification, suffering from complicating medical or
psychological factors, for the patient unsuccessful in less intensive
treatment, and for the patient who must be removed from his present
"using" environment for any chance of recovery. The length of
inpatient treatment depends on treatment response, and can vary from
as few as 7 to as many as 45 days.
Less intensive is outpatient treatment. This commonly consists of a
month of daily treatment for 3-4 hours a day while the patient
continues to live at home. Both levels of treatment are often followed
by up to 6 months of continuing care as deemed clinically appropriate.
Treatment starts by allowing patients to begin detoxifying from the
acute effects of their drug use and commence the physical healing and
neurochemical adjustments needed for sobriety. The next step is
educating the patient through lectures, films, and group therapy on
the concept of addiction as a disease along with the physical and
emotional consequences of addiction. This helps the patient realize
that many of his past behaviors are common and predictable symptoms of
the disease and not irreversible character flaws, thus allowing the
patient to get past the guilt and shame of the past and begin to
assume an active role in managing his illness. Individual and group
therapy sessions give the patient the knowledge and the behavioral
tools to support changes that allow them to begin living and
functioning effectively without drugs or alcohol. Continuing Care is
the vital system outpatient follow up, monitoring and bonding with
support groups such as Alcoholics Anonymous, Narcotics Anonymous, and
Cocaine Anonymous. It is in continuing care that physicians have one
of their most important roles.
The Stages of Recovery
It is important that physicians monitoring the recovering patient
realize that many patients go through fairly predictable stages of
addiction and recovery, each with their own difficulties.
Early Recovery
Recovery can take up to two years to become firmly established. Early
recovery spans the first six months for most patients, and is the time
when the risk of relapse is the highest. This is the time the patient
is struggling with the major adjustments he must make. He begins to
deal with the environmental and social cues to drink or use again; he
develops new ways of dealing with stress at work and in personal
relationships; he learns to deal with the mood swings and depression
common in early recovery; he must begin the process of building a
sober support system through attendance in AA or other support groups;
and he starts developing sober social circles and activities.
Middle Stage Recovery
This occurs during the second six months of sobriety. During this time
the patient must learn to deal with the physical, social, and
psychological adjustments of sobriety. New relationships must be
forged with loved ones because the behaviors of the past have changed
so in recovery. The patient commonly goes through a grieving process,
both over losses that occurred during drug use, and also over the loss
of their "old life" and old friends. Reestablishing the ability to
experience emotion is important, because addiction causes abnormal
responses to loss. Part of recovery is learning to deal with past
unresolved loss.
Late Stage Recovery
The third stage of recovery begins after one year. By this time the
patient has gone through the adjustment process of early- and
middle-stage recovery. He has gained confidence that the support
systems and tools learned in treatment and recovery work. This is a
time of stability and of becoming comfortable with recovery. However,
abstinence alone does not necessarily mean a successful recovery is
under way. There is a difference between being "Dry" (abstinent) and
"Sober" (in successful recovery).
The "Dry" patient is not presently using alcohol or drugs, however he
has not changed his past using lifestyle, nor come to comfortable
terms with the need for permanent sobriety. He is ambivalent about
life, where the "Sober" person looks forward to his new life of
sobriety. The "Dry" patient feels abstinence as a constant sacrifice,
and frequently thinks about using. The "Sober" patient sees abstinence
as a gift to himself. The "Dry" patient continues the self-centered
ways of his past, maintaining the old behaviors, friends, and
activities. He doesn’t take care of himself physically or
psychologically, and continues to suffer from guilt and shame because
he has not come to terms with his past or present life. Patients who
are merely "Dry" have a much higher risk of relapse than those "Sober"
patients who have made major life changes necessary for successful
long-term recovery.
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