The Evolution of Cravings
Featured Guest: Doug Paul
How can we better understand cravings and how they evolve throughout the recovery journey, instead of just assuming they’ll naturally disappear?
We’ll answer this with Foundations Atlanta outpatient treatment director Doug Paul on this episode of Recovery Unscripted.
Interviewer: Hi, I’m here with Doug Paul, thank you so much for being with us.
Interviewee: Glad to be here.
Interviewer: To start out, could you tell us something about your personal story and the journey you took to becoming involved with recovery because you’re in recovery yourself, right?
Interviewee: Yes, I’m in active recovery myself and it’s been over 18 years and it just takes my breath away. When you even think about that the amount of time. That is something that when I checked into treatment I didn’t never want. I never wanted 18 years sober. I just wanted my current symptoms just go away.
Interviewer: Because you couldn’t imagine that life?
Interviewee: No way. There was no possible way for me to imagine that. It was so far out there that it was just completely out of grasp and that makes sense. Now as I sit here and with the people that I work with because they go 18 years, that’s meaningless to me. I just want my current symptoms to go away and I’d go, “Yes, I remember that”. That’s what I wanted to do. It’s like a snowball, you just want the current symptoms to go away and then you get a little bit of time and then that snowball grows bigger and bigger.
Pretty soon it’s something that you don’t have to really push anymore. It just rolls down the hill on its own and it becomes this, what I call a self-sustaining recovery programs. Something that doesn’t require treatment any longer.
Interviewer: It begins to make sense for you.
Interviewee: Exactly, and it’s something that I can learn how to manage on my own as time goes by. Yes.
Interviewer: Then you began to give back and see this as a calling and you started working in this field. How did that journey began and where did you start?
Interviewee: I had gotten a couple of years under my belt and through the context of 12 step I had learned through them how to give back and that was something that was rewarding to me. I just like, “Well, let me look into this thing about becoming a counselor”. I went back to my counselor and I said, “How does that work?” He said, “You have a bachelor’s, but what you really need is a master’s degree”. I was like, “I really don’t want to go back to school, but I can do it I could probably do that.” I had very little confidence in my ability to be able to make it through Grad school.
Then when I got there I was like, “Okay, this isn’t as bad as I thought”. Like a lot of things in life when you get there, you’re like, “This isn’t as bad as I thought”. I went into grad school with full knowledge that this was what I wanted to do. Unlike a lot of my cohorts where they were like, well, “I don’t know what counseling I want to go into. That’s what I’m here to discover.” I was like, “No, I already know this is what I want to do”.
All my assignments, every book I read, every assignment I presented was all geared towards substance use disorder treatment. I had that underneath my belt. My internship site was a substance use disorder treatment center. Then my first job out of Grad school two weeks after graduation was at Tava recovery.
Interviewer: Yes. Now you’ve continued with that working with foundations in Atlanta. How did that start and how do you describe the overall approach and philosophy there at midtown?
Interviewee: The transition into midtown was a little bit long and winding. I started at topic recovery with the young adult program and helped get that program up and running and was there for seven years. I was at the main campus for half that time. Then the outpatient Dunwoody campus for the other half of that time.
Interviewer: That’s also a foundation related programming Atlanta?
Interviewee: Yes. We’re all one big happy family. Then I transitioned over to the Roswell outpatient and was a therapist there for a period and then transitioned into the clinical direction role there. It has been a long journey to be able to get to now finally get to midtown and I’ve been there for about four months and I’m really enjoying the role that I have there. It’s more of a dual role where I’m doing operations work and clinical direction. It’s a big learning curve for me. I’m excited about learning new stuff. Mainly the thing that’s so exciting about this role is that I get to look at bigger picture stuff.
How can I impact not just my own caseload of six or eight or 10 patients at a time, but a team of therapists who have six or eight or 10 patients at a time. Help them develop treatment plans and work with their patients in a way that aligns with the foundations role model. That’s the thing that’s really exciting to me.
Interviewer: Yes. I’ve been to the midtown neighborhood Atlanta and a lot of cities that would be called the downtown because it is huge. There’s tall buildings. Are you reaching a lot of business people? Like big people, without patient care, that’s something you can do like before or after work is a lot of functional alcoholics and stuff like that?
Interviewee: Yes. They like to think of themselves as functional alcoholics. I tried to get them to reframe that term that’s not really a thing. At some level of their life things are not going well. There’s some dysfunction there. That’s a little bit part of the denial system, but yes, we do work with a lot of professionals. We have a great LGBTQIA program just because Atlanta has a booming population there and we’re centrally located. Atlanta has really bad traffic and that’s another reason why we get a lot of folks from in that one area because I just don’t want to have to travel from long distances to get to their home base. We do have a lot of folks from that central Atlanta area even Decatur midtown, Buckhead that whole area.
Interviewer: Yes. That’s great you were able to reach them in their neighborhood where they are. Cool. Then here at moments of change, you’re presenting on a multifaceted approach to cravings management. To start this part of the conversation could you describe how you define cravings. Like a unique part of everything that makes up a substance use disorder?
Interviewee: Wow, it’s a complex question and a simple question of all of the definitions in the DSM for different psychological disorders. Craving is probably one of the simplest definitions and it’s just the DSM defines it as a strong urge to use just a couple of words in that definition. When we talk about the craving patterns that I’m presenting, it gets a little bit more complex. I’m using information directly out of a book by Dr. Paul Earley Who’s president elective, ASAM, American Society of addiction medicine. He wrote a book years ago called the cocaine recovery book.
I’m drawing from his writing out of chapter five in his book and I talk about the four patterns of cravings that he outlines in this book. Which of all the reading that I’ve done are the best description that I’ve seen of different craving patterns. While the DSM defines it with a couple of words, Dr Earley takes those words and expands them out into a much broader description of what cravings are and how to recognize them. I think of my presentation as watching a Scorsese movie or something. You’re looking at this character of cravings and watching the arc of the character develop over the period of time of Earley recovery a year to 18 months.
Interviewer: Doesn’t stay static.
Interviewee: Exactly. That’s one of the things about the DSM they make it very clear. All of these 11 symptoms, cravings is the one that sticks around. Even well past the first year of recovery, people with double digits, years of abstinence continue to report occasional cravings. It’s something that we have to address. We have to be talking about it with our patient.
Interviewer: Yes. That gets into the next thing I was going to ask because we all know recovery is a lifetime pursuit, a lifetime journey. Do you think cravings eventually weigh in? I know it changes. It has that arc, but it never really goes away. Is that what you’re saying?
Interviewee: It does two things and it’s interesting. Number one, they reduce in duration, intensity, frequency and I get better at managing them. As I get better at managing them, they’re going down in intensity, duration, frequency. It gets to a point where I don’t necessarily need to rely on traditional counseling services because I get to the point in my where I’ve gotten good at managing them in. Good at recognizing them. That’s one of the key components of my talk is about how do we as clinicians recognize what we’re seeing in front of us. Is this a craving?
If it is a craving that kicks in our techniques. With patients we take that information and we train them. Here’s how to manage your cravings, here’s how to recognize when you’re having a craving and when you have one, your techniques should just kick right in.
Interviewer: Yes. That’s part of like getting to know yourself and getting recognized because it be unique signs for every different person. As you mentioned you’ll be highlighting in your presentation about these four different types of craving patterns. Could you walk us through each of those and introduce them and how they affect patients?
Interviewee: Sure. This is directly out of Dr. Earley books, so I’m going to reference him on multiple occasions throughout this talk because he’s the one who sat me down and was like, “Hey, this chapter, if you’re interested in cravings, this chapters is going to be a good resource for you.” and I read through and I was like,”Oh my gosh, yes it was fantastic.” I was able to over the years, first I started developing this talk by delivering it to patient groups and education lectures. Then I was like I think therapists need to know this too because I don’t think people really know this information. He starts in Chapter Five and starts to outline several different craving types.
The first one is reinforced use which is when a patient takes in substances, chemically something happens with them and they crave more of the substance. Conceptually, that one’s the easiest one to understand. The second one is overt cravings where a patient has been in abstinence for a period of time and they have an overt craving that they recognize as this is something that is driving me back to the substance and I don’t necessarily want to use it but my body is craving it.
Interviewer: Just biologically, physically?
Interviewee: Exactly. The third type is a covert craving. This one is much more difficult to recognize. It can take on multiple different forms in a treatment setting and it’s important for the clinicians to be able to recognize this one because patients aren’t going to. Their peers will see it in them, but the patient will not recognize it themselves.
It’s up to the staff and their peers and the program that they’re in to develop techniques to intervene on this particular type of craving. The last type of craving is a condition que craving. That one runs underneath like underground river. It’s underneath all of the other craving types and runs all the way through the period of what we call post-acute withdrawal into middle stage recovery and that one is related to associations that we create for.
Interviewer: You see a place, you see a person, you smell the smell and that brings that up. With the third one, how do you clinicians learn to help people recognize that with the covert?
Interviewee: They have to come to the top.
Interviewer: I’m sure there’s much more to it. [crosstalk].
Interviewee: There is, yes. It’s a challenging thing I’ve got. The thing about the talk is I’ve got videos and anecdotal examples and we spend 25 minutes just on covert cravings. Basically, to narrow it down to a few key points is to watch for irritability, watch for a sense of feeling cured, and immediacy about non recovery goals, are the three key points that Dr. Earley highlights in Chapter Five in his book.
Those are the three key points that I try to bring up. I take those three and I expand them out into anecdotal examples and videos that we get to watch. For the viewer, for the participant of the lecture, they’re looking for these types of cravings now. It’s like an awareness thing for them of like, “What? It’s hidden but now I know the little tiny subtle signs and symptoms of this particular covert craving.” I get to watch as that ark concludes.
Interviewer: You mentioned the DSM recognition earlier. How would you say that that official recognition in the manual affects how providers approach cravings in substance use treatment?
Interviewee: It gave us a formal platform to begin talking about. It’s not like before the DSM5 came out in October 2015 officially is like the date when we started using it, the people weren’t already talking about cravings. We were talking about them all the time. Now we’ve got a formal platform to bring them up and we also have a formal platform with reimbursement as well.
That’s one of the key points that I bring up in the talk is that now I’ve got a platform to go to insurance companies and go, “This patient is experiencing relentless daily cravings and they’re disrupted to the point where they’re not able to function. They’re not sleeping well, they’re not eating well, they’re not thinking clearly. It’s impacting a lot of different areas of their life just because of cravings.” Now insurance companies are starting to recognize that. There are some more days here and there because of that discussion being more open and to talk about.
Interviewer: Then that gets into some of the techniques for treating it. I know you’re going to cover some pharmaceutical options and then some non medicinal options as well. Could you start with the pharmaceutical options that might help in these cases?
Interviewee: We’ve got many, because I’m not a doctor, I can’t go into detailed discussion about those types of medications but as clinicians, we all need to know about these medications. We need to know what they’re called, what mechanism of action they work on, which patient would probably be the best, and more appropriately, what’s the motivational tool that I can use with any particular client to underline what they’re struggling with and how medications can help. Our first line of defense is always behavioral. We’re going to train you.
So much of treatment is about behavioral training. We’re going to train you how to manage cravings and when those cravings are not effectively managed to your behavioral techniques, medicines can come in and help. It’s like if I ask you to go out and dig a ditch 100 feet long, that’s a lot of work. It’s going to take you all day. I say,”I’ll do 75 feet of it. Okay, I can handle 25 feet. I can go dig a 25 feet ditch. I can do that just a couple of hours instead of spending all day in hot sun.”
Interviewer: Now looking at it as the solution or the cure but as something that can help with the work that you already done.
Interviewer: Then what about the non-medicinal techniques? You’ll talk about the DVT, 12 Steps. [crosstalk]
Interviewee: Sure. That is wrapped up throughout the talk. It’s from the first minute all the way through to the last minute we talk about behavioral techniques. Things like playing the tape all the way through to the end that helps with the first type of craving reinforced use. The second one-
Interviewer: What do you mean the tape?
Interviewee: One of the characteristics of addiction is the inability to see how substances are going to impact me. When I first think of substance use, the only thing I can think of is the pleasure that I’m going to get from it.
Interviewer: Immediate need.
Interviewee: Exactly. I can’t see what happens down the road. The technique of playing the tape to the end is, let me think about what’s going to happen later instead of just right now. I’m craving right now but that doesn’t mean that it’s not going to end up with negative consequences because that’s what drove me into treatment to begin with. It’s the negative stuff. Let me play the tape to the very end so that I understand that it’s going to have negative consequences that can help me manage that thought in the moment. Predicting how that’s going to negatively impact me in the future.
Interviewer: Anything else about DBT, 12 Steps, do you want to cover any of that?
Interviewee: DBT is integral. We’re getting more and more research every day about how DBT and substance use disorder treatment can be integrated. There are several talks this week about DBT techniques. Being in the moment, looking down at my feet and looking at which direction my toes are pointed, that’s going to help me understand.
If my toes are pointed towards the door and I’m having a craving, then where am I going to go? I’m going towards the door. My toes are pointing towards the middle of the room, I’m going to be here in the middle. I’m going to be here in the moment. That goes along with mindfulness techniques.
Interviewer: Looking at it in a broader view now, what do you wish more therapists in treatment professionals understood about cravings and how to approach them?
Interviewee: Let me think about that for a minute. It would probably be opening up to the idea that there’s more than just one type of craving. That’s what I think the talk does so well at explaining is, the DSM has got four or five words to describe cravings but we’re going to spend an hour and a half talking about them. In expanding our knowledge base of what are they, how do I recognize them, and then how do I reframe what a patient is experiencing?
I’m sitting in a group of eight or 10 patients, I’ve got in front of me a male patient who’s been drinking for 25 years, now has 10 days abstinence. I asked him in a group setting, “How are your cravings?” He says, “What cravings?” Is that accurate? Is it accurate that he is not experiencing any cravings or is it more likely that he doesn’t know how to label them? He doesn’t know how to recognize them.
Interviewer: Or they’re not the cravings that he used to think of as cravings. They’ve changed and he does not recognize them.
Interviewer: What else do you hope that attendees might take away from your presentation here at the conference?
Interviewee: Let me think about that one. That’s a good question. Recognition of cravings and then some additional techniques, so many of the techniques that I talk about in the lecture, a lot of people already know and they’ve been using. It’s really just a highlight of, here’s maybe why you’re using that particular technique but also which technique aligns with which craving type. It really is just an explanation of techniques that are already out there within the counseling world and the substance use disorder treatment world, but I align them with different craving types. So then it helps for the clinician to conceptualize, “Okay, if I’m using this intervention, which craving type am I seeing?”
Interviewer: Yes and so you’ve been serving in this field for over a decade now, right? You’ve been in recovery yourself for 18 years, you said. Could you sum up why this mission of helping people find recovery, passing along the recovery that you found to other people, but why is that so important to you?
Interviewee: I think it goes back to my initial training, my treatment which was, you can’t keep what you have unless you give it away, and the people that I remember so fondly, that helped me in the very beginning did it for no other reason than to help themselves stay clean and sober. So, I often look back at my recovery and and then I look back at my career, and I wonder how much has my career choice impacted my recovery? And I don’t know the answer to that, because there’s no way for me to possibly say-
Interviewer: Follow a different path. [laughs]
Interviewee: -taking a different path what would have happened. Who knows? The proof is in the pudding, right? I’m sitting here today, clean, sober. That’s a wonderful thing, and I’m grateful for that. I don’t know what would have happened if I had taken a left instead of a right, 10 years ago, 12 years ago? Who knows?
Interviewer: Yes, and maybe you can, I’m sure you are, then helping people kind of discover that for themselves. Yes, and so before we wrap up, I know we have a special musical presentation going on here and we talked about this yesterday. We both have history as musicians, we understand the power of music, how big that can be for impacting our life, and you actually have an original song to share that ties in with all this. So before we get to that, could you say a little bit about how you use music in treatment for patients, part of your own recovery, just kind of like, where does that rest in all of this video?
Interviewee: I mean, for me, music is very closely tied in with my recovery. In the months leading up to me going to treatment, I was living in Nashville, playing music, trying to play music, it wasn’t going very well [laughs] and when I started to go to treatment, with the help of my family, I got into treatment and I took my musical stuff, and I put it away. And that was something that I needed to do for me. And I knew that I could not be going out into restaurants and bars and playing four or five nights a week, that was something I couldn’t do and I knew that. And so, I would take the guitar out of the case on my own, but I was not going out and performing or being professional with it at all.
So it got to a point in my recovery where I was like,”Okay, I think I’m okay, now, I think I can start to venture backed out into that.” and it was something that was incredibly fulfilling for me to be able to perform and play and write and produce and record. I did that for a number of years professionally before I went back to school to grad school. Then even through grad school and into my early career, I was doing it professionally for a number of years before I kind of transitioned and said, “Okay, I’m having kids and a family now and playing out in bars until one o’clock in the morning just doesn’t align with that any longer.” and you and I talked about that.
Interviewer: Yes we talked about that, it has, it has its place it has its pros and cons. But yes, it’s a different seasons of life for sure. And then how do you use it like, admin town at Roswell? How do you use that to help patients kind of understand what they’re going through that kind of thing?
Interviewee: Music is a universal language, and it has been as long as we’ve been on this planet. It has been something that surpasses my ability to describe feelings. I can express myself in a way through music that can’t be done with words, and so that’s one of the pieces that I bring into the group as an experiential experience of we’re going to listen to some music during group today. I’m going to play some music and then we’re going to talk about what that means. One of my favorite exercises is to have a client come into group and not perform but play like on YouTube, or something, or a podcast or something. Play a song that they relate to, and then have them play the opposite of that song and it gets them to start thinking about, “Well, wait a minute, what’s the opposite of a song?”, I don’t even know.
I’d have to really start to think about what is that? How can I describe that? And oftentimes they can, and they end up just picking a song that displays a feeling for them that they can’t put into words.
Interviewer: Yes, and so it’s kind of causes them to have to quantify, like those emotions as feelings yes.
Interviewer: All right, so now without further ado, we’re going to have the first live musical presentation here on Recovery Unscripted, and it will be Doug Paul with my chemical house.