ORTC Articles

Holidays can threaten your recovery

For people in recovery from alcoholism or drug addiction, holidays can be a threat to sobriety. In fact, the pressure of forced celebrations and family reunions can send any of us into mood swings.

Flip on the television during December and you’re likely to view scene after scene of families enjoying gentle conversation and a warm fire while they gather around a glittering tree. Before you got into recovery, you may have measured your family’s experiences against that holiday ideal and constantly found them wanting. This may have left you with a sense of loss and grief, which can lead to self-medicating with alcohol or other drugs.

Now that you are in recovery, you’ll still experience tension with your family. However, instead of lapsing back into old habits, try to use the holiday season as a time to renew your Twelve Step program and practice new tools for managing conflict. Two of these tools are awareness and planning—principles that help you let go of unrealistic expectations, acknowledge spiritual traditions, and identify safe holiday customs. The following suggestions underlie these principles:

What are some strategies that can help you safely celebrate?

Seek sober fellowship

In order to protect your recovery, plan to connect with your AA sponsor or a sober friend during the holidays. Also, consider starting a new holiday tradition by throwing an alcohol-free party for friends or attending a special AA holiday event. During holidays some recovering people find it tempting to let their program slide. It can pay to do just the opposite by giving more attention to the Twelve Steps and attending extra meetings.

Bring your own nonalcoholic beverages

You might feel awkward arriving at a party where alcoholic drinks dominate the beverage selection. Prevent this dilemma by bringing your own nonalcoholic drinks. It’s not recommended, however, to show up with nonalcoholic beer or wine. The drinking ritual paired with the smell and taste of alcohol can trigger a desire to drink.

Responsible party hosts will recognize that holiday celebrations don’t have to center on alcoholic drinks and that good cheer can be achieved by offering a range of attractive nonalcoholic beverages.

Take holidays one day at a time

Most holidays officially last only twenty-four hours. If the thought of abstaining from alcohol or other drugs for the whole holiday season seems unbearable, take it one day at a time.

Reconsider family gatherings

People in early recovery might do well to opt out of family gatherings, especially when they center on drinking. Another option is to attend but take periodic breaks to call a sponsor or sober friend. Plan to drive your own car so you can leave at any time you choose. Don’t feel guilty if you need to leave a celebration early. Make your recovery your priority.

Resentment has been described as allowing a person you dislike to live in your head, rent-free. The people we resent tend to dominate our thinking and feeling—a fact that does nothing to resolve our conflicts with them.

Resentments that gain steam during the holidays can be disastrous for anyone, especially recovering people. The book Alcoholics Anonymous refers to resentment as the number one offender, the most common factor in failed sobriety. When we notice our own resentments, we need to remind ourselves of their power and talk to a recovery friend about coping with them.

Return the holidays to a spiritual base

Drinking and drugging are powerful experiences because they deliver a counterfeit spirituality. Using chemicals can create the illusion of self-transcendence and intimacy with others. However, we can taste the real thing by reminding ourselves of the spiritual basis of many holidays. Most religious traditions stress the power of unselfish giving, and this is a spiritual practice that all of us can cherish during the holidays.

Find new ways to have sober fun

As part of your recovery, find ways to have fun without putting yourself in situations where you will be tempted to drink or use. There are many ways to have fun without your addictive substance. It just takes a concerted effort to find sober activities you enjoy and to take the time to get involved in those activities.

 Make a point of giving recovery gifts at holiday time

One way to reinforce your sobriety is to make a point to share gifts that have a recovery theme with friends you have met in the program. This helps focus the holiday on recovery success, and it’s a great way to pass on the message of the Twelve Steps.

Recovery Action Step

Write out a plan of how you are going to handle any upcoming holidays. Review this plan as the holidays approach and then put the plan into action. Don’t forget to celebrate your success in fun, sober ways. Ask others for help if needed.

Why may anxiety be an issue in recovery?

People with alcohol and other drug use disorders often suffer from co-occurring mental health issues. If these go untreated, recovery may be more difficult.

For some people alcohol and drug use and withdrawal can cause symptoms of anxiety. In these cases, the substance-induced anxiety will subside with prolonged abstinence. For others the symptoms of anxiety persist and may even worsen with prolonged abstinence, thus making recovery more difficult. For these individuals, treatment options are available.

What is an anxiety disorder?

With any major life change, we feel some anxiety. You are making major changes now, moving from a life of addiction to a life free of addiction. With that comes changes in routines, relationships, thinking, feeling, spiritual growth, and much more. This can produce anxiety and can be a normal part of positive growth.

However, if you have been in recovery for a period of time and are still experiencing significant anxiety, or were diagnosed with an anxiety disorder before or during treatment, your symptoms probably go beyond the typical anxiety reactions we all have. Anxiety disorders are illnesses that fill people’s lives with overwhelming worry and fear. They are chronic and can grow progressively worse if untreated. If this is true for you, it will be helpful to learn more about the different kinds of anxiety disorders, their symptoms, and how to manage your disorder while you continue to manage your recovery.

If you have been diagnosed with an anxiety disorder, please understand that, like addiction, this is an illness, not a reflection of personal weakness, lack of willpower, or poor moral character. You are not responsible for the disorder, but you are responsible for getting help.

If you have an anxiety disorder, you can’t wish it away any more than you can wish away your substance use disorder. But there is hope. There are effective treatments. You don’t have to live with anxiety and panic. You can get help.

First let’s learn a little bit about the main kinds of anxiety disorders and their symptoms.

How common are anxiety disorders?

Anxiety disorders are among the most common mental illnesses in America today. An estimated 13 percent of adults ages eighteen to fifty-four in a given year (more than nineteen million people) are affected by them.

What are the different kinds of anxiety disorders?

Panic disorders

People with panic disorders have unexpected and repeated experiences of intense fear accompanied by physical symptoms that may include chest pains, heart palpitations, shortness of breath, dizziness, or abdominal distress. They cannot predict when such a “panic attack” will occur, so they have a lot of anxiety between episodes, worrying about when and where the next one will happen. A panic attack may be accompanied by an unrealistic sense of impending doom or loss of control. They can occur at any time, even during sleep, and generally last about ten minutes, but some symptoms may last longer. As their frequency increases, the person often begins to avoid fearful situations where they think another attack may occur or where help may not be immediately available.

Obsessive-compulsive disorder (OCD)

Recurrent, unwanted thoughts (obsessions) and/or repetitive behaviors (com- pulsions) that seem impossible to stop or control are characteristics of OCD. Examples may include repetitive hand washing, counting things, or compulsive cleaning or checking (“Did I turn off the stove?”).

Post-traumatic stress disorder (PTSD)

This illness involves persistent symptoms that occur after experiencing a trau- matic event such as a rape or other criminal assault, war, child abuse, natural disaster, or accident. Nightmares, flashbacks, numbing of emotions, depression, being easily startled, feeling angry, irritable, or distracted are common with this disorder.

Generalized anxiety disorder (GAD)

Generalized anxiety disorder is characterized by six months or more of chronic, exaggerated, fear-based worrying that is much more severe than normal anxiety. People with this disorder usually expect the worst. They worry excessively about money, health, family, or work, even when there are no signs of trouble. They have difficulty relaxing and may suffer from insomnia. Many also have physical symptoms such as fatigue, trembling, muscle tension, headaches, irritability, or hot flashes.

For some, simply the thought of getting through the day provokes anxiety. People with GAD have difficulty letting go of their concerns, even though they might realize that their anxiety is more intense than the situation warrants. They may startle more easily than other people and tend to have difficulty concentrating.

What causes anxiety disorders?

Some research suggests that generalized anxiety disorder is hereditary and may run in families. It may also grow worse during times of stress. GAD usually begins at an early age and symptoms may develop more slowly than in other types of anxiety disorders.

The exact causes of panic disorders are unknown and are the subject of intense scientific investigation. Hereditary and other biological factors, stressful life events, and thinking in a way that exaggerates relatively normal bodily reactions are all believed to play a role in the onset of panic disorder.

Do anxiety disorders coexist with other illnesses?

It is common for an anxiety disorder to co-occur with a substance use disorder, depression, eating disorders, or another type of anxiety disorder. Anxiety disorders can also accompany physical illness. All co-occurring illnesses must be appropriately diagnosed and treated.

What can you do to recover from or manage anxiety?

Just as with a substance use disorder, there are things you can do to recover from an anxiety disorder. You will need to practice acceptance, abstain from alcohol and illegal drugs, maintain an active recovery program, and develop strategies to take care of yourself. In addition, you may need to participate in psychotherapy or take anti-anxiety medication.

Acceptance

One of the first steps is accepting the fact that you have the disorder. Without acceptance, you are likely to deny the problem or blame yourself for not being strong enough to overcome your anxious feelings or panic attacks. Accepting your disorder is an important first step that can set you on the road to recovering a life that is healthy and whole.

Abstain from alcohol and illegal drugs

Another important step is to remain abstinent from alcohol and illegal drugs. Using these substances will only make both issues, substance use disorder and anxiety, worse. By using chemicals to avoid dealing with your anxiety, you will only delay getting the help that you really need. If you have been prescribed an anti-anxiety medication, make sure you are safeguarding your abstinence. Mixing these medications with alcohol or other drugs can be dangerous to your health.

Maintain an active recovery program

Stay active in a recovery program and take action to get some help. Waiting for your anxiety to go away on its own will only threaten your ability to stay sober. Reach out and get support from others. This can be hard when you are feeling anxious, but it is a key to recovering both from substance use disorders and anxiety disorders. Attending Twelve Step meetings is important. You are probably involved with Alcoholics Anonymous (AA) or a similar program for your addiction. Emotions Anonymous (EA) is an organization that addresses emotional issues such as anxiety.

You should find nonjudgmental support at your Twelve Step meetings. Occasionally you may hear someone in a meeting discourage the use of medications to treat mental health disorders. You should know that taking medications for a condition such as anxiety is not incompatible with Twelve Step philosophy. Look for those in the program who will support your efforts to deal with both your substance use disorder and anxiety. You should be able to find them.

Let your sponsor know that you are dealing with anxiety and ask for feed- back on the issue. Find a sponsor who understands that an anxiety disorder is an illness, accepts your need for medication, and can provide extra support in your recovery.

Realize that the Twelve Steps can be applied to anxiety as well as addiction. Step One teaches us to admit that we are powerless over addiction and anxiety. It’s realizing that no matter how hard we try, we cannot make ourselves feel better. Step Two and Step Three involve realizing there is hope and we can get help. Step Four and Step Five involve realizing ways in which anxiety has caused problems for us and for others. It also reminds us that some of our problems may be unfounded, due to our anxious thinking.

Be real in working a Twelve Step program. If you aren’t real about your struggles with anxiety, it will affect your recovery from substance use dis- orders as well. Be honest with your sponsor. Be honest with others in your Twelve Step group, and be honest with yourself. If you are struggling, seek the help you need. Make your recovery from both addiction and anxiety your number one priority.

Take care of yourself

Take these self-care steps to help manage anxiety and minimize stress:

• Get plenty of rest and build lots of relaxing activities into your day. Exercise regularly and minimize caffeine intake.
• Learn new ways to manage your feelings, particularly fear, anxiety, and worry. It may help to get some counseling from a licensed therapist. A therapist can teach you new ways to handle anxious thoughts.
• Learn assertiveness skills so you can say no to stressful situations, and maintain healthy ways to handle stress in relationships.

Participate in psychotherapy

Typically anxiety disorders for addicts are treated with behavioral therapy, psychotherapy, and often with anti-anxiety medications. Psychotherapy can help teach you ways to cope with your symptoms and overcome the anxious thought processes. Find a qualified psychotherapist familiar and comfortable working with recovering people who have both a substance use disorder and an anxiety disorder.

Consider an anti-anxiety medication

A variety of medications can be used to treat anxiety. A psychiatrist or other qualified person can determine if you need medication and prescribe an appropriate one based on your symptoms.

For panic disorder, the most common medications used are selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and fluvoxamine (Luvox). Other medica- tions include tricyclic antidepressants (TCAs) such as imipramine (Tofranil) and nortriptyline (Pamelor), and monoamine oxidase inhibitors (MAOIs) such as phenelzine (Nardil) and tranylcypromine (Parnate).

For generalized anxiety disorder, the most common nonaddictive medications used are the anti-anxiety agent buspirone (BuSpar), the SSRIs, and beta block- ers such as propranolol (Inderal). However, medications are not always used to treat GAD.

Are prescription medications safe for people in recovery?

Be aware that on rare occasions you may be offered tranquilizers as a medication to treat anxiety. Tranquilizers such as Xanax and Valium can be addictive. Some prescription medications can be addictive and should be avoided by people in recovery. Take responsibility for your own recovery. Make it clear to your doc- tor that you don’t want to be prescribed any medication that would be addictive. Anti-anxiety medications designed specifically for anxiety disorders are not addictive and are safe to use in recovery.

Most anti-anxiety medications take about two to six weeks to begin working, so if you don’t see results right away, be patient. It may also take a little while to determine the appropriate dose. While you are waiting for the medication to take effect, seek support from your sponsor, Twelve Step friends, and others. These medications may have side effects: ask your doctor for a list of these side effects, so you can be prepared to handle them.

The length of time that you take anti-anxiety medications depends on the type and severity of the disorder. If your anxiety seems situational, it may be recommended that you take it for at least four to six months after your symp- toms improve or go away. Otherwise, your symptoms may return. If you have had prolonged periods of anxiety, it is often recommended that you continue tak- ing medication even after your symptoms are under control. This reduces the chance of a future episode of anxiety or panic attacks.

If you do not respond to the prescribed medication after an adequate period of time, your doctor may change your medication or add a second one.

Take your medication only as prescribed, and take it consistently: never quit your medication “cold turkey” without a doctor’s approval. Many people mistakenly think they can quit the medication once they start feeling good. But the medication may be what’s making them feel better.

What should you do if your anxiety becomes significantly worse?

Some types of anxiety are chronic conditions in which symptoms return, even after periods of relief. Preparing for this possibility puts you in a position to take quick action and improves your chances of getting back on track quickly. Sadly, some people live with the recurrence for months before they get help.

You might have problem anxiety if you:

• feel increasingly anxious, nervous, agitated, or edgy
• start having sleep problems or eating troubles
• experience panic attacks or anxiety for no apparent reason
• withdraw from other people and isolate yourself
• have difficulty concentrating because of your racing thoughts
• experience extreme fearfulness or worry over basic life situations
• think drinking alcohol or using illegal drugs will help you feel better
• cancel or miss sessions with your psychiatrist or therapist
• quit taking your medication(s) without talking with your psychiatrist or therapist
• don’t take your medication(s) as prescribed

Anxiety may be affecting your recovery if you:

• don’t attend meetings
• don’t talk with your sponsor
• try to figure things out on your own
• deny that there is a problem
• wait and hope things will get better on their own

Recovery action Step

Identify and list some of the relapse warning signs related to your anxiety. What three strategies might reduce your risk of relapse when these warning signs appear? Write them down. Keep these notes in your Big Book or in a place that will remind you to monitor your progress regularly.

If your anxiety symptoms worsen or return, seek help right away from your therapist or psychiatrist. If you become severely anxious, hopeless, or suicidal, or cannot care for your basic needs for food, shelter, or safety, seek help from a psychiatric hospital.

Let members of your support system know how to help you if such emergencies occur. Put your plan in writing to serve as a reminder.

Use your journal to write down

1. The steps you can take if you have a psychiatric emergency or feel suicidal

2. A list of your family or members of your support network who can help you in an emergency

Web resources

There are many resources out there. The websites for the following organizations were chosen for their usefulness and user friendliness.

Freedom From Fear

Freedom From Fear is a national not-for-profit mental health advocacy associa- tion that seeks to improve the lives of people affected by anxiety, depressive, and related disorders through advocacy, education, research, and community sup- port. The organization’s website offers a search tool to find a support group in your state.

National Institute of Mental Health (NIMH)

NIMH is a U.S. government organization, an agency of the Department of Health and Human Services, dedicated to research and education in the field of mental health. Its website is a great resource of information about specific mental health disorders including ADHD, depression, and anxiety disorders.

What is the connection between bipolar disorder and addiction?

People with alcohol and other substance use disorders often suffer from coexisting mental health issues. If untreated, these can make recovery more difficult.

For some people withdrawal from alcohol and drug use can cause symptoms that mimic bipolar disorder. In these cases, the manic or depressive symptoms may be substance-induced and will subside with prolonged abstinence. For other people bipolar symptoms may persist or worsen with prolonged abstinence, making recovery more difficult. For these individuals, bipolar treatment options are available.

What is bipolar disorder?

Bipolar disorder is an illness that consists of extreme mood swings and behavior changes ranging from mania to depression.

Symptoms of mania include:

• hyperactivity
• decreased need for sleep
• flamboyant, outrageous manner
• loud speech
• racing thoughts
• poor judgment
• grandiosity
• unrealistic optimism
• distractibility
• pursuit of pleasurable activities that may have painful consequences (such as spending sprees)

Symptoms of depression include:

• ongoing sad, anxious, or “empty” moods
• feelings of hopelessness, pessimism, guilt, or worthlessness  loss of interest or pleasure in hobbies or activities
• decrease in energy; fatigue
• difficulty concentrating, remembering, or making decisions
• insomnia, early morning awakening, or oversleeping
• appetite and/or weight loss, or overeating and weight gain
• restlessness and/or irritability
• persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, or perhaps chronic pain
• thoughts of death or suicide; suicide attempts

If you have been diagnosed with bipolar disorder, please understand that, like addiction, this is an illness, not a reflection of personal weakness, lack of willpower, or poor moral character. You are not responsible for the disorder, but you are responsible for getting help.

You can’t wish away the symptoms any more than you can wish away your substance use disorder. But there is hope. You don’t need to live with bipolar symptoms. You can get help.

How common is bipolar disorder?

Among the general population, an estimated 0.4 to 1.6 percent meet the criteria for bipolar disorder. Research suggests that 56 percent of individuals with a bipolar disorder also have a substance use disorder.

How is bipolar disorder diagnosed?

The effects of many chemicals can mimic the symptoms of bipolar disorder. For example, cocaine and other stimulants can create symptoms of mania, and withdrawal from them can result in feelings of depression, including fatigue, loss of energy, excessive sleeping, loss of interest in activities, restlessness, irritability, and change in appetite or weight. People with addiction or substance use disorders should have a careful and thorough assessment by a mental health professional with expertise in addiction.

What can you do to recover from or manage bipolar disorder?

Just as with addiction, there are things you can do to recover from bipolar disorder. You will need to practice acceptance, abstain from alcohol and illegal drugs, maintain an active recovery program, and develop strategies to take care of yourself. In addition, you will most likely need to take a prescription medication for bipolar disorder and participate in psychotherapy.

Acceptance

One of the first steps in recovering from bipolar disorder is accepting the fact that you have it. Without acceptance, you are likely to deny there is a problem or blame yourself for not being strong enough to overcome your manic or depressive feelings. Accepting your disorder is an important first step that can set you on the road to recovering a life that is healthy and whole.

Abstain from alcohol and illegal drugs

Another important step is to remain abstinent from alcohol and illegal drugs. Using these substances will only make both issues, substance use disorder and bipolar disorder, worse. By using chemicals to avoid dealing with your manic or depressive symptoms, you will only delay getting the help you need. If you have been prescribed a medication for bipolar disorder, make sure you are safeguarding your abstinence. Mixing these medications with alcohol or other drugs can be dangerous to your health.

Maintain an active recovery program

Stay active in a recovery program and take action to get some help. Waiting for your manic or depressive symptoms to go away on their own will only threaten your ability to stay sober.

Reach out and get support from others. This can be particularly hard when you are experiencing the depressive side of bipolar disorder, but it is a key to recovering from both a substance use disorder and bipolar disorder. Attending Twelve Step meetings is important. You are probably involved with Alcoholics Anonymous (AA) or another similar program for your addiction. Emotions Anonymous is an organization that addresses emotional issues such as bipolar disorder.

You should find nonjudgmental support at your Twelve Step meetings. Occasionally you may hear someone in a meeting discourage the use of medications to treat mental health disorders. You should know that taking medications for a condition such as bipolar disorder is not incompatible with Twelve Step philosophy. Look for those in the program who will support your efforts to deal with both your substance use disorder and bipolar disorder. You should be able to find them.

Let your sponsor know that you are dealing with bipolar disorder and ask for feedback on the issue. Find a sponsor who understands that bipolar disorder is an illness, accepts your need for medication, and can provide extra support in your recovery.

Realize that the Twelve Steps can be applied to bipolar disorder as well as substance use disorders. Step One teaches us to admit that we are powerless over substances and bipolar disorder. It’s realizing that no matter how hard we try, we cannot make ourselves feel better. Step Two and Step Three tell us there is hope and we can get help. Step Four and Step Five involve realizing ways in which your bipolar disorder may have caused problems for us and others. It also reminds us that some of our problems may be unfounded, due to our manic or depressive thinking.

Be real in working your Twelve Step program. If you aren’t real about your struggles with bipolar disorder, it will affect your recovery from substance use disorders as well. Be honest with your sponsor. Be honest with others in your Twelve Step group, and be honest with yourself. If you are struggling, seek the help you need. Make your recovery from both addiction and bipolar disorder your number one priority.

Take care of yourself

You can do many things to take care of yourself that will help in managing your bipolar disorder. Here are some ideas:

• Maintain a regular schedule as much as possible, to avoid excessive behaviors of the manic side of bipolar.
• Monitor your mood each day and learn to distinguish your bipolar symptoms from normal day-to-day mood swings.

Learn to cope with the impact of bipolar disorder on your life. Manic behaviors such as impulsivity and high-risk pursuits can cause problems both for you and those around you. Develop strategies—perhaps with a psychotherapist’s help—to avoid these behaviors as you are managing your disorder.

Participate in psychotherapy

Typically bipolar disorders are treated with behavioral therapy (which focuses on changing specific actions and uses several techniques to stop the unwanted behaviors) as well as cognitive-behavioral therapy (which teaches individuals to understand and change their thinking patterns so they can react differently to situations that cause manic or depressive feelings). Often coupled with

medication, psychotherapy can help teach you ways to cope with the symptoms of bipolar disorder and to overcome the manic or depressive thought processes. Find a qualified psychotherapist who is familiar and comfortable working with people in recovery who have both a substance use disorder and bipolar disorder.

Consider a bipolar disorder medication

To treat bipolar disorder effectively, a prescription mood-stabilizer medication is needed. Nonaddictive medications are available that have helped millions of people. These prescription mood stabilizers control both the manic and depressive mood swings, although in more severe cases, a psychiatrist or other medical person may prescribe an additional antidepressant or anti-anxiety medication.

Mood stabilizers take a while to begin working, so if you don’t see results right away, be patient. It may also take a little while to determine the appropriate dose. While you are waiting for the medication to take effect, seek support from your sponsor, Twelve Step friends, and others. These medications may have side effects. Ask your doctor for a list of these side effects, so you can be prepared to handle them.

Take your medication only as prescribed, and take it consistently. Never quit your medications “cold turkey” without a doctor’s approval. This is especially true if you start feeling better. Many people mistakenly think they can quit the medication once they start feeling good. But the medication may be what’s making them feel good.

What should you do if your bipolar disorder becomes significantly worse?

In most cases, bipolar disorder is a chronic condition in which symptoms may return, even after periods of relief. Preparing for this possibility puts you in a position to take quick action and improves your chances of getting back on track quickly. Sadly, some live with the recurrence for months before they get help. Here are some early warning signs of bipolar disorder:

Early signs of mania:

• less need for sleep
• increased physical activity
• beginning multiple projects
• racing thoughts
• difficulty relaxing

Early signs of depression:

• difficulty motivating yourself to do things you used to enjoy
• making excuses to get out of planned activities or obligations
• sleeping more or waking up more often during the night
• preoccupation with mistakes or things that haven’t worked out
• feeling tired and lethargic

Recovery action step

Identify and list some of the relapse warning signs related to your bipolar disorder. What three strategies might help you reduce the risk of relapse when these warning signs appear? Write them down. Keep this information in your Big Book or in a place that will remind you to monitor your progress regularly.

If your bipolar symptoms worsen or return, seek help right away from your therapist or psychiatrist. If you become severely manic, depressed, or suicidal, or cannot take care of your basic needs for food, shelter, or safety, seek help from a psychiatric hospital.

Let members of your support system know how to help you if these emergencies occur. Put your plan in writing to serve as a reminder.

Use your journal to write down the following:
1. The steps you can take if you have a psychiatric emergency or feel suicidal

2. A list of your family or members of your support network who can help you in an emergency

Recovery from the co-occurring disorder of both addiction and bipolar disorder takes time, effort, and a plan of action. Progress with one disorder does not guarantee progress with the other. Recovery requires you to acknowledge and accept both disorders.

Recovery also means stabilizing your mood and the other symptoms of bi- polar disorder, addressing the problems that contribute to (or result from) the disorder, being alert to warning signs of relapse, and coping with life problems without using alcohol or illegal drugs.

Web resources

National Institute of Mental Health (NIMH)

NIMH is a U.S. government organization, an agency of the Department of Health and Human Services, dedicated to research and education in the field of mental health. Its website is a great resource of information about specific mental health disorders including ADHD, depression, and bipolar disorder.

© 2014 by Hazelden Foundation. All rights reserved. This publication is not intended as a substitute for the advice of health care professionals.

Which prescription drugs are abused?

Prescription drug abuse is the fastest growing drug problem in the United States and has been classified as an epidemic by the Centers for Disease Control and Prevention (CDC). The most commonly abused prescription drugs fall into three classes:

• opioids or analgesics for treating pain (painkillers), such as methadone, oxycodone (OxyContin), fentanyl base, morphine, hydrocodone (Vicodin), hydromorphone (Dilaudid), meperidine (Demerol), and codeine
• depressants for treating anxiety and sleep disorders (tranquilizers and sedatives), such as diazepam (Valium), alprazolam (Xanax), and other benzodiazepines
• stimulants for treating ADHD and narcolepsy, such as dextroamphetamine (Adderal, Dexedrine) and methylphenidate (Ritalin)

Sources of prescription drugs used for illicit purposes include “pill mills” or illegal pain clinics, prescription fraud, theft, illegal online pharmacies, and “doctor shopping” (the practice of visiting several doctors to obtain multiple prescriptions). The biggest source of prescription drugs, however, is friends and family. Adolescents may even throw “pharmaceutical parties” where they bring pills from home and deposit them in a jar or bag mixed with a variety of pills from other people. New federal guidelines are currently in place to curb abuse and access to prescription drugs, especially painkillers.

People mistakenly think that drugs prescribed by doctors are safer than illegal drugs. But prescribed medications are only safe when taken exactly as prescribed. When abused, prescription drugs can cause addiction and put abusers at risk for other adverse health effects, including overdose, especially when taken along with other drugs or alcohol.

It is also important to note that over-the-counter (OTC) drugs can also be abused. The most commonly abused OTC drugs are cough and cold remedies containing dextromethorphan.

What is prescription drug abuse?

Prescription drug abuse occurs when a person takes a medication that has been prescribed for someone else, takes a drug in a larger quantity or in another manner than prescribed, or takes a drug for another purpose than prescribed. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines non-medical use as a person taking a prescription drug, even once, when it was not prescribed for that person, or for the experience or feeling that it produces.

If a person continues to take prescription medication long after it is needed, he or she may already have a problem or could be in danger of developing a dependency. Repeatedly trying to re-experience that feeling of a prescription medication can lead to addiction, physical dependence, and withdrawal symptoms just as with any other illicit drug bought on the street.

The American Psychiatric Association (APA) uses the term “substance use disorder” to define a pattern of substance use that leads to significant physical, interpersonal, medical, or work problems. Substance use disorder is further broken down into categories based on the substance and its effects (such as stimulant use disorder, opioid use disorder, etc.). Substance use disorders are rated as mild, moderate, or severe based on how many criteria are met. A person diagnosed with a substance use disorder can also be classified as in remission, or what is commonly referred to as “in recovery.” Those with substance use disorder should receive treatment, and those who identify themselves as addicts often find the skills and support to stay sober through peer support groups like Narcotics Anonymous.

Addiction is considered a brain-based disease characterized by abnormal drug-seeking behavior that leads to impaired control over one’s drug use. Addiction means a person will continue using alcohol or other drugs despite the harm it does to their health, family, work or school, and relationships. An addict may experience withdrawal symptoms (physical pain, fatigue, depression, trouble sleeping, irritability) if he or she stops using, and may need to keep using just to feel normal. “Curing” addiction is not a matter of willpower or moral strength any more than is curing diabetes or cancer. Like diabetes and cancer, addiction is considered a chronic disease which is beyond one’s control and fatal if left untreated.

Are prescription drugs dangerous?

Prescription drugs can be very dangerous if not taken properly. In the last decade, opioid pain relievers have contributed to a dramatic increase in the number of drug-related deaths.

Long-term use of opioids (painkillers) can lead to physical dependence and addiction. They can produce drowsiness and constipation, and depending on the amount taken, they can slow the heart rate or stop breathing. Depressants, such as benzodiazipines, slow down brain function. When combined with alcohol or other medications that cause drowsiness, a person’s heart rate and respiration can slow down to a dangerous degree. Taken repeatedly or in high doses, stimulants can cause anxiety, paranoia, dangerously high body temperatures, irregular heartbeat, or seizures.

How does prescription drug abuse affect the brain?

When prescription drugs are taken in unadvised quantities or when symptoms of illness aren’t present, they may affect the brain in ways very similar to illicit drugs. When abused, all of these classes of prescription drugs—painkillers, tranquilizers or sedatives, and stimulants—directly or indirectly cause a pleasurable increase in the amount of dopamine in the brain’s reward pathway.

Opioids or pain relievers like OxyContin attach to the same cell receptors targeted by illegal opioids like heroin. Prescription depressants produce sedating or calming effects in the same manner as the club drugs GHB and Rohypnol, by enhancing the actions of the neurotransmitter GABA (gamma-aminobutyric acid). Depressants like benzodiazepines slow down brain activity and can cause sleepiness and loss of coordination. Finally, stimulants such as Ritalin increase alertness, attention, and energy the same way cocaine does—by boosting the amount of the neurotransmitter dopamine. Taking some stimulants in high doses or repeatedly can lead to hostility or feelings of paranoia.

How does prescription drug abuse affect a co-occurring mental health disorder?

Co-occurring disorders, or dual disorders, occur when a mental health disorder, like depression or schizophrenia, is present along with addiction, alcoholism, or other substance use disorders. Screening for co-occurring disorders should be part of any good assessment or treatment plan.

The effects of prescription drugs may mask an underlying untreated mental illness, or mimic the symptoms of mental illness, leading to misdiagnosis. Because many prescription drugs are used to treat mental health disorders (like anxiety, ADHD, or depression) some may assume that the pleasure they get from taking the drug means they also have the mental illness. But these mental illnesses need to be diagnosed by a professional.

Is addiction to prescription drugs treatable?

Yes. It is important to remember that detoxification is the beginning of treatment, not the entire process. Withdrawing from certain drug types, such as long-term use of benzodiazepines, can be dangerous, and should be conducted under medical supervision. Very often a person abusing prescription drugs may also be abusing other drugs as well. It is important that medical personnel find out the exact history of a person’s drug use, as this knowledge could save his or her life.

Addiction won’t go away, like a cold or the flu. It is a chronic disease, meaning you have it all your life. However, by staying sober and getting ongoing support, recovering people live normal, healthy, productive lives.

Web resources

There are many resources out there. The websites for the following organizations were chosen for their usefulness and user friendliness.

National Institute on Drug Abuse (NIDA):This government organization is dedicated to addiction research and education. Through its website you can access up-to-date publications about many different drugs of abuse as well as emerging trends.

Substance Abuse and Mental Health Services Administration (SAMHSA): SAMHSA is part of the U.S. Department of Health and Human Services. Its mission is to reduce the impact of substance abuse and mental illness on America’s communities. Its website offers information and resources about preventing and treating addiction and mental illness.

Using this guide

Many medications, both over-the-counter (OTC) and prescription (Rx), have mood-altering effects. Not only do these medications have addiction potential of their own, but they may also lead to relapse.

This guide lists some common medications to avoid, and others that are safer to use. However, it is not meant to replace the advice of a physician, pharmacist, or other health care professional. If you have any questions regarding medication use during your recovery, please contact your physician and/or pharmacist.

Moreover, this guide is not exhaustive. With so many medications on the market, it is impossible to list them all. Instead, you’ll simply find a few common examples in various medication categories. Again, if you have questions about a specific medication not listed in this guide, contact your physician and your recovery team.

Most medications are listed here by generic name—that is, by its active ingredient—with an example of its brand name in parentheses: for example, acetaminophen (Tylenol). Some medications are sold under many brand names. Check the label for the active ingredients: any brand-name medication package should also include its generic name.

Symbols used in this guide:

Rx = prescription only

OTC = over-the-counter

General guidelines

Be up-front with your physician and/or pharmacist about your addiction. If they are aware of it, they can prescribe or recommend more suitable medications.

Important: read all labels. Many OTC medications contain one or more ingredients that you should not be taking. Check both the active and inactive ingredients, as many contain alcohol as an inactive ingredient. If a medication that you should not be taking is deemed medically necessary by your health care professional, notify your sponsor as well as your recovery team. Make a plan for use as well as a plan to discontinue use.

Cold, allergy, and asthma medications

Avoid the ingredient pseudoephedrine, which has stimulant-like properties and is contained in most OTC cold and sinus preparations.

Avoid these and other pseudoephedrine-containing OTC medications:

• Sudafed
• Tylenol Cold & Sinus  DayQuil
• Alavert D-12
• Advil Cold & Sinus
• Claritin-D
• Theraflu

Other cold/allergy/asthma OTC medications to avoid:

• diphenhydramine (Benadryl)
• chlorpheniramine (Chlor-Trimeton)
• clemastine (Tavist)
• brompheniramine (Dimetapp Elixir)
• ephedrine (Bronkaid, Primatene)
• dextromethorphan (Robitussin DM, or any cough syrup with “DM”)
• nighttime preparations, since most contain alcohol (for example, NyQuil)

Safe medications for cold, sinus, and allergy symptoms:

• loratadine (Claritin, Alavert). Beware: Claritin-D and Alavert D-12 contain pseudoephedrine. Make sure you are using the pseudoephedrine-free medication.
• saline nasal spray (Ocean)
• Vicks VapoRub, Vicks steam
• guaifenesin (Mucinex, Vicks 44E)
• benzonatate (Tessalon Perles—Rx)
• acetaminophen (Tylenol)
• NasalCrom nasal spray
• cough drops (such as Halls)
• sore throat lozenges
• salt-water gargle
• Breathe Right nasal strips

Pain medications

The first thing you need to say at any visit to an emergency room or to a physician prescribing you pain medication is that you are recovering from an addiction. The physician and you will then create a plan to resolve your pain and maintain your sobriety.

Avoid all opioids:

Opioids are the most powerful known pain relievers. Naturally occurring opium derivatives include morphine and codeine. Partially synthetic derivatives of morphine include heroin, oxycodone, and oxymorphone. Synthetic opioid com- pounds include fentanyl, alfentanil, levorphanol, meperidine, methadone, and propoxyphene.

Avoid these and other opioid Rx pain medications:

• fentanyl (Duragesic patch)
• morphine
• codeine (Tylenol #3)
• oxycodone (Percodan, Percocet, OxyContin)
• hydrocodone (Vicodin, Vicoprofen, Lortab)
• hydromorphone (Dilaudid)
• propoxyphene (Darvon, Darvocet)

For pain relief some physicians prescribe other medications, such as anti- depressants, that are also mood altering and addictive. Check this guide or talk to your doctor before adding them to your treatment plan. Avoid using all benzodiazepines (listed under “Psychiatric medications” below).

Be careful with dental procedures. Tell your dentist you’d like to avoid nitrous oxide or “laughing gas.” Injectable medications such as lidocaine or Novocaine are better because they provide the numbing pain relief without the mind-altering effect.

Safe pain medications:

Unless your doctor has told you to avoid these medications, they are generally safe (not addictive or mood-altering) to use for pain:

• aspirin (Bayer)—OTC
• ibuprofen (Motrin, Advil)—OTC
• acetaminophen (Tylenol)—OTC
• naproxen (Naprosyn, Aleve)—OTC  celecoxib (Celebrex)—Rx
• ketorolac (Toradol)—Rx
• methotrexate (Rheumatrex)—Rx
•  infliximab (Remicade)—Rx
• and many more

Psychiatric medications

Most medications that are used for anxiety, depression, and other neurological disorders are mood-altering. Some of these are safe and nonaddictive and some are not. If you are diagnosed with a neurological disorder, work with your doctor to pick the safest one that will handle your symptoms. If you are already on a medication, talk to your doctor before discontinuing its use. Some of these medications have severe withdrawal effects that require tapering down the dose.

Avoid all benzodiazepines:

• diazepam (Valium)
• oxazepam (Serax)
• alprazolam (Xanax)
• midazolam (Versed)
• lorazepam (Ativan)
• clonazepam (Klonopin)

Some acceptable prescription psychiatric medications:

• fluoxetine (Prozac)—Rx
• sertraline (Zoloft)—Rx
• paroxetine (Paxil)—Rx
• citalopram (Celexa)—Rx
• escitalopram (Lexapro)—Rx
• bupropion (Wellbutrin)
• venlafaxine (Effexor)
• amitriptyline (Elavil)
• imipramine (Tofranil)
• nortriptyline (Aventyl, Pamelor)
• clomipramine (Anafranil)
• buspirone (BuSpar)

Anticonvulsant and antipsychotic prescription medications to avoid:

Medications like the following should be avoided:

• clozapine (Clozaril)
• olanzapine (Zyprexa)
• phenytoin (Dilantin)
• risperidone (Risperdal)
• phenobarbital (Luminal)

Most medications used for attention-deficit/hyperactivity disorder (ADHD/ADD) have a stimulant property. You should try to avoid:

• methylphenidate (Ritalin)—Rx
• dextroamphetamine (Adderal)—Rx

A safe medication for ADHD is:

• atomoxetine (Strattera)—Rx

Common medications

Diet medications:

The majority of diet medications have stimulant properties; many contain actual amphetamines, which are extremely addictive. Therefore, it is highly recommended that you avoid all of these types of medications.

Some specific examples of diet pills that should be avoided are

• sibutramine (Meridia)—Rx
• phentermine (Adipex)—Rx
• dextroamphetamine (Dexedrine)—Rx

Acceptable heartburn/upset stomach medications:

• Prilosec
• ranitidine (Zantac)
• antacids such as Tums, Maalox, Mylanta, Rolaids; famotidine (Pepcid)

Acceptable diarrhea medications:

• loperamide (Imodium A-D)
• Kaopectate

Acceptable constipation medications:

These medications should all be avoided if you have an eating disorder. If you do not, the following medications can be taken:

• docusate sodium (Colace)
• Metamucil powder
• senna (Senokot)

Mouthwash:

Many OTC mouthwashes contain from 9 to 21 percent alcohol. Avoid any alcohol- containing brands, such as

• Listerine
• Plax
• Cepacol
• Scope

Some mouthwash brands that are okay to use:

• Colgate
• Fluorigard
• Act
• Act Kids

Sleep agents:

It is best to avoid all sleep medications since they have depressant-like properties. The best treatment for insomnia is to find ways to relax: meditate, listen to music, or take a hot bath before bed. Try to find something that works for you. If you still have difficulty falling or staying asleep, discuss this with your physician and recovery team.

Sleep medications to avoid:

• diphenhydramine (Unisom, Sominex)—OTC
• zolpidem (Ambien)—Rx
• zaleplon (Sonata)—Rx

Motion sickness agents:

Most of these cause mood-altering effects and should be avoided. A few examples of motion sickness medications to avoid:

• meclizine (Bonine—OTC, Antivert—Rx)
• dimenhydrinate (Dramamine)—OTC
• scopolamine patch (Transderm Scop)—Rx

What does it mean to be a loner?

A loner is one who avoids others or pursues a markedly independent course in thought or action.

How can participation in Twelve Step groups affect your recovery?

Some people in early recovery describe themselves as “loners” or “misfits.” For these people recovery can be more difficult. If you are a loner, participating in meetings by speaking or performing service work, even simple tasks such as setting up chairs or making coffee can develop your sense of belonging to the program and the group.

Being a loner may seem like a sign of strength to some, but in reality, it can be a sign that a person’s recovery is weak. If you look at the wording of the Twelve Steps, you will notice that the term “we,” not “I,” is used. Recovery is not something that can be done alone, at least not very successfully. The power of recovery is in the fellowship of alcoholics and other addicts helping each other.

Asking for help, talking about problems, and listening for advice are not signs of weakness but signs of wisdom. Others have traveled the pathway of recovery, and you can learn from their experience. And in turn, others can learn from you.

It is also true that your Higher Power will often use other people to speak to you and help you. All human beings are meant to be in community with others for this reason.

If you have been a loner, it may take a focused effort to break old habits of isolation. It may mean forcing yourself to do things and go places, even when you don’t feel like it, but it will be worth it. Try attending a Twelve Step recovery group. Most people find these meetings to be accepting, loving settings where you can just be yourself. Trust that others in the room have felt like misfits too, but have now found a place to belong.

What is humility?

“Humility” is a word that is often misunderstood, particularly by people in recovery from addiction. Humility involves a clear recognition and acceptance of one’s humanness. Learning humility means taking an honest look at your strengths and weaknesses in the spirit of attempting to become what you want to be.

Only when you work toward humility can you develop a realistic acceptance of yourself. Humility does not mean inadequacy. It means that you are no longer hiding anything. “The basic premise of humility is a desire to seek and do God’s will.”

Mother Teresa understood humility when she said:

“If you are humble nothing can touch you, neither praise nor disgrace, because you know who you are. If you are blamed you will not be discouraged. If they call you a saint you will not put yourself on a pedestal.”

How does humility affect recovery?

Learning humility will allow you to let go of feeling the need to be “right” or superior to others. This will also help you if you need to work to stop blaming others and start looking inward to take responsibility for your life. True humility also means that you have let go of your old character defects and are seeking spiritual values.

Working Steps Four, Five, and Six prepared you to understand who you are. Now you can turn to your Higher Power without pretense or shame, asking that your defects be removed.

While you are working the Steps, stay in contact with your sponsor, counselor, and others in your support group. Now that you’ve found your Higher Power, you may feel safe, secure, and motivated to work toward embracing humility and expanding your spirituality. That’s great: you should feel liberated and excited at this point. But use caution; don’t put yourself in using situations or around triggers. Don’t get overconfident. Your plans to stay away from people, situations, or places that could threaten your recovery are there to prevent the disease of addiction from overtaking you while you’re busy doing the hard spiritual work that will give you a daily reprieve.

You know you’ve achieved humility when you do your best and accept that the rest is up to your Higher Power.

What are affirmations?

Affirmations are an essential component of your ongoing recovery. To affirm means to declare something in a positive, firm, true way that is empowering. Affirmations are a way to change the messages of self-talk from negative to positive, from shameful and guilt-ridden to deserving and empowered. When many people first think of affirmations, they think of cute sayings that have little real power. But in truth, what you say is what you believe. Do you believe that you are worthy and deserve happiness, freedom, and empowerment? Can you affirm yourself with real conviction and meaning?

Affirmations are not a substitute for reality; they aren’t another way for you to exert denial, control, and reckless self-will over your life. Instead, they collaborate with surrender, spirituality, and your Higher Power.

Why are affirmations important to recovery?

You may have spent your entire life internally reciting restrictive messages about yourself and others. In recovery, you have faced your patterns of compulsion, denial, self-destruction, control, and inadequacy. But are you ready to assert that you deserve better? Are you ready to empower the good and the positive in yourself and in others?

The power to change is within you. But you have to believe it, say it, and live it.

How can you practice positive affirmations?

At first it feels awkward to practice positive affirmations. You may think, “I deserve to have a great job, a fantastic family, and freedom from pain.” But look in the mirror and say it out loud. It may seem awkward and even fake, but as time goes on, you will start to believe that you deserve these things, and the affirmations will become easier. You will start to notice that you are living the affirmations, creating a self-fulfilling prophecy that can only manifest itself by creating more positive energy in your life.

Recovery Action Step

Write down some loving, empowering affirmations for yourself. For example, “I am a beautiful person who is perfect just as I am today” or “I am a good person and I deserve to be happy.” Set a routine each day to read these. Look yourself in the mirror and believe them as you say them out loud.

Things you can do to affirm yourself and your recovery:

1. Work the Twelve Steps.

2. Read meditation/prayer books and focus on empowering thoughts every day.

3. Attend recovery groups or positive seminars or events.

4. Engage in positive self-talk, giving yourself new messages and new beliefs.

5. Write down affirmations of the positive life you imagine.

6. Surround yourself with people who support your recovery and believe in you.

7. Get a massage, go to a yoga class, or do something else positive for yourself because you deserve it.

8. Celebrate your successes with others.

9. Affirm others. Find out about the dreams and goals of others and support them.

10. Place affirmations in key places, such as on your desk at work or on the refrigerator at home. This way you will think about them on a daily basis.

Why do you need to resolve issues with challenging people?

There will come a time when alcoholics and other drug users need to resolve issues they have with challenging people. These enemies can be people or feelings, and we will have identified many of them through our Fourth Step. Step Eight instructs us to be willing to make amends to them whenever possible. The Big Book describes it this way:

It is harder to go to an enemy than to a friend, but we find it much more beneficial to us. We go to him in a helpful and forgiving spirit, confessing our former ill feeling and expressing our regret. Under no condition do we criticize such a person or argue. Simply we tell him that we will never get over drink- ing until we have done our utmost to straighten out the past.

Making amends can set straight feuds and fights that have lasted many years. It can make friends out of people who have challenged us, and at the very least provide the opportunity to have a civil relationship.

This directive does not include those who have been perpetrators of abuse. Abuse is never the victim’s fault. Making amends to someone who has hurt you physically, sexually, or emotionally is not the focus of this passage. It may help you in your recovery, however, to get to the point where you can forgive an abuser so you can be free of anger and hurt.

Feelings as enemies

Substance abusers have other enemies that are not human. Perhaps our greatest enemies are resentments, jealousy, envy, and fear. Alcoholics need to constantly monitor their feelings and handle them in healthy ways. They do this so that resentments and other strong feelings do not shatter their serenity and rob them of their sobriety.