The wide range of injuries inflicted on the human body by excessive and prolonged alcohol or other drug (AOD) use have been extensively documented for more than two centuries, but until recently little was known about the relative health of people recovering from addiction. The potential burden of continued health problems in recovery has been obscured by general findings of improved health and quality of life in recovery from follow-up studies of clinical samples. Little information has been available on the health status of people in recovery within larger community samples.

In 2010, the Philadelphia Department of Behavioral Health and Intellectual disAbility Services contracted with the Public Health Management Corporation (PHMC) to incorporate recovery-focused items into PHMC’s Southeastern Pennsylvania Household Health Survey of Philadelphia and four surrounding counties. Nearly ten percent (9.45%) of the adult population surveyed reported once having but no longer having an AOD problem. Those in recovery, compared to citizens not in recovery, were twice as likely to describe their health as poor and report higher rates of asthma, diabetes, high blood pressure, obesity and past-year emergency room visits. They were also more likely to report lifetime smoking (82% vs. 44%), current smoking (50% vs. 17%), exposure to smoke in their residence, no daily exercise, and eating fast food three or more times per week. In terms of resources to address health concerns, people in recovery compared to the general population reported greater family/social isolation, lower income, less insurance coverage, and less likelihood of past year health screenings, primary health care, and dental care.

While the Philadelphia survey findings were alarming, it remained unclear whether the survey findings were representative of all people in recovery in the United States. A just-published study by Eddie and colleagues reports strikingly similar findings in a nationally representative sample of the adult U.S. population. Relative to the general population, those self-reporting having resolved an AOD problem report higher rates of hepatitis C, HIV/AIDS, chronic obstructive pulmonary disease, heart disease, and diabetes. Quality of life among people in recovery was lower when one or more of these diseases were present.

The findings from the Philadelphia and U.S. surveys reveal the burdens of disease that can continue into the addiction recovery process–burdens that if unattended can plague personal health and quality of personal and family life for years to come. Such findings have profound implications for the state of professional care for AOD problems in the United States. At a systems level, we have a model of care that functions as an emergency room to provide acute biopsychosocial stabilization but is not designed to provide long-term health management for people in addiction recovery. The management of other chronic health disorders (e.g., diabetes, hypertension, asthma, etc.) is now viewed as requiring the management of global health (e.g., management of co-occurring medical conditions, diet, exercise, psychosocial stressors) over a prolonged if not lifelong period of time. It is past time that the treatment of the most severe and complex AOD problems was similarly conceived. Such approaches would move beyond brief episodes of symptom amelioration (recovery initiation and diagnostic remission) to the promotion of global health and quality of personal, family, and community life in long-term recovery.

At its most practical level, the survey findings suggest that every person entering recovery should have an ongoing relationship with a primary care physician who is knowledgeable about addiction recovery and who can serve as an ongoing consultant on the achievement of health and wellness. It also suggests the need for increased bi-directional integration of addiction treatment and primary health care and the potential role of the primary care physician in performing ongoing recovery checkups. Hopefully, the day when such integration constitutes mainstream practice will arrive soon.

References

Eddie, D., Greene, C., White, W. L. & Kelly, J. F. (in press). Medical burden of disease among individuals in recovery from alcohol and drug problems in the United States: Findings from the National Recovery Study. Journal of Addiction Medicine.

White, W. L., Weingartner, R. M., Levine, M., Evans, A. C., & Lamb, R. (2013). Recovery prevalence and health profile of people in recovery: Results of a Southeastern Pennsylvania survey on the resolution of alcohol and other drug problems. Journal of Psychoactive Drugs, 45(4), 287-296.

We recently explored the idea of “recovery cascade”—a sudden surge in personal change that sparks recovery initiation in the heels of past efforts or a collective surge in recovery prevalence at a community or cultural level. While there are examples of the latter in U.S. history (e.g., the explosive growth of the Washingtonian Temperance Society in the early 1840s), the most recent and dramatic example of such a population-level recovery cascade is the growth of Narcotics Anonymous and other recovery communities (e.g., Congress 60) within the Islamic Republic of Iran.

As the toll of the opioid epidemic in the U.S. rises to ever-horrific levels, the question of how to promote a counter-surge of recovery initiation and stabilization is a critical public health issue. Much in this regard can be learned from what has occurred within the Islamic Republic of Iran. Few countries have experienced such sustained opioid problems (since the 16^th century), and no country has experienced as rapid a growth of Narcotics Anonymous as has Iran.

First introduced in 1990, there are now more than 24,000 NA meetings in Iran—a third of all NA meeting worldwide and, with the exception of the NA Basic Text, Iran consumes more NA literature than all other countries combined. The 2018 NA World Convention drew 24,000 participants; the most recent NA Convention in Iran drew 32,000 participants.

Exploring contextual factors and key strategies linked to exponential surges in recovery prevalence in Iran could aid strategic counter-responses to surges in drug addiction in the U.S. I was pleased to recently collaborate with Dr. Marc Galanter and Brooke Hunter on a comparative study of NA members in the U.S. and Iran that was recently published in the Journal of Addiction Medicine.  That study afforded an opportunity to explore some of the factors that have contributed to NA growth in Iran—an issue of import given the paucity of attention given to the potential role of NA in discussions of U.S. responses to the opioid epidemic.

Based on the history of NA in Iran and my study of growth patterns within other recovery mutual aid organizations, I would propose the following factors as critical to surges in recovery mutual aid membership and parallel population surges in recovery prevalence.

*Social Density of Addiction Exponential growth of recovery mutual aid follows periods of peak per capita addiction, e.g., Iran has the highest worldwide rate of opiate addiction.  Recovery prevalence rises after, not in tandem with, peak personal and social consequences of addiction within a community/culture. A major public health goal is to minimize the time lag between surges in addiction and surges in recovery initiation. Shortening addiction careers reaps untold rewards for individuals, families, communities, and societies.

*Population Demographics Addiction recovery mutual aid growth often crests during peak concentrations of populations reaching the age of cumulative consequences of youthful drug use (e.g. ages 25-44). The aging of Baby Boomers in the U.S. and tandem growth of treatment industry fed the growth of NA, AA, and other recovery mutual aid groups in 1980s and 1990s.

*Cultural Congruence Growth of a recovery mutual aid organization is influenced by the congruence between its core values and the cultural context in which it operates or the degree to which it represents needed values within that culture.  The congruence between NA values and the Persian value placed on family, mutual help, hospitality, and service helped fuel NA growth in Iran. Growth of recovery mutual aid groups is contingent upon rights of citizens to voluntarily assemble without governmental oversight and the absence or minimization of obstacles to such gatherings (e.g., early police surveillance of NA meetings in the U.S.; “loitering addict” laws in the U.S. in the 1950s and 1960s).

*Decentralization of Leadership NA, like other 12-Step groups, utilizes a leadership rotation scheme as a means of avoiding the pitfalls of centralized and charismatic leadership that can push organizations toward cult-like systems at risk of eventual implosion.  Multiple leadership roles and the ease with which new groups can be formed help fuel member growth and retention through these mechanisms of leadership development and succession.

*Minimization of Political/Religious Resistance Recovery frameworks that do not pose threats to existing political and religious institutions have increased probabilities of survival and rapid growth. NA’s position of “no opinion on outside issues” and NA leaders meeting with political, religious, and professional leaders minimized such resistance and set the stage for NA growth in Iran.

*Delineation of Peer and Professional Support Roles Aligning itself as a potential adjunct to professional treatment (e.g., post-treatment continuing care) rather than a competing alternative minimizes professional resistance to 12-Step groups and other recovery groups. Such positioning allowed NA to grow in tandem with professional treatment resources in the U.S. and Iran while maintaining NA independence from these institutions. Professional support is enhanced by scientific studies showing mutual aid participation elevates long-term treatment/recovery outcomes and quality of life of individuals and families. More scientific studies of NA have been conducted in Iran than anywhere in world, including in the U.S. and U.K.

*Local/National Mainstream and Social Media Coverage Recovery-focused media coverage can serve as a direct catalyst for recovery seeking, e.g., growth of AA following 1939 Cleveland Plain Dealer series and 1941 Jack Anderson Saturday Evening Post article in early AA spread nationally. Active NA PR (public relations) committees have played an important role in surges in NA membership.

*Recovery Literature  Codification of core recovery literature can spur exponential growth of recovery mutual aid organizations and protect program integrity (e.g., avoidance of dilution, and corruption). Publication of the AA “Big Book” and NA “Basic Text” were critical to subsequent AA/NA growth worldwide, and translation of the NA Basic Text into Farsi was a key catalyst for NA growth in Iran as was Iran’s extensive use of other NA literature.

*Sponsorship and Recovery Induction Use of “home groups,” sponsorship, guidance in completing core recovery activities, and celebrations of recovery milestones have all served to aid engagement and retention within recovery mutual aid groups.  NA in Iran has several unique adaptations that played a role in its unprecedented growth, e.g., sponsors regularly meeting with sponsees in groups distinct from regular NA meetings, focused attention on completing Step work, and celebrating completion of Step work rather than an exclusive focus on duration of abstinence.

*Service Ethic and Service Structure  Recovery mutual aid growth is greatest in settings with a strong service ethic and a service structure that allows frequent service opportunities via service committees and expectations of larger service to the larger community. Recovery surges are contingent on reaching a critical mass of people achieving sustained recovery—living proof within the overall culture and visible to those seeking help. Defining need for long-term recovery support combined with a strong service ethic assures such availability and visibility and enhances organizational stability and sustainability.

*Membership Diversification Recovery mutual aid growth is aided by the advent and expansion of demographic, cultural, and special interest groups, e.g., women, young people, cultural minorities. Diversification and growth of specialty meetings attracts new populations and retains populations that might otherwise be lost due to failure of mutual identification.

*Recovery Culture The growth of a recovery mutual aid society is aided by development of a distinct recovery culture with its own core ideas, language, rituals, symbols, history, iconic figures, memorial sites, etc. Distinct recovery mutual aid cultures are sometimes followed by emergence of an ecumenical culture of recovery within the larger society. This broader culture may set the stage for further population surges in recovery prevalence.

*Organizational Integrity Sustained growth within recovery mutual aid societies requires forging a set of principles of organizational management that help groups avoid the organizational pitfalls that can feed explosive growth in the short run only to then rapidly decline and experience institutional death, e.g., rise and fall of the Washingtonians, Synanon, and other recovery mutual aid groups.

Considerable time is invested within professional and public policy arenas exploring factors related to population-level surges in substance use and related disorders. Perhaps it is time similar attention was devoted to exploring the conditions and strategies that could spark population-level surges in recovery initiation.

Reference: Galanter, M., White, W., & Hunter, B. (In Press). Cross-cultural acceptability of the Twelve Step model: A comparison of Narcotics Anonymous in the USA and Iran.  Journal of  Addiction Medicine.

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]