desperate deranged talking in my sleep again … breakdown amidst the mixtures avoid addictive plea

I am somewhat familiar with the substance use literature; however, I have always approached the issue in terms of what factors contribute to initial use, problem use, and the continuity of problem use. While discontinuity is inherently intertwined with continuity of use, it is a different perspective. It is quite different to think about what triggers relapse (and how to prevent it) than to think about what turns use into problem use. However, there is quite a bit of overlap as well, especially when it comes to abstinence vs. harm reduction. (But I’ll save this for another time…)

Despite the fact that I had to constantly remind myself that I was looking at a relapse model rather than a use (per se) model, I found multidimensional model outlined by Witkiewitz & Marlatt (2004) fairly comprehensive. While not explicitly stated, it does encompass some important factors that are often ignored. For instance, substance availability is a huge factor in terms of frequency and amount of use, and I would assume in terms of potential relapse as well. While the article indirectly implicates substance using friends, peers, etc. as a high-risk factor in terms of relapse, it may also be useful to think about the availability of a substance locally and regionally. Of course, this (likely) has greater implications for illegal drugs than for alcohol and tobacco. There can be quite dramatic fluxuations in the availability of street drugs, which does indeed influence individual use. For instance, there was a time in Pittsburgh (sometime in the 90s, I believe) when heroin was widely available and relatively inexpensive. There were more heroin users at that time in the area than there had been before, and consequently more deaths. When the supply dwindled, drug use changed. Anecdotally, I have been told that this lead some people to stop using heroin altogether (and did not substitute another drug) while others began using other drugs (e.g., benzodiazapines) to simulate or replace the high once provided by heroin. In terms of relapse, when the market is flooded with a cheap substance there is a greater likelihood that a person will be in a high-risk situation where availability and therefore use / relapse is more probable. When thinking about illegal drugs it may also be important to consider the potency of the drug locally and regionally available. As Witkiewitz & Marlatt suggest, relapse is likely to occur – especially early on in or after treatment. When the drug available is highly potent and highly addictive, as was the case about a year ago when Midwest and Eastern areas were flooded with heroin cut with phentonyl, the potential to continue to use after the first relapse is heightened. Not only is the likelihood of continued use heightened, so is the likelihood of death.

However, this is not to downplay the importance of affect, coping behavior, and social support. I believe these factors are hugely important – and not just because I willy nilly decided this was so! There is a whole literature on coping behavior and alcohol/drug expectancies that agree with me! (or maybe I agree with the literature?) Turning the relapse issue around a little bit … Kandel and Ravies (I think) found that substance use was more likely to continue and to become problem use when the substance was used to cope with negative affect versus for social reasons. While this research looked at the continuity of use (rather than treatment and relapse specifically), it seems logical that those who had been using substances socially, even though perhaps problematically, would be in a better position to avoid relapse, especially in terms of coping. In this case, coping is fundamentally paired with substance use for one group and not for the other, implying that the “social” group may have better coping resources. Litt et al. (2003, as reported in Witkiewitz & Marlatt, 2004) report that the relationship between “readiness to change” (I’m assuming here this means quit or reduce substance use) and drinking outcomes is mediated by coping.

…and no I have not been sitting here (in my bed) typing this response with a cigarette between my lips wondering how much more I’m going to write before I can go outside.

*Title taken from Skinny Puppy's Addiction, lyrics by Nivek Ogre.