Defining And Operationalizing Recovery From Substance Use .
Defining and OperationalizingRecovery from Substance UseDisordersChristine E. Grella, Ph.D.Department of Psychiatry and Biobehavioral SciencesUCLA Integrated Substance Abuse Programs (ISAP)Semel Institute for Neuroscience and Human BehaviorDavid Geffen School of Medicine at UCLAWorkshop on Integrating New Measures of Recovery fromSubstance Use or Mental DisorderInto SAMHSA’S Data Collection ProgramsFebruary 24, 2016The National Academies of Sciences, Engineering and Medicine
Topics Background and overview How has recovery from substance usedisorders (SUD) been conceptualizedand measured in research? How do individuals define the meaningof “recovery”?
Historical PerspectivesDetail from the Taylor Map of New York (1879)
How has the concept of“Recovery” from SUD evolved? The concept of recovery from alcohol problems (i.e.,intemperance) dates to the emergence of mutual self-helporganizations within the context of 19th century temperancemovements: Washingtonian Temperance Society (1840): non-sectarian,personal testimonials, temperance pledgePost Civil War evangelical temperance movements: gospelrescue missions, prayer meetings, focus on sinful nature1935: Alcohol Anonymous (AA) founded – begins massmovement of mutual support groups for recoveryRecovery has broadened to have more general usage in society.White, W. L. (2005). Recovery: Its history and renaissance as an organizing construct. Alcoholism Treatment Quarterly, 23, 3-15.
Jellinek, E.M. (1946). Phases in the Drinking History of Alcoholics. Quarterly Journal of Studies on Alcohol.
Faces & Voices of SUD Recoveryhttp://www.facesandvoicesofrecovery.org/
International Quit & RecoveryRegistry: Web platform to crowdsource research on SUD recoveryLaunched in September 2011, theInternational Quit & RecoveryRegistry seeks to understand whatallows people to succeed inovercoming addiction.Led by Warren Bickel, PhD,director of the Addiction RecoveryResearch Center at Virginia TechCarilion Research Institute, theregistry taps the insights andexperiences of people who are inrecovery from an addiction.https://quitandrecovery.org/
Scientific interest in SUD recoveryhas increased Google Scholar between 1959 and 2012 shows an exponentialincrease in the number of articles about substance use with“recovery” in the title in the past decadeGrowth in number of articles about recoveryKaskutas, L.A., Witbrodt, J., & Grella, C.E. (2015). Recovery definitions: Do they change? Drug and Alcohol Dependence, 154, 85-92.
How has recovery from SUD beenconceptualized and measured in research?Developmental/life course approach Age-related differences Maturational process Clinical indicators of remission from SUD Symptom remission Covariates of recovery Behavioral indicators of SUD recovery Focus on use/abstinence Multi-component indicators Cross-sectional status vs. person-centered trajectories What is Recovery? Study
Developmental/Life CourseApproach to UnderstandingRecovery from SUD
Developmental/life courseapproachSource: U.S. National Household Survey on Drug Use and Health, 2001Dennis, M. & Scott, C.K. (2007). Managing addiction as a chronic condition. Addiction Science & Clinical Practice, 4(1), 45–55.
Related constructs indevelopmental perspective Natural recovery: Most people in the general populationwho have a SUD go into remission without any formalintervention.Turning points: A life event, experience, or role transitionthat results in changes in the direction of a pathway orpersistent trajectory over the long-term (e.g., marriage,childbirth, employment, incarceration, illness).Recovery capital: Refers to assets or resources thatindividuals with substance use problems can use to copewith stressors and sustain recovery; e.g., having access totreatment services and supportive family, friends, and socialnetworks, including 12-step groups.Granfield, R., & Cloud, W. (2001). Social context and “natural recovery”: The role of social capital in the resolution of drug-associated problems.Substance Use and Misuse, 36, 1543-1570. Laudet, A., & White,W. (2008). Recovery capital as prospective predictor of sustained recovery, lifesatisfaction, and stress among former polysubstance users. Substance Use & Misuse, 43, 27 54. Teruya, C., & Hser, Y.I. (2010). Turning pointsin the life course: current findings and future directions in drug use research. Current Drug Abuse Review, 3(3), 189-195. Waldorf, D. (1983).Natural recovery from opiate addiction: Some social-psychological processes of untreated recovery. Journal of Drug Issues, 237-280.
“Maturing Out” of Narcotic Addiction Study used records of narcotics addicts (N 45,391) reportedto the Federal Bureau of Narcotics from federal, state, andlocal law enforcement and health agencies in the U.S.beginning in 1955. Examined the extent to which individuals “were considered tobe inactive” by the end of 1960. 16% were classified as inactive They ranged in age from 18 to 76 years. Average age of inactivity was 35.12 Average duration of addiction was 8.6 years; rangedfrom 5 – 56 yearsWinick, C. (1962). Maturing out of narcotic addiction. Bulletin on Narcotics, 14(1), 1-7
“Maturing Out” of Narcotic Addiction Factors that influenced cessation: external circumstances relationships jeopardized by drug use weariness personality and insight incapacitating physical problems Interpreted the findings to support that maturationout of addiction occur: as a reflection of their life cycle as a function of the length of their addictionWinick, C. (1962). Maturing out of narcotic addiction. Bulletin on Narcotics, 14(1), 1-7
Maddux & Desmond: Re-examinationof the “maturing out” hypothesisSubjects were 248 opioid users in San Antonio who weretreated at the PHS Hospital in Fort Worth from 1964-1967;their status was recorded through 1975.Five conditions that “probably facilitated”recoveryN%Relocation away from usual source of drugs1936Evangelical religious participation1325Employment with drug abuse treatment agency1019Probation or parole for 1 year or more2242Alcohol substitution2343Maddux, J.F., & Desmond, D. P. (1980). New light on the maturing out hypothesis in opioid dependence. UNODC - Bulletin on Narcotics, 1- 002.
Opioid drug use status of 248 subjectsin July of each year, 1966-1975Maddux, J.F., & Desmond, D. P. (1980). New light on the maturing out hypothesis in opioid dependence. UNODC - Bulletin on Narcotics, 1- 002.
George Vaillant’s longitudinal studiesof male heroin addicts and alcoholicsStudy sample: AlcoholicsStudy sample: Heroin users268 Harvard undergraduates and456 non-delinquent, sociallydisadvantaged Boston adolescents100 men admitted to the US PublicHealth Service Hospital in Lexington, KYbetween 1952-1953Participants were followed from age 20to age 70–80 yearsParticipants were followed from age 20to age 70–80 yearsVaillant, G.E. (2003). A 60-year follow-up of alcoholic men. Addiction, 98(8), 1043–1051. Vaillant, G.E., & Milofsky, E.S. (1982). NaturalHistory of Male Alcoholism IV. Paths to Recovery. Archives of General Psychiatry, 39(2):127-133. Vaillant, G.E. (1988). What Can Longterm Follow-up Teach us About Relapse and Prevention of Relapse in Addiction? British Journal of Addiction, 83(10), 1147–1157. VaillantGE: (1966). A 12-year follow-up of New York addicts: IV. Some determinants and characteristics of abstinence. American Journal ofPsychiatry, 123, 573-584.
George Vaillant’s longitudinal studiesof male heroin addicts and alcoholics By age 70: 21% - 32% of surviving alcoholics were abstinent; 11% - 12% were stillabusing alcohol35% of surviving heroin users had achieved stable abstinence ( 3 yrs)and 25% were still usingIn both samples, “freedom from relapse” was associated with: community compulsory supervision a substitute dependence new relationships inspirational group membership (religion or AA)Stable “pre-morbid” adjustment, especially employment, wasmost predictive of outcomes
Clinical Indicators of Recovery fromSUD: Focus on Symptom RemissionDSM-V Substance Use DisorderEarly remission: lifetime SUD; at least 3 but lessthan 12 months with no symptoms (except craving)Sustained remission: lifetime SUD; at least 12months with no symptoms (except craving)
Cumulative probability of remission fromlifetime dependence bytype of substance in NESARCQuintero, C.L. et al. (2010). Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: Results fromthe National Epidemiologic Survey on Alcohol and Related Conditions. Addiction, 106, 657–669.
Remission vs. Recovery in NESARC Among those with lifetime AUD, past year-status: Full Remission Still dependent: had 3 positive criteria for alcohol dependencePartial remission: did not meet the criteria for alcohol dependence, butreported 1 symptoms of either alcohol abuse or dependenceAsymptomatic risk drinker: past-year risk drinker, but no symptoms ofeither abuse or dependence: Men: drank 14 drinks/week, on average, or drank 5 drinks in a single day 1time in past year. Women: drank 7 drinks/week, on average, or drank 4 drinks in a single day 1time in past yearRecovery Low-risk drinker: non-risk drinker with no symptoms of either abuse ordependenceAbstainer: did not consume any alcoholDawson et al. (2005). Recovery from DSM-IV alcohol dependence – United States, 2001–2001. Addiction, 100, 281 -292.
Correlates of recovery fromalcohol dependence in NESARCAbstinent Recovery Black, Asian, Hispanic (vs. White)Child 1 year old in householdAttends religious services weeklySought help that included 12-stepparticipationMarginal: Divorced or separated Employed with job problems Number of AUD symptomsNon-Abstinent Recovery Never married (-)Unemployed or job problems (PY)Attends religious services weeklySmoking (-)Volume of alcohol consumed (-)Marginal: Divorced or separated Child 1 year old in household Past-year DUD (-) Has 1 medical problem (-); 2problems ( )Dawson et al. (2012). Correlates of recovery from alcohol dependence: A prospective study over a 3-year follow-up interval . Alcoholism:Clinical And Experimental Research, 36, 1268–1277.
Age-related correlates of drinkingcessation (over 3-year follow-up)among regular drinkers in NESARCYounger (18 – 54) BL pregnant/has infant –Nicotine or DUD Personality disorder (cluster A)Liver disease Incident retirement Older (55 )Non-age SpecificFamily income 70,000 –Volume of alcohol intake –Male Asian ethnicity (vs. White) Mood disorder Onset of CVD College educated (vs. HS) –Black or Hispanic (vs. White) Smoking cessation Months since last drink Dawson, D.A., Goldstein, R.B., & Grant, B.F. (2012). Prospective correlates of drinking cessation: Variation across the life-course. Addiction,108, 712–722.
Refining the Maturing Out Theory: Dorates of persistence change with age? Decomposed DUDstatus at followup by age Age effect is dueto decreases innew onset andrecurrence ofDUD, whereaspersistence isrelatively stableacross age Role transitionsco-varied withchanges in statusAlvaro Vergés, A., et al. (2013). Refining the notion of maturing out: Results from the National Epidemiologic Survey on Alcohol and RelatedConditions. American Journal of Public Health, 103(12), e67–e73.
Behavioral Indicators of Recoveryfrom SUD in Clinical & CohortStudies:Focus on Abstinence andPsychosocial Functioning
Kaiser cohort study: Multi-componentdefinition recovery from SUDStudy Sample:Patients (N 991) treated for SUD in a managed care system;Follow-up data were obtained from patients at 1, 5, 7 and 9 yearsfollowing intake.Remission was defined as abstinence in past 30 days or non-problematicsubstance use, which was defined as:-drinking 4 times in the previous month-not having 5 drinks on any given day-not using marijuana more than once-not using any drug other than alcohol or marijuana-not having suicidal ideation, violent behavior or serious conflict with friends, family orcolleaguesChi, F.W., Parthasarathy, S., Mertens, J.R., et al. (2011). Continuing care and long-term substance use outcomes in managed care: Earlyevidence for a primary care-based model. Psychiatric Services, 62:1194–200.
Latent measure of SUD recovery inPathways Study (N 1,008)Garner, B.R., Scott, C.K., Dennis, M.L., & Funk .RR. (2014). The relationship between recovery and health-related quality of life. Journal ofSubstance Abuse Treatment, 47(4), 293-298.
33-year Follow-up Study of Civil AddictProgram (CAP) SampleOriginal study sample:581 men with a history of heroin dependenceoriginally in the California Civil Addict Programin 1962-64, with 3 follow-up wavesCharacteristics: Ave age 57 years at most recent follow-up wave;white (36.8%), Hispanic (56.2%), African-American (7.0%)Followed for more than 30 years in 3 waves; deaths weredocumented with records from CDC-National Death IndexMV analyses used predictors from prior waves to model recovery atmost recent wave;Stable recovery: at least 5 years of sustained abstinence fromheroin (43%)Hser, Y.-I., 2007. Predicting long-term stable recovery from heroin addiction: findings from a 33-year follow-up study. Journal ofAddictive Diseases, 26, 51–60.
Natural History of Narcotics AddictionAmong CAP Sample (N 581)Hser, Y.I., Hoffman, V., Grella, C.E., and Anglin, M.D. (2001). A 33-year follow-up of narcotics addicts. Archives of General Psychiatry, 58, 503-508.Hser, Y.I., Evans, L., Grella, C., Ling, W., & Anglin, M.D. (2015). Long-term course of opioid addiction. Harvard Review of Psychiatry, 23(2), 76-89.
Comparisons between individuals withat least 5 years of abstinence vs. others Recovery group (Mean 19 9 years abstinence) and nonrecovery group did not differ in substance use initiation,conduct problems, or family/school problems prior to age 15Both groups had multiple treatment episodes (primarilymethadone treatment) and self-help participationIn MV models, stable recovery at most recent follow-up waspredicted by: Hispanic vs. non-Hispanic (-) Self-efficacy and coping skills ( ) Psychological distress (-)Hser, Y.-I., 2007. Predicting long-term stable recovery from heroin addiction: findings from a 33-year follow-up study. Journal of Addictive Diseases, 26,51–60.
30-Year follow-up study of men andwomen sampled from methadonetreatment in CaliforniaOriginal study sample:Participants were sampled from methadone maintenanceclinics in 6 counties in Central & Southern California andinterviewed in 1978-81At follow-up in 2005-08: 47% verified as deceased;71% of those still living were interviewed (N 343);Average age: 58.3 for males, 55.0 for femalesTrajectory group analyses generated 4 clusters of individuals withsimilar patterns of heroin use over time (person-centered analysis),controlling for time incarcerated;Bivariate comparisons across 4 trajectory groups, including patternsof other substance useGrella, C.E., & Lovinger, K. (2011). 30-year trajectories of heroin and other drug use among men and women sampled from methadone treatment inCalifornia. Drug and Alcohol Dependence, 118, 251-258.
Trajectory group outcomes over 30year follow-up study30-Year Heroin Use Trajectories in aCalifornia Treatment-Based Cohort Rapid Decrease(22%*): 60% women;less school problems,CD, ASP; most % timeusing alcohol & meth Moderate Decrease(47%*): 46% women Gradual Decrease(64%*): 39% women;more ASP, most %time incarcerated No Decrease (84%*):46% women; most %time MMT & usingcocaine; youngest at1st heroin use & arrestN 341; observed use based on joint heroin and AOD use trajectory models; odds of heroin use calculatedper year beginning with year of heroin use initiation, excluding periods institutionalized; probability of groupmembership: all 0.95; *percentage of time using heroin; Grella & Lovinger, 2011
Australian Treatment Outcome Study (ATOS):Past-month heroin abstinence over 11 years Independent correlatesof 5 or more years ofheroin abstinence: female gender (OR 1.73) not being currentlyenrolled in a treatmentprogram (OR 2.16) fewer discretetreatment episodesacross the follow-up(OR 0.90)Darke et al. (2015). Patterns and correlates of sustained heroin abstinence: Findings From the 11-year follow-up of the Australian TreatmentOutcome Study. Journal of Studies of Alcohol and Drugs, 76(6), 909-15.
How do Individuals Define TheMeaning of “Recovery”:What is Recovery? Study
What Is Recovery (WIR) Study The “What is Recovery?” study aimed to empirically identifythe domains and specific elements of recovery as experiencedby persons in recovery from diverse pathways.An Internet-based survey was completed by 9,341 individualswho identified themselves variously as: In recovery (75%) Recovered (13%) In medication-assisted recovery (3%) Used to have a problem with alcohol and drugs (but nolonger do) (9%)Kaskutas et al. (2014). Elements that define recovery: the experiential perspective. Journal of Studies on Alcohol and Drugs, 75, 999–1010.
What Is Recovery (WIR) Study Individuals rated 47 items as to how much each:“belongs in a definition of recovery as you haveexperienced it.” Factor analyses used to statistically reduce and groupthe elements into 4 factors (35 elements): Abstinence Spirituality Essentials of recovery Enhanced recovery
What Is Recovery? (WIR) StudyWIR Study sampleSample Characteristics:(N 9,328) 98% met DSM-IV criteria for dependenceLatent class analysis derived fivegroups based on their adherenceto items in each of the fourfactors 59% endorsed alcohol as their primarysubstance; the remainder cited other drugs Nearly all (96%) had attended treatment,12-step and/or other recovery groups 54% were female, 82% over age 35, 80%had a some college/college degree, andmost (88%) were white (88%) A follow-up study with a sub-sample foundrelative stability in adherence to beliefsabout recovery over approximately 3 years 12-step Traditionalists12-step EnthusiastsSecular ClassSelf-reliant ClassAtypical Class(52.7%)(21.6%)(10.5%)(11.1%)(4.1%)Witbrodt, J., Kaskutas, L.A., & Grella, C.E. (2015). How do recovery definitions distinguish recovering individuals? Five typologies. Drugand Alcohol Dependence, 148, 109-117.
What Is Recovery? (WIR) StudyThe five groups differed in their beliefs and behaviorson: abstinence, spirituality, 12-step participation, andsocial interactions. 12-step Traditionalists (57.7%): Strongly abstinenceoriented, with most indicating no alcohol use (87%),no use of non-prescribed drugs (72%), and no use ofnon-prescribed drugs (84%); high treatment and 12step participation; strongly endorsed spiritualityelements and identied as “in recovery.” 12-step Enthusiasts (21.6%): Mainly differed from theTraditionalists in less strongly endorsing: no use ofnon-prescribed drugs.
What Is Recovery? (WIR) Study Self-reliant Class (11.1%): Moderately endorsed abstinencefrom alcohol and illicit drugs and no abuse of prescriptiondrugs; lower endorsements to items pertaining to socialinteractions, e.g., learning how to get support, helpingothers, giving back, being able to have relationships.Secular Class (10.5%): less endorsement of spirituality, moretolerant of non-abstinence, younger, fewer years in recovery,more often identified as used to have a problem, higher ratesof using alcohol, and lower rates of 12-step participation. Atypical Class (4.1%): Less endorsement of spirituality andabstinence; high intolerance for recovery being religious innature; strongly endorsed being able to enjoy life asfundamental to recovery.
Implications for MeasuringRecovery Time frame: recovery is both a process of change andpoint-in-time status Study design: longitudinal vs. cross-sectional Sampling: general population probability surveys vs.clinical/targeted samples Criteria: abstinence as critical component vs. multicomponent measure Abstinence/use: strict adherence vs. more tolerantdefinitions Perspective of the individual: does self-definition matter?
Feb 24, 2016 · UCLA Integrated Substance Abuse Programs (ISAP) Semel Institute for Neuroscience and Human Behavior . David Geffen School of Medicine at UCLA . Workshop on Integrating New Measures of Recovery from . Substance Use or Mental Disorder . Into SAMHSA’S Data Collection Programs . February 24, 2016
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