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[US] Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Intellectual Disability Services and Northeast Addiction Technology Transfer Center, 2012.
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Positive message of this compendious synthesis of hundreds of studies is that "Recovery is not an aberration achieved by a small and morally enlightened minority of addicted people. If there is a natural developmental momentum within the course of [these] problems, it is toward remission and recovery."
Summary Emergence of recovery as an organising paradigm for addiction treatment and the larger arena of behavioural health care underscores the need to measure both early recovery initiation and stabilisation and the prevalence of long-term recovery maintenance. Such measurement is critical in evaluating addiction treatment as a system of care and monitoring broader dimensions of community health.
Efforts to measure recovery are challenged by the lack of professional and cultural consensus on the definition and measurement of key constructs (recovery, remission, abstinence, and subclinical/asymptomatic/controlled/moderate use) and by conflicting rates of recovery reported across clinically and culturally diverse populations in studies marked by widely varying methodologies, follow-up periods, and follow-up rates. Of particular import is the wide divergence between portrayals of the natural course of alcohol and other drug problems in community populations and portrayals of such problems in clinical populations following specialised treatment. These divergent portrayals constitute the ultimate 'apples and oranges' of this arena.
The question of recovery stability and prevalence is more than an academic one. The constant media onslaught of celebrities heading back to 'rehab' after their latest falls from grace has produced a public unsure what 'recovery' means and whether it is really attainable for all, or for only a few 'morally enlightened' exceptions. Failure of a celebrity to achieve stable recovery attracts great cultural attention, while the masses in long-term recovery pass invisibly through our culture each day. Recovery surrounds us in our neighbourhoods, businesses, schools, and houses of worship, but we do not see it. We see instead the highly visible fruits of the problem. The pessimism flowing from such selective attention feeds misunderstanding and fuels stigma and its far-reaching consequences.
This paper reviews 415 scientific studies of recovery outcomes (79 community studies, 276 adult clinical studies, and 60 adolescent clinical studies) conducted with clinically and culturally diverse populations in multiple countries over the past century. It provides preliminary answers to five of the most important questions about recovery from alcohol and other drug problems.
1 How many people are in recovery from substance use disorders in the United States? This was answered by extrapolating national estimates from the major governmental surveys Including: the Epidemiologic Catchment Area Study; the National Comorbidity Survey and its replication, the National Health Interview; the National Longitudinal Alcohol Epidemiologic Survey; and the National Epidemiologic Survey on Alcohol and Related Conditions. of the course of alcohol and other drug use and related problems and from a 2010 recovery survey conducted by the Public Health Management Corporation in Philadelphia and six surrounding counties. Based on this analysis, the proportion of adults in the general US population in remission Meaning that the person once met diagnostic criteria for a substance use disorder but has not met such criteria in the past year. from substance use disorders ranges from 5.3% to 15.3%. These rates produce a conservative estimate of more than 25 million adults Not including those in remission from nicotine dependence alone. in remission from significant alcohol or drug problems in the United States and possibly up to 40 million.
2 What percentage of those who develop alcohol or drug problems eventually achieve remission/recovery? Of adults surveyed in the general population who once met lifetime criteria for substance use disorders, an average of 49.9% (53.9% in studies conducted since 2000) no longer meet those criteria. In community studies (ie, not sampling treatment populations only) reporting both remission rates and abstinence rates for substance use disorders, an average of 43.5% of people who have ever had these disorders achieved remission, but only 17.9% did so In relation to this high prevalence of non-abstinent remissions in community populations, it should be noted that alcohol and other drug problems in the community – even problems that meet diagnostic criteria for substance use disorders – are generally less severe, less complex, and less prolonged than those problems found among people starting treatment for substance use problems in the United States. through complete abstinence.
3 What is the rate of remission/recovery for people whose problems are severe enough to warrant professional treatment? Across 276 substance use treatment follow-up studies of adult clinical samples, the average remission/recovery rate was 47.6% (50.3% in studies published since 2000). In studies with sample sizes of 300 or more and follow-up periods of five or more years – used as proxy for greater methodological sophistication – average remission/recovery rates were 46.4% and 46.3%, respectively. In the 50 adult clinical studies reporting both remission and abstinence rates, the average remission rate was 52.1%, and the average abstinence rate was 30.3%.This 21.8% difference appears to reflect the proportion in post-treatment follow-up studies who are using alcohol and/or other drugs asymptomatically or are experiencing problems not severe enough to meet diagnostic criteria for substance use disorders.
4 Does the rate of remission/recovery for adolescents following specialised treatment differ from that of adults? Yes. This analysis compares 276 adult substance use treatment outcome studies conducted between 1868 and 2011 with 60 adolescent substance use treatment outcome studies between 1979 and 2011. The average recovery/remission rate following specialty treatment for adolescents was 42% (35% for studies since 2000), compared to 47.6% for adults (50.3% for studies since 2000). Interpretation of this finding should be tempered by the greater number of adult studies and their larger sample sizes and much longer follow-up periods. While the high percentage of adolescents who report some alcohol or drug use in the months following treatment is discouraging, longer-term studies confirm post-treatment increases in abstinence, reductions in use, and gains in global health among treated adolescents. There is cause for optimism regarding adolescents' long-term prospects for recovery from substance use disorders.
5 How can local communities establish baseline remission/recovery prevalence data? To evaluate community-wide strategies by tracking changes in recovery prevalence over time, local communities can integrate recovery prevalence questions into regular community health surveys. A model for potential replication is the integration of recovery prevalence questions into the bi-annual community health survey conducted in Philadelphia and surrounding counties. Such baseline data are being used there and could be used in other communities to guide recovery-focused systems-transformation efforts and to evaluate planned interventions in particular geographical areas (eg, evaluating service needs by postcode/planning areas and matching treatment/recovery support resources to areas where problem severity is highest and recovery capital lowest).
Instability within the course of alcohol and drug problems and their resolution Point-in-time or short-term studies can mask the complex course of these problems by conveying prognoses that are overly optimistic (assumption that short periods of abstinence or remission are naturally sustainable) or overly pessimistic (assumption that persons resuming substance use following intervention will all revert to symptomatic use and further escalation of problem severity). Periods of abstinence as long as three months are prevailing features of addiction careers and should not be interpreted as sustainable recovery or as evidence that professional help or peer support is not indicated. Successful recovery initiation is distinguishable from a respite within a prolonged addiction career only within a longer time perspective. Both addiction and recovery are best viewed as fluid rather than fixed states, but buried within this fluidity is a natural momentum toward remission and recovery. Even the most chronic, intractable patterns of addiction contain opportunities for full recovery, and buried within even the most seemingly solid recoveries lie vulnerabilities for reactivation of addiction. This fluidity underscores the need for sustained and assertive recovery management.
Windows of opportunity for early re-intervention Of those who resume alcohol or drug use following treatment, most do so in the first days and weeks. This underscores the need for and value of assertive approaches to post-treatment monitoring, support, and early re-intervention.
Role of community in recovery The effects of brief professional interventions on long-term recovery outcomes are more ephemeral than enduring family and social support within one's natural environment. Recovery prevalence is influenced by personal and family factors and by broader historical, cultural, political, and economic influences on the resources available to those who have developed severe problems. Recovery prevalence is shaped as much by community recovery capital as by personal recovery capital.
Solution perspective versus problem perspective Substantial benefits might accrue from studies of the prevalence, pathways, stages, and styles of long-term recovery, but not until recently have these been the subject of focused attention. Much of the data available about recovery in this analysis has been extracted from studies of other issues such as the duration of treatment effects, relapse rates, or mortality rates. It is time for focused attention on the lived solutions to alcohol and drug problems at personal, family, organisational, community, and cultural levels.
Definition and measurement Challenges in defining and measuring recovery can be overcome to generate national, regional, state, and local recovery prevalence data for purposes of planning, resource allocation, and programme- and system-wide performance evaluation. The establishment of such a recovery-focused database should be a high priority.
Recovery mobilisation There is a significant population of individuals and families in recovery from alcohol and drug problems in the United States who could be mobilised more widely to support prevention and early intervention programmes, serve as volunteers in addiction treatment and recovery support programmes, and provide leadership of policy advocacy initiatives. Those who were once part of the problem constitute underutilised resources in the search for fresh solutions to America's alcohol and drug problems.
Recovery momentum Studies of clinical populations suffering from severe, prolonged addictions – and the selective media coverage of these populations – create a pessimistic portrayal of the prospects for long-term recovery. According to the data reviewed in this paper, 'insanity', prolonged institutionalisation, and death are not the normative outcomes of alcohol or drug problems. Recovery is not an aberration achieved by a small and morally enlightened minority of addicted people. If there is a natural developmental momentum within the course of these problems, it is toward remission and recovery. The central problem is not the difficulty of making recovery possible – that potential clearly exists. It is instead the long time between problem onset and successful recovery stabilisation – and the significant harm to individuals, families, and communities in the interim.
Key questions and challenges Recovery from a substance use disorder is more the norm than an anomaly. Given what we know about recovery prevalence and the natural momentum toward recovery, the central research, clinical, and policy questions are:
• What characteristics of the adolescent, family, treatment milieu, and community environment promote or inhibit the achievement of long-term recovery?
• What strategies can be used to enhance the resolution of less severe alcohol and drug problems (via the elevation of community recovery capital) without the need for professional interventions?
• How can addiction careers be prevented, quickly aborted, or shortened, and recovery careers extended, to reduce addiction's toll on the individual, family, workplace, community, and society?
• What professional and peer support interventions can successfully elevate recovery outcomes for those with the greatest problem severity/complexity/chronicity and the least recovery capital?
• How can recovering people and their families be mobilised to break intergenerational cycles of alcohol and drug problem transmission and to serve as a healing force within their local communities and the country as a whole?
These questions lie at the centre of the movement to shift substance use treatment from a model of acute biopsychosocial stabilisation to a model of sustained recovery management for individuals, families, and communities.
Thanks for their comments on this entry to author William White of Chestnut Health Systems in the USA. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 07 October 2013. First uploaded 04 October 2013
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