factors in recovery

The Recovery Process

Following on from our recent blog on “What does Recovery mean to you?” we now look at the process of recovery itself and important changes that contribute to successful recovery.

Many recovering persons report quitting drugs because they are ‘sick and tired’ of the drug life. Recovery is the path to a better life but that path is often challenging and stressful.

However, the main message from this study (1) is that those individuals who manage to get to  5 or more years abstinence have an 86% chance of long term recovery !

Not only do the recovering persons benefit in many ways but families and societies also see major benefits of recovery too. The initial cost of recovery, i.e. if via treatment facilities, is offset by increased employment, less penal costs, financial contributions to society of recovering persons etc.

Not only does it make ethical, moral and medical sense to spend much more on treatment facilities it makes makes very obvious financial sense.

Although substance use disorders are increasingly recognized as chronic relapsing conditions that often span decades and require multiple episodes of treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001; Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos 2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome 2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996), approximately 60% of the people with lifetime substance disorders do eventually reach a state of sustained abstinence (Cunningham 1999a, 1999b; Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).

This has led to multiple calls to define and better understand and study “recovery” in terms of not only abstinence but improvements in health, mental health, coping, housing, social and spiritual support, illegal activity, and vocational engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen, and White 2006; Laudet, White, and Storey [in press]; White 2005).

Using data from 1,162 adults living in a large metropolitan area who sought substance abuse treatment in 1998 and who were subsequently interviewed annually between Years 2 and 8 (greater than 94% follow-up rate each year), this study addresses the following four questions:

1. How do health, mental health, and coping vary by duration of abstinence?

2. How do illegal activity, incarceration, employment, and family income vary by duration of abstinence?

3. How do housing, clean and sober friends, recovery environment, self-efficacy to resist relapse, and social and spiritual support vary by duration of abstinence?

4. How does the likelihood of sustaining abstinence another year vary by the duration of abstinence?

Health, mental health, and coping. Abstinence is generally associated with better health, mental health, and coping. Among people in the community, less substance use is associated with lower rates of chronic health and psychiatric problems, which are in turn associated with high societal costs and death (Mokdad et al. 2004).

Abstinence is also associated with less “avoidance” coping styles, such as cognitive avoidance and emotional discharge, as well as more “approach” coping styles, such as logical analysis, seeking guidance, problem solving, seeking alternative rewards, and positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos 2005).

Abstinence has generally been associated with reductions in illegal activity, incarceration, poverty, and improvements in vocational activity. Reductions in substance use are associated with relatively rapid reductions in illegal activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).

Although this often involves some period of residential treatment or incarceration, such costs are typically offset by reductions in other costs to society, increased employment, and increased productivity (Bray et al. 2000; French, Salome, and Carney 2002; McCollister and French 2003; Rajkumar and French 1997; Single et al. 1998).

Abstinence is generally associated with being housed and having some friends, fewer problems in the recovery environment, and more personal, family, social, and spiritual support.

Risks (e.g., substance use among family, friends, and victimization) and protective factors (e.g., treatment and self-help participation, peers in recovery) in the recovery environment and self-efficacy to resist relapse were also among the major predictors of transitions from using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte et al. 2001; Scott et al. 2005b).

The general association between relapse and stress has also been found to be moderated by the extent of support one gets from self-perceived personal strengths, family, and social peers (Jessor, Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996; Procidano and Heller 1983; Schutte et al. 2001).

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We found no studies to date using the “duration of abstinence” to predict the likelihood of sustaining abstinence for another year. However, a recent extensive review by Moos and Moos (2007) found one or more of four dozen studies reporting that the odds of sustaining abstinence was positively associated with abstinence self-efficacy, approach coping styles, vocational engagement, income, having clean and sober friends, and having social and spiritual support and inversely related to an avoidance approach coping style.

Findings – This study demonstrates that duration of abstinence is related to changes in other aspects of recovery but at different rates and times.

Use of coping mechanisms started out high and decreased as the number of years of abstinence increased, suggesting that the high rates of these coping strategies previously reported by others (see Moos and Moos 2007) may actually be a characteristic of early abstinence. Mental health problems peaked during 1 to 3 years of abstinence and decreased thereafter.

The rapid decrease in illegal activity and illegal income sustained across varying lengths of abstinence was consistent with the literature given that many of the crimes were drug related. Following 1 year of abstinence, the number of days worked and legal income generated significantly increased and days with financial problems decreased. After 3 years of abstinence, there were also significant reductions in the percentage of families living below the poverty line, which indicates continued gains in financial status.

Consistent with the literature, the duration of abstinence was associated with reduced environmental risks and increased number of clean and sober friends, level of social support, spiritual support, and self-efficacy to resist relapse.

The odds of sustaining abstinence increased dramatically during the first 3 years and then leveled off. Among people with 5 or more years of abstinence, there was still some risk of relapse (14%) – but equally a 86% chance of remaining in recovery!

Consistent with earlier findings by Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al. [in press]) that women were more likely to enter and stay in recovery.

Implications for Practice, Policy, and Research

Findings suggest the need for a shift from focusing on acute episodes of treatment to the management of recovery during longer periods of time.

Most of the drug abuse treatment research to date has focused on reducing days of use or abstinence in the first 6 to 12 months after treatment (Dennis and Scott [in press]; Prendergast et al. 2002). More health services research is needed on managing long-term recovery, both in terms of how to deliver it in ways that are both effective and cost effective for multiple years. This includes research on ways to integrate these other kinds of services, minimize some of the negative trends (e.g., the early peak in mental health problems), and accelerate the positive trends (e.g., more positive recovery environment and vocational activity).

Conclusion

Although much of the research on substance abuse treatment outcomes has focused on abstinence in the first 6 to 12 months after treatment, this article suggests that initial abstinence and the initial time period do not fully represent the changes associated with long-term recovery. This research shows that risk of relapse is particularly problematic in the first 3 years of abstinence and never completely goes away, suggesting the need for promoting strategies and programs that support the long-term management of recovery.

References

1.  Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.

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5 replies »

  1. Hi Paul,
    if you don’t mind I’m going to spam a methode in here, I call it the nutrients approach, that, according to the figures, has a VERY high percentage of people staying sober. 74% After 3 years. – that is high. The idea is to fix addiction with cutting out the cravings by repairing the body and mind with supplements. But please do read through the anger of this doctor, that is, well, not attractive. :-(. Please delete if you think it should not be in here.
    xx, Feeling

    http://www.healthrecovery.com/pick-treatment-center/

    • thanks for this but I am not sure I agree I with yet another chemical solution!? Even if it appears benign. Also scare tactics are a negative way to sell your stuff and the lack of attraction not promotion did’nt help. Plus the Rand Report cooked it’s figures, that is well known! It was fraudulent and financed by pharmaceutical companies Plus, no links to the study purporting the 75% success rate!! No thanks Paul

      • Not sure if I think additional vitamines and minerals are ‘chemical solutions’. As we well know we all have depleted quite some of our stock… And I for one used several of these and had no problem quitting and only a tiny urge, more like a thought than any serious cravings so I am convinced that there is truth in it. If we say it is a physical, mental and spiritual illness, why leave the body untreated?
        I’m not agreeing with the way they promote, but lets be honest, AA does not put Bill’s sex life on the cover either. So…
        Don’t know about the Rand report. I’ve read the book, with what I know from nutrients I think it is good. The country where I live you are not allowed to advertise with studies that are not proven. So I would assume that she is speaking the truth. I certainly think getting some vitamins in addicts is a good idea and knowing how sugar cravings work… getting the sugar out is very important too. Also smoking and drinking coffee all set off the spiral of addiction in the brain – so I don’t think there is in fact anything wrong with what she writes. Apart from the fact that she is VERY angry about things in the past (she lost her son to people that she thinks were inadequate..) and I don’t think that belongs in a book. But it was her motivation to search for other ways and around the net there are quite a lot of links showing that several of the supplements she prescribes are indeed deminishing cravings. So… not liking the way it is brought into the world but if the result it there – why not? It helped me.
        xx, Feeling

  2. that is not to say we should not use this type of supplement to our recovery programs, any thing that helps is helpful. But to say that one can chemically change the effects of abuse, trauma, insecure attachment, impairment of various areas of the brain via chronic neurotoxicity etc is rather naive. It also ignores the fact that learning about yourself through a recovery process is one of the most enriching process that one can ever hope to engage in. We are more than an accumulation of chemicals. I have learned about humanity via recovery. It has been a priceless journey. 🙂

  3. Hi firstly no one ever recovered by looking at another person’s inventory even Bill W who it is widely reported “never got” the recovery he helped others get so I guess the messenger and the message are quite different but you have more in common with Bill W than you may know as he was convinced alcoholics could be helped recover via vitamin therapy and made some alcoholic friends try this therapy. He was sold on it for some time too. I know nutrients can help in recovery as food with Gaba helps calm cortical arousal and dampens stress response but for me they supplement other parts of recovery. There is more to alcoholism than urges and craving. I did not know the underlying conditions to my addictions until I entered treatment and started doing 12 step recovery. For me’ after years of academic research, I reconceptualised my addictions as emotional dysfunctions. It was these dysfunctions that drove my addiction and threaten recovery. I believe these are wired into neural networks of my brain which behavioural change based neuroplasticity helps the addicted brain get better. I do not think any injection of biochemical can altered whole ingrained neural networks – only time can do that. I believe that they may help with urges but this in itself is a symptom of my illness of addiction.

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