Why Addiction Treatment Needs to Be Informed by Natural Recovery Data
Most people recover from addictions whether they are treated or not; however, whereas about half of people who recover from alcohol dependence choose moderate drinking, the majority with illicit drug use problems choose abstinence, although many with illicit drug use problems pass through a moderation phase first.
Although popular mythology states that substance use disorder (SUD) is a chronic, progressive disease which is 100% fatal unless treated (Milam & Ketcham, 1983), current research shows that over 90% of people with alcohol use disorders (AUD) and 97% to 99% with Illicit Drug Use Disorders (IDUD), meaning they use illegal drugs in ways that cause them health and social problems, do in fact recover (Blanco et al., 2013; Lopez‐Quintero et al., 2011).
The vast majority of those who recover never receive treatment: only 14.6% of those with lifetime AUD receive any treatment (Cohen, Feinn, Arias, & Kranzler, 2007). Compton, Thomas, Stinson, and Grant, (2007) found that, based on data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC-I) data, only 37.9% of people with drug dependence seek treatment and only 8.1% of people with drug abuse seek treatment.
Data from the NESARC study, which surveyed over 43,000 people about their drug and alcohol use habits, showed that about half of people who recover from AUD do so via controlled drinking and about half via abstinence (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2009). Many pass through a phase when they have fewer symptoms of AUD before reaching recovery (Dawson et al., 2005). Most who recover from illegal drug abuse (IDUD) achieve stable abstinence. However, many who recover from IDUD go through a phase of reduced and moderated drug use on the way to abstinence (Newcomb, Galaif, & Locke, 2001).
The likely explanation for outcome differences between AUD and IDUD is social rather than chemical. The process of natural recovery is often called “maturing out.” A common part of being a grown up is sharing a social drink. Sharing a joint or a shot of heroin is less a part of most Americans’ conception of mature adult behavior.
Given the data on natural recovery, in which people recover without any form of treatment whatsoever and many (half of all who formerly alcohol dependent) recover into safe drinking versus total abstinence, the most ethical form of addiction treatment is to adopt a harm reduction perspective and encourage every positive change rather than to insist upon abstinence as the only acceptable goal and chastising and discharging those who fail to achieve it.
Although it may be legal, it is unquestionably unethical to sell a treatment which is either ineffective or actively harmful. It is not well established that those who receive most SUD treatments currently in use have better long term outcomes than those who get no treatment whatsoever. Few studies have compared those who received treatment to a control group who did not receive treatment. The few studies making such a comparison include Brandsma, Maultsby, and Welsh (1980) and Vaillant (1995). Neither of these studies found that the treated group did better than the untreated group at long term follow up; differences only appeared in the short term. In fact, a Cochrane Review (Ferri, Amato, & Davoli, 2006) failed to find evidence that 12 step treatment, the most common type of SUD treatment as usual in the United States, was more effective than no treatment at all.
Still worse, graduates of 28-day style abstinence based inpatient treatment programs for people with heroin use disorder are about 30 times more likely to die of overdose than heroin users who receive no treatment and continue active heroin use (Strang et al., 2003). The only treatment unequivocally shown to reduce death from overdose is opioid substitution therapy (Sordo et al., 2017), meaning treating people who use heroin with methadone or Suboxone. If we wish to help rather than to kill our clients our treatments need to be informed by what is known of spontaneous remission.
Details About Remission From Alcohol Use Disorders
Dawson et al. (2005) examined data from Wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-I), a cross sectional retrospective study consisting of 43,093 subjects who were a representative sample of the American public.
Of these, 4,422 subjects were identified as having past prior year (PPY) DSM-IV alcohol dependence, i.e. alcohol dependence with onset at least 12 months prior to the time of interview. Dawson et al. found that of those with PPY alcohol dependence, 25.0% were still dependent, 27.3% were in partial remission, i.e. they met at least one but fewer than three DSM-IV (the manual by which psychiatrists and psychologists make diagnoses) criteria for dependence/abuse, 11.8% were asymptomatic risk drinkers, i.e. they met no DSM-IV criteria for dependence/abuse but exceeded NIAAA criteria for low risk drinking, 17.7% were low risk drinkers and 18.2% were abstainers.
NIAAA criteria for low risk drinking are no more than 14 standard drinks per week and no more than four per day for men and no more than 7 per week and three per day for women.
The largest group was that with harm reduction outcomes, in other words those in partial remission and the asymptomatic risk drinkers, which when combined comprised 39.1% of the sample.
Details About Remission From Drug Use Disorders
Newcomb, Galaif, and Locke (2001) observed an untreated community sample (UCLA Longitudinal Study of Growth and Development) over a four year period from the time they were in their mid twenties until they were in their late twenties or early thirties. Each subject was rated as having DSM-IV substance dependence, abuse, or no diagnosis at the beginning and end points of the study. Diagnoses for three substances were tracked: alcohol, marijuana, and cocaine. Newcomb et al. found that of those having alcohol dependence at the beginning of the study, 47% remitted, 22% transitioned to abuse, and 30% remained dependent. Of those with alcohol abuse at the beginning of the study, 62% remitted, 13% transitioned to dependence, and 25% retained the abuse diagnosis.
In the case of marijuana, 24% of those with dependence transitioned to abuse, 64% remitted, and 39% remained dependant, whereas for those with abuse, 9% transitioned to dependence, 64% remitted, and 27% retained the abuse diagnosis. Among cocaine users, 22% with a diagnosis of dependence transitioned to abuse, 39% remitted, and 39% remained dependent. For those with abuse, 20% transitioned to dependence, 50% remitted, and 30% retained the abuse diagnosis.
This data shows that for all three substances, progression is the exception, not the rule. Remission, whether abstinent or non-abstinent, is the most common outcome and transition from the more severe category of dependence to the less severe category of abuse is more common than getting worse.
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Treatment Utilization and Effects
Cohen, Feinn, Arias, and Kranzler (2007) examined data from NESARC-I, a cross sectional retrospective study which included data on lifetime alcohol use disorders (AUDs). The sample consisted of 43,093 subjects, 11,748 (30.3%) of whom met criteria for lifetime AUD. 6,890 met criteria for abuse only, 669 met criteria for dependence only, and 4,189 met criteria for both abuse and dependence. Of those subjects with any lifetime AUD, only 14.6% had ever sought any form of help whether formal treatment or self-help group. Only 11.8% had sought formal treatment. Help seeking was highest among the group meeting criteria for both abuse and dependence: of these, 27.9% sought some form of help.
Dawson, Grant, Stinson, and Chou (2006) investigated the effect of help seeking on DSM-IV alcohol dependence for the NESARC-I data set. Dawson et al. defined abstinent recovery (AR) as 12 months abstinence from alcohol, non-abstinent recovery (NR) was defined as asymptomatic low risk drinking for one year; all other categories, asymptotic high risk drinking, partial remission, and continued dependence were lumped together in a single category: “unremitted.” Only 25.6% of individuals with PPY alcohol dependence had ever sought any form of help at all. When the data is analyzed, we find that those who receive treatment and recover are more likely to be abstinent, whereas those who never go to treatment are more likely to recover into a safe and controlled drinking pattern.
The natural outcome of addiction is not progression and death: it is spontaneous remission, meaning that most people get better on their own, with no treatment. Although most users of illicit drugs who recover from a drug use disorder eventually achieve total abstinence from illicit drug use, people who recover from AUDs are as likely to recover into moderate drinking as into abstinence. Both people with AUDs and IDUDs tend to move through a phase of reduced use and reduced harm on the way to recovery.
Designers of SUD treatment programs should take these factors into account to create programs which maximally utilize the inner strengths of people who use intoxicants.
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