Addiction Recurrence after Prolonged Recovery

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Philip Seymour Hoffman died February 2, 2014 of an apparent heroin overdose.  On that day, like every day in the United States, between 75-100 less known individuals also died of a drug overdose.  One of the factors distinguishing Philip Seymour Hoffman’s death, other than his fame, was that the recurrence of his addiction and its fatal consequences occurred after 23 years of stable recovery and a life of exemplary achievement.  In the days since his death, I have been bombarded with emails focused mostly on one question:  What do we know from the standpoint of science about addiction recurrence after prolonged recovery?

Treatment outcome studies suggest a principle:  recovery stability and permanence increase with duration of recovery, with the risk of future lifetime addiction recurrence declining to below 15% for those who have achieved 5 years of continuous recovery (see White, 2008 for a review).  That said, little information exists on the prevalence or processes involved in such recurrences after 10, 15, 20 or more years of recovery.  In 2009, Mel Schulstad and I published an article in Counselor entitled, “Relapse following Prolonged Addiction Recovery: Time for Answers to Critical Questions.”  We lamented the lack of research on long-term recovery, including research on what we referred to as late stage relapse (LSR, relapse after more than five years of stable recovery).  Here are some of the questions we posed in 2009.

 

What is the prevalence of relapse across the life cycle of recovery? Are there points of vulnerability identifiable by age or duration of recovery?

 Does the rate of LSR differ by primary drug(s) involved in past dependence; across religious, spiritual, and secular frameworks of recovery; or by gender, race/ethnicity, sexual orientation, and the presence of co-occurring medical/psychiatric disorders?

Are there critical transition points between stages of recovery that constitute periods of increased risk of alcohol and other drug use and related problems?

Is there a relationship between LSR and the onset or progression of physical illnesses and their treatment (e.g., prescribed medication for acute or chronic pain)?

Is there a relationship between LSR and changes in intimate and social relationships (e.g., separation, divorce, or death of one’s intimate partner; onset of new intimate or social relationships)?

Is there a relationship between LSR and major life transitions, such as death of a parent or sibling, children leaving home, “midlife crisis,” geographical relocation, menopause, occupational displacement, retirement, diagnosis of serious illness?

Is there a relationship between LSR and the presence or loss of religious faith? Does religious faith constitute a protective shield against LSR?                  

What factors, other than the above, are linked to LSR?

What is the common course of LSR, e.g., duration, intensity, consequences, and long-term outcomes?

To what extent is the outcome of LSR influenced by the family, professional, and social responses to it?

What is the effect of LSR on the family?

What are the mortality rates associated with LSR?

What approaches are most effective in re-involving a family member in professional treatment and/or recovery mutual aid following LSR?

What are shared issues commonly confronted in the treatment of LSR, e.g., isolation, shame, loss of status, depression, suicidal ideation?                  

What are the factors associated with successful re-initiation of recovery following LSR?                         

How can the LSR risk be best conveyed to enhance the vigilance of those in recovery?

 

Philip Seymour Hoffman’s death is a tragedy that we as a country are collectively mourning.  But it is also a tragedy after billions of dollars spent on addiction research that we still do not have definitive or even preliminary answers to most of the above questions.  The reason we do not is our failure as a country to formulate and aggressively pursue a comprehensive recovery research agenda and to disseminate findings from that research to those who need it most: individuals and families seeking and in long-term addiction recovery. 

 I’m deeply saddened by the death of Philip Seymour Hoffman, but I am also saddened at the stark absence of science-grounded information that could have made a difference in his life and in the lives of others who the public will never read about.  People are dying because of what we do not know about the long-term processes of addiction recovery.