The Addiction Process and Stages of Recovery | Addiction Counselor Certification Training

Hey there, everybody, and welcome to this presentation on the addictive process. I'm your host, Dr. Donnelly Snipes. In this video, we're going to define addiction using the new 2019 definition from the American Society of Addiction Medicine. We'll briefly review changes in the brain and neurotransmitters caused by addictive behaviors. We'll learn how triggers become conditioned to produce cravings and review the different stages of addiction and recovery. So let's start out with that definition. I was thrilled to see that in 2019, the American Society of Addiction Medicine did broaden their definition of addiction. According to this definition, addiction is a chronic medical disease which is influenced in its development by genetic, neurological, psychosocial, and environmental factors. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Okay, so let's break this down, and I know I'm really excited. A chronic medical disease. For a long time, we've referred to addiction as a disease. And the American Society of Addiction Medicine is recognizing that it is not just a thought process. It is not just a set of behaviors. It involves changes in the neurochemistry of the brain, changes in the neurochemistry of or in the chemistry of the gut, microbiome, changes in the way the body functions. For a lot of people, it goes on to recognize that there is no one cause for addiction. There are a lot of things that contribute to the development of addiction, including a genetic predisposition. Neurological responsivity to drugs, for example, may also impact it as well as neurological dysfunction that may lead to self medication with addictive behaviors. Additionally, a person's psychological makeup, as well as any coexisting mental health issues, may contribute to the development of addictive behaviors and their social network, as well as their environment. Accessibility to drugs and whether their social network is supportive of drug use or use of addictive behaviors may also influence the development of addictive behaviors or addictions in people. The biggest part that I really like, the biggest change that I really like, is that in 2019, the ASAM definition changed to read people with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. So it is now embracing the notion that addictions are not just chemical or substance related. It gives validation to those concepts that we have been talking about for a long time in addiction circles, such as process addictions or behavioral addictions, which, for the most part, are not yet recognized in the DSM 5 trigger or the diagnostic and Statistical Manual of Mental Disorders. So again, I think this is a really wonderful first step towards identifying the fact that there are a lot of things that can become problematic for people and we need to not minimize just because it's not an illicit substance. So let's talk about some of these changes in the brain. Pro survival behaviors like eating or exercising triggers the limbic system. The limbic system rewards us by releasing dopamine, endorphins, norepinephrine and other pleasure neurochemicals. When we do something that is pro survival or when we do something that produces pleasure, we're going to do it again. The limbic system, when it releases dopamine and endorphins, gives us that rush, gives us that pleasure. Hit if you will. Most chemical and behavioral addictions cause the brain to release 2 to 10 times the normal amount of dopamine, causing the person to experience a rush or a high. I use normal in quotes because what is normal for one person may be different than for another person, but it increases the steady state, if you will, two to ten times above that person's baseline, which produces those pleasurable feelings. Prolonged engagement in addictive behaviors can lead the brain to stop producing as much dopamine as it naturally does. Our brain is really cool because our whole body is self regulating and it recognizes how much dopamine and how much activity should be happening in the dopaminergic system at any one time, based on a person's basic, basically their biological set point. Now, I'm grossly oversimplifying these things, but bear with me. So a person has a baseline biological set point for dopaminergic or dopamine activity. When the brain recognizes that, hey, we're being overstimulated, it actually acts to reduce that stimulation by shutting down or pruning back the dopamine receptors is what they are hypothesizing happens right now. And that reduces the amount of dopamine that actually gets through. The same amount may be released into the synaptic space, but less actually makes it through into the next neuron and so on. So that is really important to recognize. When the brain recognizes that, hey, there's too much dopamine, it may shut down those receptors, it may not produce as much dopamine, or it may not release as much dopamine. We know that there is a reduction in dopaminergic receptor activity. Therefore, when the person doesn't use, the brain registers that as not getting enough dopamine. So instead of having a tsunami of dopamine coming through, there's not much coming through. And the brain's like, well, we're not getting enough through these few portals that we've left open. The prefrontal cortex is involved in planning and executing goal directed behaviors. The prefrontal cortex is interesting because this is where we do our executive functioning, our higher order thinking, our decision making, our impulse control. But it is the last part of the brain to actually finally develop and mature. Imaging studies in brains of people with addiction show disruption in multiple regions of the prefrontal cortex. Interestingly, people who begin use of some sort of addictive behavior or substance prior to their mid-20s tend to show more damage in those areas. Because until the prefrontal cortex is thoroughly mature, if you will, it is much more susceptible to insults from surges of excitatory neurochemicals, including dopamine. These changes in the prefrontal cortex may underlie the inflexible behavior when faced with conditioned cues. If this area in the prefrontal cortex is not able to take in this information and go, okay, what are my options? And it just takes in the information and goes, when I see this, I do this. This is how it has to happen, then that may be a problem. It may underlie the disruption in inhibitory control that results in impulsivity. When our prefrontal cortex is activated, it is engaging what we call the executive control network. When the executive control network is activated, it takes us off autopilot. What they're saying here is that disruption in this prefrontal cortex may make it more difficult for the brain to turn off autopilot and engage thinking processes. This also may underlie some of the impaired decision making and impaired internal awareness and error detection. The person, again is on autopilot, so they're having more difficulty making accurate and appropriate decisions in this context. At this time, they're operating off of prior expectations. Other glutamatergic neurological changes may also be triggered by repeated use. When people use, and I'm using the term really broadly, that includes porn addiction, sex addiction, gambling, anything that causes that rush of dopamine, and it happens with regularity, it happens chronically, can create what they call a neurotoxic environment in the brain. When dopamine levels go up, when a person is stimulated, the excitatory neurochemicals flood the brain. Now, I want you to think of the excitatory neurochemicals as hot neurochemicals and our calming neurochemicals as cool neurochemicals. What we want is something that's akin to a warm Bath. We don't want to be burning, and we don't want to be freezing. We want something that's somewhere in the middle. But when somebody repeatedly engages in addictive behavior or uses that keeps the hot chemicals, the excitatory chemicals, the levels of those really high in the brain, which creates a. What they call a neurotoxic environment. It creates an environment that actually kills brain cells in this very short explanation. So it's important to recognize that addiction is not just dopamine. When dopamine levels are altered, it alters every other neurochemical in there. And there are changes in multiple brain systems, including the glutamatergic or the stress response system. So we've talked about the fact that addiction can be chemical or behavioral. We've talked about some of the changes in the brain that occur as a result of repeated use and repeated insults the brain due to use. And excessively high levels of the excitatory neurochemicals. But what causes these neurochemicals to go up, and what are triggers and cravings? Because we hear about that a lot in addiction. So where do they come in? Well, we gotta back up a little bit. Classical conditioning is one form of association. That is centered on involuntary physiological reactions. Like when you think about lemons, you may start to salivate. When you smell brownies or Cinnabons, those are mine. You may start to salivate. When it's hot outside, you may alter your respiration rate. Or when you see something that scares you, you may start breathing more quickly, your heart rate may increase. When those things happen, there are neurochemical releases. When we. When there's a stimulus, when there's something that happens that triggers a feeling. Between noticing that stimulus and having that feeling, your brain has released a cocktail of neurochemicals that either, say, fight or flee or chill the heck out, basically. And it's important to recognize that that is an involuntary process. That can be sort of hijacked, if you will, by addictive behaviors. When you start seeing things that remind you of cocaine, for example, if that is your drug of choice, then just seeing something that reminds you of it may also trigger that neurochemical release. So now I've used the word trigger. Operant conditioning is focused on voluntary behavior. When you feel X, you do Y for a reward. So when you feel these feelings, when you feel anxiety, when you feel a craving, you may engage in particular behaviors. So internal states can also be a trigger that prompts cravings. It's important to recognize that because of those brain changes, that happen due to chronic use of an addictive behavior. When people are not using, then their neurochemical balance is going to be out of whack because the brain has. Determined it's balanced itself around the state where the person is using. So when the person's not using, the system's all out of whack again. So it's tuned for use, and when they're not using, it is out of balance. Engaging in a behavior that produces dopamine and endorphin releases produces a reward, so people are likely to do it again. You do something that's pleasurable, you want to do it again. Novelty also encourages you to want to do things over again or to want to try new things. Generalization occurs when a reminder like a stimulus or a trigger for a behavior occurs in different settings. A very common example, maybe somebody, and most people don't start out using and being addicted to something. They start out with recreational use. Okay? They're doing something, whatever it is, and it produces pleasure. It helps them feel relaxed. They're like, oh, this is pretty cool. So somebody may start out by when they're drinking. Maybe the only time they drink is at a poker game with friends. They just don't drink that much. And then they start hanging out with those same friends, and they may start drinking while watching football with friends. So now poker, playing poker has become associated not only with those friends, but also with drinking. So they can go to a poker game with other people, and it may trigger that desire to also have a drink. Now, football has become associated with drinking. So they may, when they're watching football by themselves, when they go to a football game, when they're watching with other people, they may also want to drink at the same time, because football and drinking have now become paired. Drinking at a barbecue with friends, okay, you think that's pretty benign too. However, drinking at a barbecue, let's think about all of the other things that may be associated with it. A lot of times when there's a barbecue, we're sitting out on the deck and we're hanging out, and people may be drinking and barbecuing. So then it's possible that that stimulus is generalized. So maybe you don't even need to be barbecuing. But sitting out on the deck with friends or even sitting out on the deck by yourself triggers the desire to have a drink of alcohol. Because the stimulus, the alcohol and the deck have become associated with relaxation have become a. So all of those have been paired, grouped together. So you can see how this can become really generalized. We're not specific in our, the way we form our schema. So your schema is generally not going to be. The only time I want to drink is when I am playing poker with these friends. Saturday night poker is going to become associated with drinking, those friends are going to become associated with drinking, and maybe even Saturday night is going to become associated with drinking. And the same thing with football and barbecue games or football and barbecue with friends. So you can see how very quickly lots of stuff can start triggering your brain to say, hey, a drink would be pretty good with this. Aren't we supposed to be drinking with this? So let's talk about the conditioning process really quick. And I have other videos on the YouTube channel that go more in depth about triggers and cravings. But we're really focusing on high level on the addictive process in this video. So the conditioning process, remember I said people don't generally start out with, with problematic use, they start out recreationally. So the positive aspects outweigh the negative aspects. Positive aspects of use. Physically, it may help them feel relaxed affectively, it may improve their mood cognitively, depending on the substance, it may help them think more clearly. Or on the other side, it may help them just shut off the intrusive thoughts and the constant bombardment and racing mind relationships positively in the initial recreational use stage or even up to problem use where they're using a little bit more than they should. A lot of the use is probably associated with being with friends and hanging out with friends and engaging in social activities. Our society is, is. Has a lot of correlations or connections between socialization and particular behaviors that can become problematic. So in this stage, the person is either recreationally using, it's not a problem yet, or they've started using heavily, but they're not having a lot of problems yet. Okay, so the positive out aspects still outweigh the negative ones. What are the negative ones at this stage? Well, they're way up here, so we know that there's not going to be as many. They may start, you know, if it's alcohol, maybe they start gaining weight or having some upset stomach process. Affectively, the recovery period when they are sobering up can be problematic. There may be some guilt after they use or if they, when they sober up after being hungover, cognitively, they may have difficulty focusing the next day. The withdrawal is almost always the opposite of the intoxication. So during that withdrawal period, they may start having some negative impacts which, and I'm not advocating for it, but that's Kind of where that saying, hair of the dog, that bitch ya comes from. Because when people are going through withdrawal, if they use again, Then it's going to increase those neurochemical levels. And it's going to reduce the withdrawal symptoms. But guess what? It's contributing toward more brain changes. And heading down that road of persistent tolerance and addiction. The next phase is disenchantment. The person is continuing to use despite negative consequences. So the negative aspects far outweigh the positive aspects. At this point. Positive aspects still may be there, Enabling the person to relax. Or maybe it numbs emotional or physical pain in some way. Affectively, it may help them either feel better for a moment While they're intoxicated. Or maybe just not feel anything at all. And again, this only lasts while they're using or while they're intoxicated. Cognitively, whatever positive cognitive changes. They had before. May still be persisting. And their relationships, the positive aspects, are probably starting to dwindle. However, as addiction progresses, we do generally see people's social circles change. So instead of going from having all of these wonderful friends. That they love to spend time with. And then being rejected by those friends. Because of what they're doing in their addiction, they may just switch. So they don't go from having a lot of friends. To having no friends. Most of the time, they go from having friends, a lot of friends, a few friends, Whatever's normal for that person, to having different friends. And these different friends are often supportive of their addictive behaviors. And engage in those same behaviors. So they are likely to, as we say in recovery. Cosign on their bullshit. Negative aspects. Physically, we start seeing the body deteriorate. If you do fmris, you can start seeing changes in the structure of the brain. And changes in the areas that are highlighted. In response to pleasure as well as in response to withdrawal. Affectively, people tend to become more moody. And then when they're not using, they're experiencing the opposite affect. So, so if they're using stimulants, that promotes euphoria. When they are detoxing or not using, they are depressed. If they are using sex or gambling, that has a euphoric component to it. When they're not able to engage in those behaviors, Even if they're not trying to abstain. When they're not actively engaging in those behaviors. They may feel less motivated, more irritable, more depressed. Cognitively, as the chemical environment in the brain changes and becomes more neurotoxic. The glutamate increases, the dopamine increases, the thoughts Become more centered around the drug. The person's cognition, their ability to think clearly, tends to decrease dramatically. Environmentally, at this point, the person may be in jeopardy of losing their housing or getting kicked out of the house or losing their job. So environmentally not only accounts for, you know, what you have in your environment, but also housing and finances that are supportive of keeping a roof over your head. And relationships, as I mentioned, relationships often change. And relationships with the people that love them and care for them and worry about them may become very conflictual, if not completely distanced during this phase. Because the addiction has become so rewarding and so ingrained in this person's neurochemical makeup that it is hard for them to make those changes. Their body has become dependent on that substance or activity. So let's talk about the progressive phases of addiction. As I said, people don't just start out being highly addicted. It is possible with certain drugs. Sometimes we offhandedly call them one hit wonders. That the drug is so potent it may produce a euphoria that's so great that the person is very quickly addicted to that substance. So there isn't a period like with crack cocaine. There's very rarely a period of recreational use. People usually, when they start using it, the addiction begins very quickly. Pornography, on the other hand, usually is a slower onset. So you've got four main introduction or beginning of use, which some people call recreational use, maintenance, or early problematic use. This is when the person is using. They may be using heavily, but it's not yet causing them significant problems in their life. Disenchantment is when they continue to use despite problems in their life. And then disaster is obviously the place where their problems have become so great that they decide that they need to seek help. Stages of recovery, withdrawal, honeymoon, the wall, and readjustment. And I want you to recognize that these are additive. So withdrawal period takes one to two weeks. And that is on the very conservative side. Some drugs have something called protracted withdrawal that may produce withdrawal symptoms a month, six weeks after the cessation of use. But the initial withdrawal period that we generally talk about, and this is often the detox period is one to two weeks. It's not two days, it's not three days. It takes your body a minute to recover from the toxic environment. Honeymoon lasts about four weeks. So we're by the end of the honeymoon period, you're six weeks out from last use. The wall lasts another 12 to 16 weeks. So that's another four months. And then readjustment is eight weeks or longer after that. So this recovery process, it's not 28 days, it's not even 90 days. The recovery process is the very minimum six months. And for a lot of people, we know that post acute withdrawal symptoms can last 12 to 18 months and sometimes even up to two years, depending on the substance or the behavior. So it's really important to recognize what's going on. And I'll talk more about some confounding factors as we go through. So the withdrawal period, as I said, lasts one to two weeks. During this period, the person is going to experience extreme cravings. The brain, remember, has become tuned to having those surges of dopamine and endorphins and those kinds of things. So it's quit making those or balancing those on its own. It's just waiting for you to do what you do in order to get that rush. And when it doesn't happen, the body's going, somebody forget to do something. Low energy regardless of the substance of choice. In most cases, people experience low energy because the producing pleasure in the brain ultimately produces a lot of excitation of the entire body. So when the person is not using, when they're withdrawing, they often are exhausted. Now they may feel anxious too, but there's often concurrent low energy. There are changes in sleeping depending on the person and depending on the drug of choice. Some people may have difficulty sleeping at all. Other people may sleep for literally days on end unless they are awakened. Increased appetite is very common regardless of the substance of choice. Because many times in addiction people have neglected their nutrition and their appetite starts to return as their circadian rhythms start to get reset and as their body starts saying, oh, hey, I need some of those building blocks so I can repair myself. So the body starts craving the nutrients it needs to repair itself. For some people, there's also an increase in pain. If the drug of abuse was either an opioid or a anti anxiety medication like Valium, There may be an increase in pain because of a reduced pain threshold. And that's a topic for a whole nother article or a whole other video. But it is important to recognize that this can be very real. It's not necessarily drug seeking behavior. It may be relief seeking behavior. So we may need to have strategies, whether it be non pharmacological strategies like massage and heat and ice, or non addictive pharmacological strategies, and that is between the person and the attending physician, how to manage that pain during the withdrawal period. Affectively, during this first two weeks, people's moods tend to be all over the place. Depression Anxiety, irritability, guilt, grief, sometimes occasional rages. It's very common. Their impulse control centers of their prefrontal cortex have been inhibited, and the brain is trying to rebalance itself. So there may be surges and spurts, if you will. And again, that's not the clinical explanation, but it gives you an idea of what may be going on. There are some connections that may be trying to rebuild, but they're not quite strong enough, so they short out. You want to think about it that way. Cognitively. Concentration and memory during the withdrawal period are in the crapper. The prefrontal cortex is where most of this happens and is going to be more difficult for people to focus. Their circadian rhythms are out of whack. They're feeling irritable, they're feeling anxious. Irritability and anxiety increase the stress response, increase those excitatory chemicals, and make it more difficult to focus. So there are some confounds that we've got to deal with interpersonally or relationally. We often see people in this withdrawal period being very impatient. It's hard. I mean, think about it. When you're sick, when you're in pain, when you feel like crap, do you have a lot of patience to deal with other people's drama? Most people would say no. So, okay, we can expect that. It's important that we have tools, if you're working in a detox unit, that we have tools to help people trigger their relaxation response and react appropriately when they're feeling impatient. Instead of reacting impulsively, reacting with mindfulness or appropriate responses. There's also a lot of abandonment fears that come up during this withdrawal period. People start sobering up, and they start looking around going, oh, crap, what the heck did I do? Many times they don't like themselves very much, so they wonder how anybody else could love them or forgive them, which triggers all those abandonment fears. And because people are impatient, because people are impulsive, because people are not feeling well. Communication. Even if they've got good assertive communication skills, communication tends to be less than assertive during this period. Some people will become much more passive, and they're just like, whatever, I don't care. Just leave me alone. Other people will become much more aggressive. Then you have yet another group of people who alternate. Sometimes they're very passive, but then you push them to a certain point, and they will rage. We want to recognize that this is going on and help them most effectively communicate their needs throughout this process. The honeymoon period, some call it the pink cloud. It lasts about four weeks the person experiences increased energy, enthusiasm and optimism. Treatment started, they can see a light, they're like, I might be able to kick this, I might be able to move forward. During this period, they are typically engaging in good health behaviors, they're eating well, they're setting their circadian rhythms, and all of that will contribute to increases in energy, enthusiasm and optimism. When people get through this stage, they often feel cured. And my experience over the past 20 some odd years has been that people don't really start hitting that pink cloud phase until towards the end of that four week period, which is about the time that they're discharging from residential or they feel like they've got a substantial, substantial amount of clean time under their belt. Once that's happened, they start feeling like, okay, I got this, not a problem. And family members unfortunately have seen this happen too many times and may view it as the beginning of a relapse. It's crucially important during this period to maintain open lines of communication between the individual and, and their family members so family members don't inadvertently create a self fulfilling prophecy. If family members think, here we go again, we've been down this road, then they may start treating the person as if they have already relapsed. And then the person who may still be quite clean, may feel unsupported, may feel rejected, may feel a lot of negative feelings, and ultimately that additional stress may contribute to relapse. Now I said that the duration that it takes people to move through this varies depending on a lot of factors. If the person has an unsupportive environment or they have co occurring mental health issues that can make the process take longer because as they sober up, they are still being exposed to really high levels of stress. And those high levels of stress maintain the high levels of neurotoxicity in the brain, which can make it take longer to recover. This is why co occurring treatment is so important. We can't just say, okay, you know, we're going to treat your alcoholism or we're going to treat your porn addiction and all that anxiety and PTSD that'll get better on its own or we'll deal with that later. It doesn't work that way because those mental health issues, those environmental issues, those relationship issues that contribute to the person feeling stress are going to slow down the rate at which the brain and the body can recover. The wall. This is the highest risk of relapse. It lasts about 12 to 16 weeks. So by the time the person gets through this period, it's been about Five months, maybe six months since their last use. Remember I said that post acute withdrawal syndrome can last 18 months to two years? We don't want to assume that, hey, if you get through six months, you're gold. No, it is really important to recognize that some symptoms can continue. However, during this several month period is when the brain is doing a whole lot of rebalancing and rebuilding. During this period is when the person is doing a whole lot of treatment and cognitive restructuring and building of supportive relationships and creating a foundation to support recovery and developing tools that they can use to continue to build their recovery. During this period, reconditioning is going on. And some people, like I said, say this is the hardest part of the recovery process. Other people may argue with that, but it depends on the person, and we want to validate their experience in the moment. During this period, physically, their brain and body are still recovering from the effects of the substances. The neurotransmitters, the neurons, the receptors don't just suddenly poof, recover as soon as the person stops using. It takes a while to rebuild those affectively. The person may still be experiencing what we call dysphoria or unpleasant moods. Many times in people's addiction, they've done a lot of stuff that they feel regretful for, that they feel guilty for. They may have a lot of anger, they may have a lot of resentment, they may feel exhausted and depressed. So there may be a lot of issues that are contributing to their dysphoria. Additionally, our moods are created, if you will, by the cocktail of neurochemicals that our brain releases. And if the brain is still not functioning, if the body's still not able to produce the cocktail in the right balance for somebody to feel happiness, for somebody to feel curiosity, then they may still feel what we call anhedonic. They don't feel much of anything at all, or they feel distressful thoughts or distressful feelings. Cognitively, people during this period are still easily overwhelmed and often have poor concentration. Dopamine is one of our main neurochemicals that help us with motivation, focus, attention, and concentration. And we know that dopamine gets all out of whack in addiction. Helping people recognize this and develop strategies to cope with it and to take note, to journal or keep logs, to take note of gradual improvements in their concentration, in their mood, in their energy, can be hugely helpful toward helping them see those gradual moves towards recovery. During this period, people are also engaging in environmental interventions, if you will. They may be having to fix their finances, address their debts. They may be looking for new housing. Whether it's because they lost their housing or their available housing or was still contaminated with the substance. And they may be job seeking, they may have lost their job and need to find another job. All of those things can be really stressful for people relationally. There is still a lot of mistrust and fears from significant others. And the person is having to deal with the guilt. They're having to deal with, processing with their significant others, processing through those people's anger and frustration and heartache. They are hopefully making new friends in support groups and in recovery and also developing their self esteem. But all of these things take energy. Readjustment is the final phase and it's eight weeks or longer, depending again on the substance of choice, the intensity and chronicity of use and any concurrent stressors, including trauma and mental illness. The person in recovery and the family at this point may begin returning to a healthier lifestyle after extended abstinence. So when the person really has, not only do they have tools that they can talk about, that they can tell you about, but they can effectively use those tools to deal with life on life's terms. Once they have that new rhythm and they have really honed some of those new skills, then the person in recovery and family members may begin working on marital, emotional and psychological issues that will hopefully strengthen the family. Now, when we say family, it's important to recognize that family are those people that the person defines as their family. It may not be their blood relatives, it's the people that are supportive of them as human beings and supportive of their recovery. Relapse issues for people in recovery. Well, there can be a lot. And again, I have many videos on relapse prevention. Ultimately, there are three big umbrella issues. Lack of self care, creating vulnerabilities. We often talk about the mnemonic hungry, angry, lonely and tired. If people are not getting adequate nutrition, then the body can't make the hormones and neurotransmitters to support the recovery process and to support happiness. If they are not getting adequate quality sleep, their brain cannot clear out the adenosine from the day they're going to have more difficulty concentrating and they may experience more systemic inflammation which contributes to impaired mood and potentially craving exposure to triggers. Without a relapse prevention plan, and that's the important clause without a relapse prevention plan in the I suggest during the wall period, people start really developing a relapse prevention plan. They start learning what are my physical triggers for use, what physical sensations may make me want to use, what Are my affective or emotional triggers for use? What thoughts do I have that are triggers for use? That stinking thinking that we talk about? What things in my environment, what sights, smells, sounds, may trigger my desire for use, and what relationships or relationship behaviors may trigger my desire to use and how do I deal with those things? That relapse prevention plan is so crucial because you can't avoid all of your triggers. You can't even avoid most of your triggers, probably. So having a relapse prevention plan in place will give you alternatives that you can choose from when faced with a trigger instead of relapse. And finally, a lack of self awareness or mindfulness. Triggers and vulnerabilities. If you're creating vulnerabilities, but you're aware of them, then you can respond. Ideally, you quit creating them, but sometimes you're gonna wake up in the morning and maybe you didn't sleep well through no fault of your own, and that's a trigger for you being tired. Well, if you're self aware of that, then you can do things to protect yourself, so that doesn't end up causing an issue. If you're not self aware, then you're kind of walking blindly through a mind field. The same thing with triggers. When people are not mindful, when they're operating on autopilot, triggers may just suddenly, quote, sneak up on them. And it's much harder to deal with unexpected triggers than it is to cope with triggers that are not so unexpected they don't create a surprise and trigger that stress response. Nearly as strongly. Addiction causes changes in the brain. Using produces feelings of escape or euphoria, which often become associated with people, places and things. When exposed to those people, places or things, people may begin to have cravings. When faced with unpleasant emotions or situations, people also may have cravings. Recovery involves creating new associations and developing new ways to feel good and deal with stress and help the body recovery.