Recovery Attempts: New Data and Their Implications (Bill White and John Kelly)

 

What is the number of serious attempts required to achieve stable resolution of a significant alcohol or other drug (AOD) problem? Previous studies of addiction treatment populations suggest prolonged addiction careers, and a substantial proportion (over half) of people in the United States admitted to addiction treatment indicate one or more prior treatment admissions. These reports stand as justification for the characterization of addiction as a “chronic relapsing” disorder. Such clinical studies, however, may not be representative of the larger pool of people experiencing AOD-related problems.

Convenience studies of community populations of “people in recovery” reveal a different profile. A recent Canadian study found that more than half of those surveyed reported no problem recurrence after the first initial recovery attempt, and that only 15% of those surveyed required six or more attempts prior to achieve stable recovery. But it has been unclear whether such convenience samples accurately represent the experience of all people who have resolved AOD problems, including those who do not embrace a recovery identity.

Having normative information about recovery attempts prior to successful AOD problem resolution is critically important to the individuals and families affected by such problems, to the multiple professionals and institutions seeking to help such individuals and families, and to drug and health care policy makers. A newly published study by Dr. John Kelly and colleagues provides the first available data on recovery attempts based on a national representative sample of people who have resolved a significant AOD problem. Findings and implications of this landmark study include the following.

  1. In contrast to public and professional perception, the number of recovery attempts to achieve stable resolution of an AOD problem is actually surprisingly low, with most people surveyed achieving resolution within the range of 1-2 attempts. The range of time in recovery within the study sample was from a few months to 40+ years and it may be likely – particularly for those in the early phases of recovery – that there could be further AOD problem recurrence and thus additional recovery attempts made that could add to the estimated tally of serious recovery attempts. The researchers found that those with more stable recovery (5+yrs) were no different than those in the first 5 years of recovery – for both groups of individuals the median number remained at 2 and the mean was still just over 5.
  2. A greater number of recovery attempts is associated with greater problem severity and complexity, to include a history of mood and anxiety disorders, past history of treatment services and mutual help group participation, greater social isolation, and/or higher levels of current psychological distress. While this pattern of high problem severity, complexity, and chronicity is seen as the norm, most people with AOD problems do not experience this pattern.
  3. Interestingly, the number of recovery attempts to resolve AOD problems is far lower than the number of attempts required to successfully stop smoking—the latter ranging from 6-30 attempts depending on the study methodology (Chaiton, et al., 2016).
  4. The difference between the mean (average) recovery attempts (5.35 attempts) and the median (2 recovery attempts) indicates wide divergence in characteristics of those experiencing AOD problems and the presence of outliers with high problem severity and low recovery capital that require a much higher number of recovery attempts prior to successful problem resolution. Reporting average recovery attempts produces a distorted representation of the intractability of AOD problems, whereas reporting the median conveys more positive expectations for problem resolution.
  5. “…a treatment system designed around the mean clinical profile would have 2 unforeseen consequences: overtreating those persons with lower severity patterns and high recovery capital and undertreating those with high problem severity patterns but minimal recovery capital.” (Kelly, et al., 2019)
  6. The characterization of all AOD problems as a “chronically relapsing disease” erroneously conveys an image of endless recovery attempts with limited likelihood of success when, in fact, successful recovery with a low number of attempts may well be the norm with the pattern of prolonged “chronic relapse” the exception to this more positive general rule.

Data from the Kelly study should spur optimism among people seeking resolution of low to moderate AOD problems, their families, and their service providers. The study also encourages persistence and possibility among those with the most severe and complex problems. Recovery is possible in both circumstances though with varying levels of effort.

Future reports on recovery attempts and reported treatment history should report both the mean and median of such episodes to assure that the prospects of problem resolution are not over or under estimated. AOD problems are not a single clinical entity and representing them as such may do great disservice to both those with the lowest and highest levels of problem severity.

References

Chaiton, M., Diemert, L., Cohen, J. E., Bondy, S. J., Selby, P., Philipneri, A., & Schwartz, R. (2016). Estimating the number of quit attempts it takes to quit smoking successfully in a longitudinal cohort of smokers. BMJ Open, 6:e011045.     

Kelly, J. F., Greene, M. C., Bergman, B. G., White, W. L., & Hoeppner, R. B. (2019). How many recovery attempts does it take to successfully resolve a drug or alcohol problem? Estimates and correlates from a national representatives study of recovering U.S. adults.  Alcoholism: Clinical & Experimental Research. May 15. doi: 10.1111/acer.14067. [Epub ahead of print]