Sober Day #70- Those Negative Emotions again.

Seventy seems like a huge number- I feel surprised to find myself here, seventy days since a glass of wine.  It's been much easier than I expected, except when it isn't (y'all likely know what I mean).  Thankfully, the 'isn't's are less intense and less frequent, but I am still uncomfortable with negative emotions.

I am realizing now that negative emotions and events are just part of life.  As the first Noble Truth of Buddhism says, Suffering (dukkah) occurs.  It isn't punishment for something you've done wrong or failed to do, it isn't karma doubling back to slap you in the face, it is just an inevitable part of human existence.

So all normal human life includes negative thoughts, emotions and occurrences.  Once I accept this, it is no longer compelling to need to escape from these via alcohol.  But those old neural connections run deep, and can kick in when I least expect it.

The bonus of accepting and feeling the negative emotions is that when I am not busy blocking thinking about scary things, not busy avoiding them with alcohol, the other things in my environment, including positive events and emotions, become brighter and more intense.  This is one of the major benefits, for me, of backing away from alcohol!!

Sober Day #68: Stress and Thinking

Sobercourage.com just wrote a great post on how to get started with sobriety.  In it she mentions a Time mag cover story in 2007 on How We Get Addicted.  I read this with great interest!

From this story:

"Another fundamental target for addiction treatments is the stress network...stress can increase the desire for drugs."

"The part of the prefrontal cortex that is involved in  deliberate cognition is shut down by stress. " (Carrie says:  this is part of the fight or flight response).  "It's supposed to be, but it's even more so in substance abusers."

"A less responsive frontal cortex sets up addicts to be more impulsive as well".  (Carrie says:  impulsivity includes accepting and consuming alcohol or drugs without fully considering the consequences).

And another piece of my personal puzzle fell into place.

I remembered reading past stories about how success can set people up for failure.  What these studies showed was how stress can set one up for failure to apply logical thinking to situations.

Here's how it works.  Give a big group of students all the same test.  Regardless of performance, tell half that they did really well, but not outstanding.  Tell the other half that they did OK, but might do better another time.  (Remember there was no real difference in performance between the groups; the students were just told that there were).

Then offer both groups a chance to take a similar test, and to use the second score instead of the first. Many more in the 'OK' group chose to take the second test than did those in the 'Really Well' group.  It could be, of course, that the 'Really Well' group decided they were content with a 'good' score, and didn't need to stretch for 'fabulous'.  But in many, it was a fear that they would not do as well on the second exam.  Succeeding the first time made them afraid to tackle the task again.

How does this relate to the Time magazine piece?  Any test is, for most people, a stress.  And in this situation, the prefrontal cortex (Carrie:  this bit is all my connections and conclusions, not part of either article), the deliberate cognition part, begins to respond to stress by shutting down.  This shutting down keeps the 'really well' students from logically concluding that by taking the test once, they are now familiar with the test type and general content, and are likely to do better on a second test.

There are many parallel challenging or stress-inducing situations in each of our lives daily:  the store is out of the one ingredient we need for our special recipe, the washing machine breaks down, one of our kids is behaving badly, etc.   What if we retreat from dealing with these situations logically because stress has shut down our logical thinking? As the Time article says "(The shutdown of prefrontal cognition by stress) is supposed to be, but it's even more so in substance abusers."-  which would make those of us who turn/turned to alcohol for stress relief even more prone to this impulsivity and avoidance of rational considerations.

Here's a very crisp situation where I encountered this in my life.  I've mentioned before the website Lumosity, with brain-training-type games which give short time limits to complete.  On each visit, it sums up your performance with respect to you age peer group.  On my first few visits I did very well, with nice ego-stroking scores.  Then over the next weeks, I kept finding more reasons not to visit.

I finally realized I had some underlying fear of not doing as well on future games as I already had, and seeing my score sink.  "Really, Carrie!", I said to myself.  "A silly computer game is not so stressful that you have to avoid it for fear of your performance!".

After contemplation, I decided that Lumosity was an ideal training ground for me, a limited-risk stress-desensitization opportunity.  An so I have been doing it daily, whether I felt like it or not.  Yes, there is a general upward trend to my scores- but that isn't the point.

The point is:  Lumosity is a situation where I am able to feel stress and practice not shutting down, not shifting my prefrontal lobe into a Fight or Flight response.   And what I can handle here will slowly but surely be translating into my daily life, when a car unexpectedly cuts in front of me, or when the house is on fire, or when someone offers me a lovely glass of wine.  By exercising my ability to keep rational thinking (cognition) present in the face of stress, I am increasing my chances of long-term successful sobriety.

I love it when I find these connections and Aha! moments!!

Sober Day #66- the Burden of Shame

So many new to or considering sobriety talk about shame:  the shame of misusing alcohol, the shame of relationship or job problems caused by over-use of alcohol, the shame of alcohol-fueled obnoxious or illegal behaviour.

And shame feels so bad, so soul-destroying, that we will do almost anything to avoid it.  For most of us, the easiest most familiar escape is the anesthesia of alcohol.  Bottoms up! Pour another glass!

This becomes a very vicious self-replicating circle.  Feel shame, feel bad, escape with alcohol, feel more shame about drinking, more alcohol to escape....  

Shame is a powerful negative, unwarranted and useless emotion.  Useless? you say??.   Unwarranted?  Yes.  Shame involves feeling defective, feeling powerless, feeling as though one doesn't deserve happiness, doesn't deserve sobriety, doesn't even deserve a life.  Shame is poisonous and destructive.  Shame serves no useful purpose, and is a huge de-motivator for sobriety.  (Randles, Tracy 2013- see full reference below)

Guilt can be useful- it may feel bad, but it can also motivate appropriate reparation.  Embarrassment also feels bad, but can motivate avoidance of repeating the situations causing the embarrassment.  But shame?  It just cuts you off at the knees.  It makes you feel useless, defective, unworthy.  And none of us should feel shamed.

It is part of our birthright as human beings that we are inherently worthy people.  We have made mistakes and bad choices, have done things we are sorry about-  but we are still worthy people:  People who deserve to escape the trap of alcohol, people who deserve friends and support, people who deserve to pursue sobriety and happiness.

Let go of shame.  I deserve better, and so do you!


Randles D, Tracy JL.  Nonverbal Displays of Shame Predict Relapse and Declining Health in Recovering Alcoholics.  Clinical Psychological Science, April 2013; vol. 1, 2: pp. 149-155., epub February 4, 2013 

Sober Day #58- Medication help for Quitting Alcohol (long post!)

All of us who have struggled with addiction are wary of adding another medication to our intake- wary of another dependence, wary of in-authenticity, wary of adding to our woes.  But a recently-published study offers a potentially axis-altering option for making quitting a bit easier.  (The full reference is below)

This was a 12 week randomized double-blinded placebo-controlled trial  (DBPCRT).  This is the gold standard for clinical studies:

Randomized:  Participants are randomly assigned to treatment (in this case, active medication) or control (placebo, inactive medication) arms.  This avoids the potential bias of patients ending up in a group because of their own or the researchers expectations of which arm they'll do better in.

Double Blinded:  Neither the participants nor the researchers interacting with the patients are aware of which ones are getting active vs. placebo medication.  This is important because many many studies have shown that expectations (on the part of the patient or the research) can subtly influence interactions, and actually affect outcome.

Like one study of grade school kids and their teachers.  The teachers were told that tests showed certain students were expected to excel during this school year.  Analysis at the end of the year showed that these students had indeed done very well, achieving excellent grades and great evaluations from the teachers.  EXCEPT:  There was no testing.  The students were randomly chosen for the 'expected to excel group'.  Which means this group included the extra-smart and the not-so-smart, the previous-thrivers and the previously-indifferent students.  Expectations of excellence on the part of the teacher apparently helped each student to achieve his/her best.

The medication used in this study was gabapentin (trade name Neurontin), basically an anti-seizure medication.  It has, however, proved useful for lots of other problems.  Chronic cough and laryngeal sensory disorder are areas I have experience with using it, and it can work very well for these.  One really important thing about this medication in the alcohol-context is that is has no abuse potential.  Unlike the benzodiazepenes (valium, klonopin, xanax, etc) frequently used for alcohol withdrawal, and sometimes for help with anxiety in early sobriety, which have major abuse potential.  People have inadvertently replaced an alcohol addiction with a pill addiction!  Other medications like Antabuse cause physical sickness (nausea, vomiting) when alcohol is consumed while taking them.  So these options make Neurontin look like a less disagreeable or dangerous option!

This current study included 150 men and women who were alcohol-dependent, and lasted for 12 weeks.  The participants were divided into 3 groups.  One received placebo tablets, the second received a total of 900 mg of gabapentin daily, and the third received 1800 mg daily.  (The pharmacy prepared special versions of the medication so that the pills received by each of the three groups appeared identical, even though the active medication was different).

The outcomes measures tabulated by the researchers were whether complete abstinence occurred.  And if not complete abstinence,  did the patient at least have no episodes of heavy drinking.  They also looked at some secondary outcomes like changes in mood, sleep, cravings.

Here's where the results get fascinating:

Abstinence rates were 4.1% for the placebo group, 11.1% for the 900 mg a day group, and 17% for the 1800 mg a day group.  This shows a dose-dependent improvement in abstinence, that is, more of the medication was associated with higher abstinence rates.  Further statistical analysis showed that there was a very small chance of such a result occurring by chance alone, allowing presumption of a cause and effect relationship between more medication and better abstinence rates.

Occurrence of No Heavy Drinking showed a similar spread:  22.5% in the placebo group, 29.6% in the 900 mg a day group, and 44.7% in the 1800 mg per day group.

My editorializing:  that means that over 12 weeks,  over 60%, nearly two thirds, of the alcohol-dependent subjects in the 1800 mg per day group made a major change in their alcohol consumption:  17% did not drink at all, and another 44.7% did no heavy drinking.  Wow!

My Epocrates iPhone app says that the maximum dose per day of neurontin is 3600 mg, which obviously leaves more room for research about the optimal dose.

There is no Magic Bullet for quitting alcohol.  And Neurontin (Gabapentin) is not one either.  But perhaps, especially for those who have cycled through Day #1 of Abstinence again and again, getting more and more frustrated-  maybe, just maybe, this could be the little shove over the top that is needed to get to longer abstinence.

CAVEAT:  Although I am a medical doctor, I do not know you individually.  I have not sat with you, listened to your medical history, and examined you.  So this post is tantalizing information to consider, not a prescription for you to start taking Neurontin on your own.  Although impressive, this study mainly opens the door to further questions that need to be answered before this medication is recommended on a routine basis.  What is the best dose?  How long should the medication be continued?  What ancillary services best reinforce this anti-alcohol effect?  Are there particular types of people/drinking patterns for whom this works better/doesn't work?

In the US, at least, this remains a prescription-required medication.   Even if you could get some on your own, it would be A VERY BAD IDEA to experiment with this without the approval of your personal physician!!

Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A.  Gabapentin treatment for alcohol dependence:  a randomized controlled trial.  JAMA Int Med 2013.  doi: 10.1001/jamaintmed.2013.11950

Sober Day #51- Settling into Sober (Neuroplasticity)

It's starting to all add up.  A night without wine is beginning to seem like the norm.  I think about my typical 'before' evenings-  coming home from work and immediately pouring a nice glass of cold crisp white wine.  My norm for so many years-  and yet, thinking about that now, I caught a thought flitting across my mind-  Why would I want to do that?  And I don't, really, most of the time now.

I think it has to do with laying down those new neuronal circuits, connections.  Remember the neuroscientists' maxim:  What fires together wires together?  Think of it in the context of piano practice:  The first time through a new piece, it is awkward and stumbling (for most of us, anyway, lol).  Each time through, our brains change a tiny bit, and the neurons directing each of the finger movements begin to lay down stronger and stronger connections between themselves.  Eventually, those connections are so strong that playing the piece seems automatic, like something you've known forever.  Professional pianists actually grow the part of the brain that controls finger movements to be larger than the normal person's.

So every night that I come home and do something other than pour a glass of wine, the connections between those non-alcohol-consuming activities becomes stronger.  The connection between 'coming home' and 'pour glass of wine' begin to wither, lose strength.  So now there is seldom that automatic thought:  home-wine.

When I was in medical school, they taught us that by early adulthood, the brain was set, finito, no longer capable of changes.  That this is NOT true is one of the most amazing bits of knowledge since then.  Our brains CAN change- a lot- and these changes can continue through our last breath.  This neuroplasticity- the ability of the brain to change, to be plastic- is amazing to contemplate for those of us who want to make major changes in our lives.  It IS possible, we CAN do it!!

I sometimes picture what is happening in my brain-  visualize little construction equipment paving the new roads I want to build, using little jack-hammers to remove the ones I want to change.  It is surprisingly satisfying!

Here's to each of us, building our new brains!!

Sober Day #46- Suddenly a Free Weekend

No trip to visit DH this weekend after all.  Snowing here, snowing there, snowing everywhere in between.  Winter storm advisories, travel advisories:  Not auspicious for a 5 hour drive!

So 15 yo daughter Sadie and I have an open weekend at home.  I'd cancelled all usual weekend classes and engagements in anticipation of being gone.  So there is nothing on the calendar today and tomorrow, nothing we have to do.  This is what I see out the kitchen door (complete with reflected kitchen lights, lol!)

Sad:  Haven't seen sweet husband in almost 2 weeks now.  But we talk/text/skype-  a lot!!  And he will be home here for the entire week of Christmas!!

Glad:  Instead of this being the 4th of 4 weekends out of town, there is a lovely aspect to being at home.  Laundry and dishes are all caught up.  Tree decorating and present wrapping are next.  And this is what I see with a 90 degree turn from that snowy landscape.  Ahhhhh.

Conundrum:  In the not so very distant past (i.e., 46+ days ago), a totally free weekend would have been a joyous time for wine-drinking!  No concerns about driving, no having to be a certain place at a certain time-  a wine free-for-all!  And I DO feel a bit of that pull, toward that lazy, no-concerns, dreamy, floaty place.  But I could never stay there for long.  In my efforts to keep the 'tank' (of alcohol in my system) continuously 'topped up'-  I would always overshoot.  (There's that 'no more, thank you' button that is missing in my system!).  The next stage would be falling asleep, where-ever I was- bed, sofa, dining room chair).   Then waking up groggy and stiff, and starting again.

I guess that's where commitments and obligations, most of which involve driving here or there, kept me from just diving into alcohol and staying there.  But most Mondays I would think:  gosh, that sure was a short weekend!  I really didn't get to do much that I needed to/was looking forward to doing.

This weekend:  I'm focusing on:
     *the pleasure of working toward a clean tidy house
     *enjoying sweet daughter
     *enjoying some cooking-experimenting time
     *pinterest
     *Wall street journal
     *decorating house for Christmas and wrapping presents
     *a new mystery novel
     *catching up on charts and email from work (on my treadmill desk!)
     *working on quilts and glass beads
     *online yoga and pilates classes
     *frolicking with the dogs

That sure looks like enough to fill an entire weekend with nourishing and relaxing activities.

No Alcohol need apply!!

Sober Day #45- Respite and Empty Calories

Yet another calm, no alcohol evening at home.  Excellent!

15 year old daughter and I are planning to drive to the city where daddy/husband works today.  And attend his work Christmas party tonight.  BUT...

There is a winter snow advisory here in our city, and also in his city 5 hours north of here.  They already have about a foot of snow, and are expecting more snow starting this afternoon and continuing through the weekend.  I do have a new car with all-wheel drive.  I guess we'll start out, and be ready to stop for the night or turn back if the roads get treacherous.

It's funny, in thinking about this plans and possible modification, how little thought I've given to alcohol.  In the past, such a journey would have required stock-piling wine, in case we arrived really late- and arguing myself into no alcohol before the journey (at least I've always had good common sense about not drinking and driving- small favors!).  Even with husband's Christmas party this evening, it just hasn't been much on my mind.  And to me, that is really a miracle!

I know Wolfie will be back again, but it is such a gift to have this respite from dealing with him.  Now to tackle the empty calories I've been consuming to keep him at bay!!  On the other hand, I figure I was consuming about 800 - 1000 empty wine calories a day before, so that should give me some leeway!

Sober Day #36- Month Two Blues

The past few days I've been having a more difficult time with alcohol-resisting.  I've even caught the thoughts going through my head "Why am I doing this stupid challenge anyway?" and "Surely just one night of drinking wine wouldn't harm me now?" and "I wouldn't even have to admit it on my blog!"

Oops.  Full stop.  Think again.

#1:  I am committed to telling the truth, the whole truth, and nothing but the truth on this blog.  So much for lying about alcohol intake!!

#2:  I am doing this challenge because alcohol was affecting much more of my life than I felt was safe or healthy.  I am doing this challenge because I made a commitment to it. And I am stubborn.  And I am competitive with myself.  And so I will complete these 100 days, even when it is uncomfortable or stressful.

#3:  In light of these truths, even one night of wine now would be harmful, and I will not do it.

Sigh. 

Sober Day #33- Vitamin D deficiency and Alcohol Use Disorders

Vitamin D (the one we get from sun exposure on our skin) deficiency is wide-spread in the US, and its lack is associated with occurence and worsening of all sorts of chronic inflammatory diseases.  For example, if you plot the average vitamin D levels on a US map, levels get lower and lower as you go further north- which makes sense if you consider the sun exposure and intensity increases as you head south.  The decreasing levels as you head further north correlate with increasing ER visits for asthma. 

This study finds that lower vitamin D levels are associated with more alcohol-use problems in an Asian population.  It's not much of a stretch to guess that the same pattern occurs in the US.  The association, of course, does not prove or disprove causality.  Does low vitamin D predispose to alcohol overuse?  Or does alcohol overuse cause vitamin D deficiency?  Or is there even a direct connection between the two, or might they be totally independent variables?  

What action to take while waiting for more data to answer these questions?  I suggest that each of us should check our serum vitamin D levels, a simple blood test.  If we are indeed low, taking enough vitamin D to bring our levels at least halfway up the range of normal levels (i.e., at least 50-60 nmol/L) will have all sorts of health benefits, and might make (this is a stretch, not fact) early sobriety easier.  (More to come in future posts about other baseline blood and other testing that might be useful in early sobriety).

Abstract

BACKGROUND:

Mounting evidence suggests that deficiency of vitamin D may be associated with major health problems, including alcohol-use disorders (AUD) and major depression (MD). This study aimed to identify the vitamin D status of Nepalese inpatients with an AUD. We explored socio-demographic and alcohol-use related correlates and the relationship between vitamin D deficiency and comorbid MD.

METHODS:

A cross-sectional study was conducted on AUD inpatients (N=174) at eight alcohol/drug treatment centres around Kathmandu. Structured questionnaires were administered to assess the socio-demographic and alcohol-use parameters and to establish DSM-IV diagnoses of AUD and MD. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25(OH)D) concentration of <50nmol/L.

RESULTS:

The prevalence of vitamin D deficiency was 64%. Higher age, having a stable job or business, shorter time since last alcohol intake and winter serum samples were related to having lower 25(OH)D levels. Several features of AUD severity were associated with low vitamin D levels: guilt about drinking, using alcohol as eye-opener, and history of relapse after alcohol treatment (p≤0.03). Patients with a comorbid major depression, in particular secondarily depressed cases, were less likely to have vitamin D deficiency (X(2)=6.8; p=0.01).

CONCLUSIONS:

This study confirms high rates of vitamin D deficiency in alcohol treatment sample and shows a positive association between vitamin D deficiency and severity of alcohol-use disorders. Competing risk and other confounders may help explain the vitamin D status among patients with alcohol-use disorders and comorbid major depression.

Neupane SP, Lien L, Hilberg T, Bramness JG.  Vitamin D deficiency in alcohol-use disorders and its relationship to comorbid major depression: A cross-sectional study of inpatients in Nepal.  Drug Alcohol Depend. 2013;133:480-5.

Sober Day #32- First Holiday/Vacation without Wine

Today it is official!  Thanksgiving without wine, and a week's vacation in New Orleans without wine.  Truly a Milestone for me.

These are the things I did to help ensure my No Wine success this week:

(1)  As soon as we arrived, I stocked up on flavored seltzer water and diet soft drinks.
(2)  I permitted myself food treats this week that I usually steer clear of- my usual diet is No grain, No sugar- and this week I had some of both.
(3)  I arranged distractions of Non-Wine things I enjoy:  crossword puzzles, jigsaw puzzle, new embroidery threat, a quilt that was done except for hand-stitching the binding, a large stash of magazines and a few new books, etc
(4)  I enlisted the help of a few trusted folks- DH, one sister, my nephews- to help distract attention from me if there were questions about my not drinking.  DH was kind enough to refrain from ordering any alcohol when we ate out.
(5)  I took my kindle with me to social gatherings, and occasionally excused myself for a few minutes of Reorientation by Book.
(6)  I invented the Detail Game:  When I feel disoriented or regretful about no wine, I refocus on my surroundings.  I challenge myself to notice at least 10 details that I haven't seen before.  This turns out to be fascinating:  from cracks in the ceiling (a la Madeline in Paris?) to a carved wooden edge to the table I'd never noticed, to a column of caged oyster shells at the restaurant-  this approach seems to add a richness and grounding.

What do you do to help set yourself up for No Alcohol Success?

Sober Day #29- Bone Density Improvement after Quitting Drinking!

As a, ahem, mature female, I do think about my bone density.  I want to keep it strong and normal to support a healthy active life as I age.  My weight-lifting, pilates, yoga, TRX, cardio, etc, certainly help-  but I also know chronic alcohol overuse has an adverse affect on bone density.  Therefore I was very happy to come across the following article.  What I have reprinted here is the article's abstract.  The full reference is at the bottom of the post, for anyone who wishes to review the original article in it's entirety.  It is available at www.pubmed.com as a free full text article.  I have highlighted the bits that are the most relevant!  

AIMS:

The aims of this study were to assess bone mineral density (BMD) and content (BMC), osteocalcin, serum telopeptide, PTH and vitamin D in alcoholics, and to determine if a 6-month period of abstinence leads to changes in these parameters.

METHODS:

Serum osteocalcin, insulin-like growth factor 1 (IGF-1), telopeptide (40 patients) and 1,25 dihydroxyvitamin D, were measured in 28 controls and 77 alcoholic patients, 48 of whom were evaluated again 6 months later. All patients underwent whole-body assessment of BMD by a Hologic QDR-2000 (Waltham, MA, USA) bone densitometer, at the beginning of the study and 6 months later.

RESULTS:

Patients showed higher serum telopeptide levels **(0.59 +/- 0.40 versus 0.19 +/- 0.10 nmol/100 ml, P < 0.001), lower IGF-1 [median = 49, interquartile range (IQR) = 31-121 ng/ml versus 135, IQR = 116-237 ng/ml, P < 0.001], vitamin D [26.5, IQR = 17.0-37.8 pg/ml versus 82.4 (IQR = 60.9-107.4 pg/ml, P < 0.001] and osteocalcin (2.1, IQR = 1.1-3.6 ng/ml versus 6.65, IQR = 4.9-8.8 ng/ml, P < 0.001) than those in controls. Patients also showed lower BMD values, Z- and T-scores at many levels of the skeleton and reduced total BMC. After 6 months, those who continued drinking showed a loss of bone mass, whereas those who abstained showed either no change or increase, differences being especially marked at pelvis, right arm and total BMD and BMC. Simultaneously, abstainers showed a significant increase in osteocalcin (versus a decrease among those who continued drinking). Serum telopeptide increased in both groups.

CONCLUSION:

Ethanol consumption leads to osteopenia, and decreased serum osteocalcin, which improve with abstinence, whereas those who continue drinking show a worsening of both parameters.

Full Reference: 

Alvisa-Negrín J, González-Reimers E, Santolaria-Fernández F, García-Valdecasas-Campelo E, Valls MR, Pelazas-González R, Durán-Castellón MC, de Los Angeles Gómez-Rodríguez M.   Osteopenia in alcoholics: effect of alcohol abstinence. Alcohol Alcohol. 2009;44:468-75.