A just-published review of the scientific literature on untreated remission from alcohol problems by Richard Mellor and colleagues offers insightful clues about the role of professional treatment and non-treatment resources in the resolution of alcohol problems. Here are some key findings and my take on their implications.
Only a small subset of people with alcohol problems—about 20%–seek treatment related to these problems. This figure is most commonly cited by the treatment industry as justification for increased funding of professionally-directed addiction treatment. That rationale is challenged by data confirming that a significant portion of the 80% of non-treatment-seeking individuals are experiencing problems of lower severity, complexity, and chronicity that will resolve naturally without professional assistance and often without embracing a recovery identity. This process of problem resolution without professional assistance has been variably labeled in the clinical literature as spontaneous remission, autoremission, natural recovery, self-managed change, and quantum change.
Estimates of the prevalence of untreated remission from alcohol problems vary widely—from 2.7% to 98.3% in the 28 studies recently reviewed by Mellor and colleagues. The reasons for such wide variations in findings can be attributed to different definitions and methods of measuring 1) alcohol problems, 2) treatment, and 3) problem resolution. Such wide variation suggests that studies could be cherry picked to support widely varying policy positions, e.g., support and opposition to the need for addiction treatment expansion. Studies of high prevalence of natural recovery could also be isolated to morally castigate those needing professional assistance—adding to the stigma attached to help-seeking for alcohol and other drug problems.
Estimates of the probability of resolving an alcohol problem without treatment decline as alcohol problem severity increases, e.g., when studies are limited to those meeting diagnostic criteria for an alcohol use disorder or a higher number of diagnostic criteria. This underscores the “apples and oranges” dilemma within the alcohol and drug problems arena. Understandings of the cause, course, and resolution processes of mild to moderate alcohol and other drug (AOD) problems cannot be indiscriminately applied to AOD problems of great severity, complexity, and chronicity—or vice versa! The category of “AOD problems” embraces what may be fundamentally different entities, underscoring the importance of differential diagnosis as well as the need for individualized treatment and recovery planning. Failing to recognize such distinctions produces both overtreatment and undertreatment of AOD problems.
Estimates of the probability of resolving an alcohol problem without treatment decrease as the definition of treatment narrows. Definitions of treatment may be restricted to professionally-directed addiction treatment or may encompass a broad spectrum of other professional helpers, e.g., physicians and other medical personnel, psychiatrists, psychologists, social workers, clergy, etc. And definitions of treatment may erroneously include face-to-face and online recovery mutual aid participation as a “treatment.” Estimates of untreated remission should include disclosure of how treatment is being defined.
Estimates of the probability of resolving an alcohol problem without treatment increase when the definition of resolution is expanded beyond abstinence to include non-problematic drinking. Different measures of resolution, remission, and recovery will result in widely varying estimates of the potential to resolve AOD problems without the aid of professional treatment. Such words/phrases as resolution, remission, recovery, and no longer have the problem are often used interchangeably, but may mean very different things when heard by diverse audiences.
Estimates of the probability of resolving an alcohol problem without treatment decline with longer periods of follow-up and number of follow-up points. This finding underscores that some periods of temporary resolution are not stable over time and may be part of the natural course for some patterns of alcohol problems. This raises an essential point: how long does one need to be free of an alcohol problem before that problem can be stably resolved? Research to date suggests 4-5 years of remission stability is required before the risk of future lifetime alcohol problem recurrence drops below 15%. (See HERE). In contrast, most of the studies reviewed by Mellor and colleagues defined remission in terms of 6-12 months.
So, what do we make of all this? Beyond the implications noted above, the Mellor review cautions us to “read the fine print” when such studies are cited and to consider the motives and interest of the persons/institutions citing an estimate of untreated remission from AOD problems. Measuring AOD problems and their resolution is a complex business without consensus on the methodologies through which such estimates are best determined.
Reference: Mellor, R., Lancaster, K., & Ritter, A. (2019). Systematic review of untreated remission from alcohol problems: Estimation lies in the eye of the beholder. Journal of Substance Abuse Treatment, 102, 60-72.