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Journal of Addiction Medicine: 2012, 6(1), p 1–9.
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What is 'recovery' and what does it mean for the roles of treatment and of doctors? This analysis based on the last ten years' writings on the subject draws a parallel with mental health, where recovery in terms of a meaningful and self-directed life is reserved for persisting severe illness resistant to 'cure' via treatment.
Summary This literature review focuses on the history, definitions, and forms of 'recovery' from addiction, its nature and time course, and the implications for managing substance use disorders. The reviewer searched the English-language peer-reviewed literature of the past ten years using the key words "recovery from addiction" and followed up references in retrieved papers.
Over the last 200 years terms for the resolution of severe substance use problems have been based on ideas about the causes of those problems. Such terms have included moral 'reformation', religious 'redemption', criminal 'rehabilitation', and medical 'recovery'.
Traditionally in medicine recovery has connoted a return to health after trauma or illness. In 1939, Alcoholics Anonymous (AA) published the book How more than one hundred men have recovered from alcoholism. For AA 'recovery' was a central concept underpinning the ongoing cognitive, emotional, behavioural, and spiritual reconstruction of the sobered alcoholic, shifting the emphasis from recovery initiation (how to stop drinking) to recovery maintenance (how not to start drinking) and from chemical sobriety to "emotional sobriety".
Though sobriety is central, 12-step movements acknowledge its limitations as the sole defining feature of recovery by recognising 'dry drunk' and 'white knuckling' forms of sobriety. In 1982, the American Society of Addiction Medicine differentiated between recovery ("a state of physical and psychological health, such as his/her abstinence from dependency-producing drug is complete and comfortable") and remission ("freedom from the active signs and symptoms of alcoholism, including the use of substitute drugs, during a period of independent living"), and conceptualised recovery as a "process".
More recent definitions have highlighted the experiential process involved: "recovery is the experience (a process and a sustained status) through which individuals, families, and communities impacted by severe alcohol and other drug (AOD) problems utilize internal and external resources to voluntarily resolve those problems, heal the wounds inflicted by AOD-related problems, actively manage their continued vulnerability to such problems, and develop a healthy, productive, and meaningful life".
A consensus panel convened by the US Betty Ford Institute defined recovery as a "voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship", where "sobriety" meant abstinence from alcohol and other non-prescribed drugs, considered "stable" after five years, "personal health" referred to improved quality of personal life, and "citizenship" to living with regard and respect for those around you.
In mental health and psychiatry, 'recovery' emerged as a reaction to the perceived shortcomings of an established system of care, and is defined somewhat differently. For the American Psychiatric Association, 'cure' through treatment is the resolution route for most mental health problems, while recovery is for the severe and persistently mentally ill. For them, it is seen as "emphasizing a person's capacity to have hope and lead a meaningful life ... It recognizes that patients often feel powerless or disenfranchised, that these feelings can interfere with initiation and maintenance of mental health and medical care and that the best results come when patients feel that treatment decisions are made in ways that suit their cultural, spiritual, and personal ideals. It focuses on wellness and resilience and encourages patients to participate actively in their care, particularly by enabling them to help define the goals of psychopharmacologic and psychotherapeutic treatments".
In both addiction and mental health fields, concepts of recovery have been shaped by service user experience described in firsthand accounts of recovery as individualised growth, emphasising the importance of family and peer support. In contrast, organised systems of care have been seen as focusing on cyclical episodes of symptom manifestation and clinical stabilisation and providing inadequate long-term services and supports. Of note, consumer advocacy in mental health thrived after the onset of deinstitutionalization without appropriately resourced community alternatives. The "learned helplessness" fostered in the asylums of old was replaced by the messages of hope and individual responsibility promoted in recovery.
Of the varieties of recovery, 'natural recovery' without treatment has been found the most common way out of alcohol use disorders, though in some studies for relatively low-risk drinkers to begin with, and usually followed by one or more relapses. Challenging recovery as a 'process' are accounts of sudden 'transformational' change, often an unplanned but permanent reaction to some event which involves profound religious, spiritual, or secular experiences that radically redefine personal identity, interpersonal relationships, and the prior pattern of substance use. 'Medication-assisted' recovery is increasingly recognised as a legitimate variant, exemplified by medically and socially stable patients on methadone. Of significance in defining this variant is whether the medication incites or quells compulsive drug-seeking, enhances or inhibits broader dimensions of global health, and increases or decreases the harm to individuals and their environment.
From these considerations several implications emerge for the management of addiction, among which are:
Strategies for a chronic disorder Implied by seeing addiction recovery as a long-term and ongoing process which does not have an end point. The truism that 'there is no such thing as graduating'; is consistent with the prevalent view of addiction as a chronic condition and with findings that resolving addiction often takes multiple attempts and treatment episodes.
System implications of a recovery paradigm Constructing a continuum of care requires treatment providers to shift focus from acute biopsychosocial stabilisation to sustained recovery management, starting with pre-treatment services to strengthen engagement and motivation and remove obstacles to recovery, then in-treatment services to enhance retention and acquisition of skills transferable to one's community, and finally post-treatment recovery management involving extended monitoring, use of incentives and sanctions, recovery education and coaching, active linkages to communities of recovery, and early re-intervention. This continuum might be delivered via a cost-saving 'stepped care' process, whereby more intensive interventions are reserved for those who would not be or have not been well served by less intensive interventions, and intervention stepped down in intensity as recovery stabilises. To address the workforce needs of this new paradigm, recovery advocacy organisations and peer-based recovery support centres have expanded and new roles such as recovery coaches and personal recovery assistants have been created.
Monitoring and sustenance of recovery Managing addiction as a chronic condition requires more assiduous continuing care protocols such as regular check-ups, which have been found to facilitate early return to treatment when needed and more treatment. Recovery may also be sustained through various mutual help networks, randomised urine testing, journaling and daily readings (mostly based on relapse prevention strategies), the imposition of contingencies for behaviour, and e-health management programmes. Following the trend in other chronic disorders, technology-based initiatives have been developed and tested to improve outcomes and cost-effectiveness.
Although the conceptualisation of recovery from addiction remains complex and a consensual theoretical framework is lacking, nevertheless it is also ushering in a transformation of treatment to a stepping-stone to recovery and to the range of long-term resources needed to sustain it. Major features of recovery include a healing and growth process spanning years rather than weeks or months, involving the initial stepping stones of treatment, such as biopsychosocial stabilisation, skills building, and relapse prevention, followed by a reconstructive journey ultimately aimed at discovering a meaning and purpose to one's life. While originally the goals of 'abstinence' and 'recovery' were used interchangeably, abstinence now emerges as significant means to an end, not the end itself.
This understanding of recovery allows for the inclusion of several pathways, including the use of medically monitored medications, whose recovery status is best evaluated in terms of the motivation for medication use and its effects. Harm reduction programmes not aimed at reducing drug use as such do not preclude, after an appropriate stabilisation period, renewed attempts to achieve a goal of recovery without the assistance of medication.
More so than recovery from other chronic health conditions, recovery in addiction is seen as entailing personal character change – a broader transformation of personal character or identity, enriching one's life with progress toward global health. 'Recovery' is not only about abstaining from drugs but also about becoming a better person.
All this means changes for the roles of doctors to span the recovery-oriented stages of care. They are involved in pre-treatment screening, brief intervention, and referral, acute biopsychosocial management, can provide appropriate medication and (along with other health providers) empirically proven interventions such as motivational interviewing and relapse prevention. At the post-treatment stage, primary care physicians or addiction specialists can provide systematic medical/recovery check-ups, facilitate the provision of health care resources based on a stepped care model, and the provision of laboratory monitoring of substance use associated with rewards and sanctions. The premiere models for such a medical programme are US physician health programmes.
However, this literature and these conceptions overwhelmingly arise from a North American culture shaped by 12-step philosophy. Although the need for mutual help is universally recognised, traditions elsewhere vary in terms of autonomy from professional treatment, tradition of anonymity, and relative role of religion.
Last revised 17 April 2013. First uploaded 17 April 2013
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