Addiction: A Question of Chronicity

Chronic Disease Image.jpgThree recent reviews call into question the conceptualization and treatment of addiction as a chronic disorder.   

 Lopez-Quintero, C., Hason, D. J., de los Cobas, J. P., Pines, A., Wang, S., Grant, B. F., & Blanco, C. (2010).  Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence:  Results from the National Epidemiologic Survey on Alcohol and Related Conditions.  Addiction, 106(3), 657-669.

 Cunningham, J.A. & McCambridge, J. (2012).  Is alcohol dependence best viewed as a chronic relapsing disorder?  Addiction, 107-6-12.  

 Heyman, G. (2013).  Quitting Drugs:  Quantitative and qualitative features.  Annual Review of Clinical Psychology, 9, 29-59. 

These reviews leave readers viewing alcohol and other drug (AOD) problems as transient, developmental issues that resolve themselves naturally without sustained professional treatment or involvement with addiction recovery mutual aid groups.  Each review arrives at this portrayal through a review of epidemiologic studies of AOD problems among community populations.  And yet one is left wondering how the understanding of the course of AOD problems can appear so different among people involved in addiction treatment and most recovery mutual aid groups.  This is not merely an academic question.  Are families reading the headlined summaries of such reviews to conclude that the prolonged addiction of their family member results from moral and character defects of self-control that prevent “maturing out” of such problems that most people, according to these reports, achieve?  Should such chronicity render one unworthy of family and community support?  Or perhaps be deserving of the severe punishment and sequestration from the community that has been a continuing theme within America’s response to severe and prolonged AOD problems? How can the conclusions of these population studies be reconciled with the lived experience of those closest to addiction and recovery?

If there is anything that the full scope of modern research on the resolution of AOD problems is revealing, it is that the dichotomous profiles of community and clinical populations represent the ultimate apples and oranges comparison within the alcohol and other drug problems arena.  I briefly addressed this dilemma in the introduction to a recent monograph on recovery prevalence.  I repeat part of that discussion here as a context within which to view these latest survey articles.  (To view the full monograph and the complete citations–pp. 12-16–for the excerpt below, click here)

 A Problem of Population Diversity

            There is considerable disagreement between addiction treatment clinicians and community researchers on the long-term course of alcohol and other drug (AOD) problems.  This is due in great part to the differences in etiology, patterns, and outcomes of AOD problems between treatment populations and larger community populations.  As early as 1970, Cahalan and Room, based on their study of problem drinking among American men, cautioned policy makers concerned with such problems against assuming “that the target population is simply the institutional population writ large.”

            Clinicians who see the most severe, complex, and chronic AOD problems are prone to assume that the problems they see clinically are the tip of an iceberg of similar problems in the larger community that has yet to reach them.  They tend to see these problems as progressive, chronically relapsing disorders that can be resolved only through professional treatment and permanent abstinence.  Cohen and Cohen christened this worldview of AOD problems as the “clinician’s illusion.”  The problem with the clinician’s lens is that only a small percentage (1-3%) of the general population exhibits drinking patterns at levels reported by those entering treatment for alcohol use disorders.  This suggests that knowledge of alcohol and drug problems gained in the treatment setting may have only limited applicability to the broader range of such problems in the community.

            Epidemiologists who study the trajectory of AOD problems in larger community populations reveal the course of such problems for the 75-90% of affected people who do not seek specialty treatment.  These scientists tend to see AOD problems as inherently self-limiting (rather than progressive), resolvable through natural internal and external resources (rather than only through professional treatment), and often resolved through a deceleration of the frequency and intensity of use (rather than through complete and enduring abstinence).  Moos and Finney christened this worldview of AOD problems the “epidemiologist’s illusion.” 

            The widely differing views of addiction and recovery across these clinical and community realms are particularly evident in the portrayal of relapse among those seeking recovery.  In the clinical world of addiction treatment, relapse is defined as a normal part of the chronic nature of addiction.  Addiction treatment professionals can regularly be heard purporting that “relapse is a normal part of the recovery process.”  Such communications contribute to the public perception that recovery is a process of trying to stop using alcohol and other drugs rather than a stable, achieved state.  And yet surveys of the recovery community reveal that most people in recovery from alcohol and other drug problems either experienced no AOD use (54%) or only a single brief episode of such use (16%) following recovery initiation. 

            The clinician’s pessimism and the epidemiologist’s optimism constitute the “two worlds” of AOD problems.  Any discussion about measuring and reporting prevalence and styles of long-term recovery must be based on an understanding of the highly variable course of AOD problems and the differences in resolution frequency and resolution methods across these two worlds. 

            Conclusions drawn from studies of persons in addiction treatment cannot be indiscriminately applied to the wider pool of AOD problems in the community, nor can findings from community studies be indiscriminately applied to the population of treatment seekers. Prolonged repetitions of the abstinence-relapse cycle are not typical in community populations, although they are typical for a subset of the clinical population characterized by high problem severity/complexity and low recovery capital.  Most (as many as 75%) people who resolve alcohol-related problems do so without formal treatment.  Those who seek help for such problems are the exception.  For example, Dawson et al. reported from a national U.S. community sample that 3.1% of persons meeting lifetime criteria for alcohol dependence had attended 12-Step meetings, 5.4% had had treatment only, and 17% had participated in both 12-Step meetings and treatment.  

             Adults and adolescents entering specialized addiction treatment are distinguished by:

1) greater personal vulnerability (e.g., male gender, family history of substance use disorders, child maltreatment, early pubertal maturation, early age of onset of AOD use, personality disorder during early adolescence, less than high school education,  substance-using peers, and greater cumulative lifetime adversities),

2) greater problem severity (e.g., longer duration of use, dependence, polysubstance use, abuse symptoms co-occurring with substance dependence;  opiate dependence),

3) greater problem intensity (frequency, quantity, high-risk methods of ingestion, and high-risk contexts,

4) greater AOD-related consequences (e.g., greater AOD-related legal problems),

5) higher rates of developmental trauma and post-traumatic stress disorder,

6) higher co-occurrence of other medical/psychiatric illness,

7) more significant personal and environmental obstacles to recovery, and

8) lower levels of recovery capital–internal and external resources available to initiate and sustain long-term recovery.

             Rates of remission/recovery vary significantly across levels of problem severity, complexity, and duration.  Prediction of recovery rates, whether for individuals or for communities, must be based on an understanding of this principle….  Caution is the watchword as we proceed to summarize what we know about recovery prevalence across these two overlapping worlds. (White, 2012, pp. 12-16)   

 

             That caution is still warranted.  So when you are asked by someone about a news app headline and a three-sentence summary of a new study concluding that addiction  is not a chronic disorder, remember to discuss the apples AND the oranges.  

             There is also the incorrect suggestion in some of these recent reviews (e.g., Heyman, 2013) that the conceptualization of addiction as a chronic disorder contains the view that stable long-term remission/recovery is not possible or is extremely rare.  For a review of what this conceptualization does convey by way of messages to individuals,families and communities, see this article by Tom McLellan and myself.