Helping Clients Manage Their
Cravings continued from page 14
Still , concurrent with the brain ’ s elastic healing , the duration , intensity , and frequency of post-acute withdrawal symptoms does lessen over time . In addition , many people who are in recovery are able to develop and refine their coping skills to assist with cravings so that relapse potential is less probable as time goes on . However , some individuals continue to report cravings even years after the resolution of the disorder , when we would expect post-acute withdrawal to have all but vanished .
I have read a lot over the years about cravings , and despite the number of years that “ The Cocaine Recovery Book ” by Paul Earley , MD , FASAM , has been around , it contains perhaps the best description of cravings I have come across . In Chapter 5 , Dr . Earley describes in detail four types of cravings — reinforced use craving , overt interoceptive craving , covert craving , and conditioned cue craving . I ’ ve summarized each type of craving below and included a link after each description to a short video that depicts each of the craving types in action .
REINFORCED USE CRAVING
Conceptually , this craving type is the easiest to understand . When substances , in any amount , are introduced into the body of someone with a substance use disorder , this craving takes hold and demands the person take more over a longer period of time than was intended , no matter how damaging . When the recovery literature mentions the word “ craving ,” this is the type being referred to ( and none of the others discussed below ).
In treatment , we encourage abstinence from all substances of abuse to avoid reinforced use craving . The concept of “ crossaddiction ” demonstrates that when an individual uses another substance that they explicitly do not consider problematic for them , there ’ s a greater potential for the individual to experience craving to use their drug of choice . A simple corollary : Once a person has ceased using substances of abuse , they will never again experience this type of craving .
I feel compelled to mention here that partial agonist medications like buprenorphine — an opioid used to treat opioid use disorder , acute pain , and chronic pain — complicate the simplistic presentation of reinforced use craving . It can be argued that the dopamine response from the use of partial agonist medications like buprenorphine is much more controlled than illicit substance use : There are no massive spikes and resultant crashes . In this way , buprenorphine and other partial agonist medications actually assist in the management of cravings .
Individuals who choose to use partial agonist medications as a part of a multifaceted treatment plan often face the stigma that they are “ switching one drug for another .” This is not an accurate depiction of how these medications work , and it only further deters their helpful application .
• VIDEO : “ I ’ ll Be a Good Boy ,” a scene depicting reinforced use craving from the 1995 movie , “ The Basketball Diaries ,” featuring Leonardo DiCaprio
VIDEO LINK : https :// www . youtube . com / watch ? v = R- suEQP9i3iw
OVERT INTEROCEPTIVE CRAVING
This type of craving occurs once substance use has ceased . It is described it as overt because the client experiences the craving directly ( this is explained in the next section on Covert Craving ), and it is described as interoceptive because it is triggered by sensations in the body that typically preceded substance use . In the case of cocaine users , for example , they will remember that just before they used to use cocaine , they may have experienced sweaty palms , dry mouth , and gastrointestinal urgency . When former cocaine users experience these same symptoms now , combined with something internal like normal anxiety , a spontaneous thought emerges : “ I want to use .” These types of cravings are a normal occurrence in residential treatment ; in fact , they are the reason that residential treatment exists .
When they occur , treatment staff are trained to help the client by reviewing an established protocol that involves asking the client to :
• Describe what was going on internally and emotionally just before they realized they were craving .
• Catalog those sensations as craving triggers for future reference .
• Briefly describe the craving to their therapist , therapy group , or a supportive friend , stopping short of what they would do if they had alcohol or other drugs . The treatment staff encourages the client to block themselves from romanticizing what would happen if substances were available .
During the period when overt interoceptive cravings are most likely , which can be between 7-40 days of abstinence , two phenomena must be addressed in the treatment setting : romanticizing substances and “ using dreams .” ( See the box on page 16 for more information on both .) continued on page 16 The Advocate Magazine Fall 2021 American Mental Health Counselors Association ( AMHCA ) www . amhca . org
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