Life In Recovery (Part 3)

“This story is only starting to be told.

We have much work to do … to challenge the stereotypes of both the general public and our own professionals.

Addiction may well be a chronic, relapsing condition but people can and do recover.

They can change and that change is not only personal but social and societal.”

COMPARISONS:

US & AUSTRALIAN LIVES IN RECOVERY

In the US, a total of 3,228 people completed the online survey and as in the Australian survey just over half of the sample was female.

The samples were also very similar in that the mean length of the substance using career was 18 years in the US and 18.6 years in Australia. The average ages of recovery initiation were also very similar – 34.8 years in Australia and 36 years in the US.

While 75.2% of the US sample described themselves as being ‘in recovery’ and 13.7% as recovered, this was true for 79.8% and 6.3% respectively in Australia.

In terms of problem profile, primary alcohol was the problem for 29% in the US and 35% in Australia, drugs only for 13% in the US and 11% in Australia, and both alcohol and drugs for 57% in the US and 54% in Australia.

In terms of their pathway to recovery, 70.5% of the US sample had received formal treatment, compared to 69.8% in Australia; 94.6% of the US recovery group had attended 12-step meetings compared to 82.0% of the Australian sample. Although a wide range of other mutual aid groups was reported, there was much less frequent use of mutual aid groups other than 12-step in Australia.

There is a higher rate of lifetime mental health problems in Australia – while 62.4% of the US sample had been treated for a mental health condition, 91.5% of the Australian sample reported lifetime mental health problems and 56.8% reported current involvement with mental health services. In the US, 55.6% had a bachelor or graduate degree, while this was true for 41.4% in Australia. At the time of the survey, 70.8% of the US sample was employed compared to 68.2% of the Australian participants. Thus, it is reasonable to conclude that the histories and careers of the Australian sample were very similar to their American counterparts.

THE IMPACT OF RECOVERY IN THE US AND AUSTRALIA

The most dramatic and powerful findings of the US survey, that addiction involves “many heavy costs … to the individual and to the nation” and that “recovery from alcohol and drug problems is associated with dramatic improvements in all areas of life” (FAVOR, 2013, page 1) are clearly replicated in the Australian context.

As in the US, where 4 out of 10 individuals experienced financial problems while in recovery, this was also the case for around one in 3 in Australia who owed back taxes and / or had bad debts. However, there were dramatic effects in Australia as in the US of family functioning with significant reductions in domestic violence.

The Australian study also successfully replicates the US findings around health and criminal justice – with marked improvements in positive health markers such as regular exercise, registering with a GP and regular dental check-ups and significant reductions in negative health factors such as ED attendance and untreated psychological problems.

As in the US sample just over half of the Australian sample had a lifetime arrest history (although significantly fewer Australians in recovery had been incarcerated following sentence), the reduction in arrests and in any involvement with the criminal justice system was even more dramatic – around 40% of the US sample and 90% of the Australian sample had no criminal justice system involvement while in recovery.

There were similarly positive differences in work and study – showing the same overall pattern of reduced burden to the taxpayer and the same improvement in personal, family and community wellbeing and connectedness.

CONCLUSIONS

Similarly, there is a dramatic reduction in involvement with the criminal justice system from around half to less than one in ten, particularly involving the areas of drink-driving and criminal damage. There is also a dramatic improvement in both employment and education, and in successful engagement and retention of jobs. This is a story of overcoming adversity and transforming lives to make a significant and positive contribution in their families, in their communities and to society. These results are consistent with the findings of the US Life in Recovery Survey (Laudet et al, 2013) in showing dramatic reductions in pathology and improvements in wellbeing from active addiction to recovery. This is the first attempt at undertaking a recovery survey in Australia and the results are unequivocal in showing that there is an accessible population of Australians who will classify themselves as being in recovery or recovered and who are willing to complete a survey about their experiences.

There is a critical message here for policy makers and treatment providers – that people in Australia can and do recover from addiction problems.

However, there are two nuanced factors that are important to emphasise.

The first is that this is a long and challenging journey for many people and that there will still be residual and ongoing problems for many throughout the recovery journey.

However, there are two nuanced factors that are important to emphasise. The first is that this is a long and challenging journey for many people and that there will still be residual and ongoing problems for many throughout the recovery journey

The findings also emphasise the fact that those in recovery are a very diverse population and that there is no single road to recovery, with a proportion of those participating describing themselves as in ‘medication-assisted recovery’ and a much larger population having ongoing contact with specialist services for addiction or mental health issues.

Nonetheless, the transition reported from active addiction to recovery is a dramatic one.

This is particularly striking in key areas around social and family functioning where the rate of involvement in domestic violence decreased from more than 50% to less than 10% and in volunteering where participation increased from less than 20% to more than 50%.

Similarly, there is a dramatic reduction in involvement with the criminal justice system from around half to less than one in ten, particularly involving the areas of drink-driving and criminal damage. There is also a dramatic improvement in both employment and education, and in successful engagement and retention of jobs.

This is a story of overcoming adversity and transforming lives to make a significant and positive contribution in their families, in their communities and to society.

These results are consistent with the findings of the US Life in Recovery Survey (Laudet et al, 2013) in showing dramatic reductions in pathology and improvements in wellbeing from active addiction to recovery

Those in recovery for the longest term report markedly higher levels of psychological wellbeing and quality of life and much lower levels of need for professional support for emotional or mental health issues.

The other more surprising domain of consistency with the US results is around the demographics and career factors of those who took part. Average age at time of survey completion, average duration of recovery and average length of addiction career are all markedly similar across two countries with differing cultures, treatment systems and philosophies around addiction and recovery.

RECOMMENDATIONS

POLICY RECOMMENDATIONS

It is critical that the implications from the Australian Life in Recovery survey are acknowledged and addressed at a federal, state and local level to ensure that the achievement of recovery is extended across families, communities and professional settings (such as health and legal systems).

As such, the following policy recommendations are suggested for consideration:

1. Policy makers should acknowledge and recognise in drug and alcohol commissioning the key role that recovery organisations play in the initiation and sustaining of recovery journeys that benefit wider society and challenge stereotypes and stigma around addiction

2. Greater policy and funding commitment to recovery support services to ensure that those who initiate recovery journeys are supported to maximise their own wellbeing and their contributions to family and community

3. That greater funding is provided for alumni and aftercare organisations to enable the informal community support that is essential to build recovery capital and recovery communities

This story is only starting to be told.

We have much work to do – and we hope to do this through academic publications and presentations – to challenge the stereotypes of both the general public and our own professionals.

There is one core message that the data presented here in Australia and by FAVOR in the US

Addiction may well be a chronic, relapsing condition but people can and do recover.

They can change and that change is not only personal but social and societal.

The next step on this journey is to repeat and augment this work. At the date of publication this survey has already been approved and will be conducted in the UK and we we await the survey outcomes with great interest.

This survey has already followed in the footsteps of the FAVOR survey with almost no resources and supports and we should aim both to do this in more countries and to continue to repeat the surveying to allow us to map global changes and implications in recovery pathways (see final recommendations below).

LIFE IN RECOVERY SURVEY RECOMMENDATIONS

1. That the ‘Life in Recovery survey’ is undertaken in other countries to increase the comparability and so that a shared evidence base can be generated.

2. That repeat surveys are undertaken in Australia to assess change in the nature of the recovering population and in the journeys and stories they provide.

3. That the results from this survey are widely distributed and used to contribute to the policy debate about recovery in Australia.

4. That the results from the current survey are used for academic journal publications to augment the empirical evidence base around recovery.

http://www.southpacificprivate.com.au/sites/default/files/2015%20Australian%20Life%20In%20Recovery%20Survey.pdf

 

Impulsivity is an Independent Predictor of 15-Year Mortality Risk among Individuals Seeking Help for Alcohol-Related Problems

In yesterday’s blog we looked at how AA membership and the 12 step program of recovery helped reduce impulsivity in recovering alcoholics.

We mentioned also that impulsivity was present as a pathomechanism of alcoholism from vulnerability in “at risk” children from families, were there was a history of alcoholism, right the way through to recovering alcoholics in long term recovery (i.e. many years of recovery).

We cited and used excerpts from a study written by the same authors as the study we cite now (1).

This study shows and highlights how, if untreated, by recovery programs such as AA’s 12 steps, that “trait” impulsivity can lead to increased mortality in alcoholics.

This study interestingly shows there is a difference from “state-like” impulsivity in early recovery when recovering people are still distressed and “trait-like” which is after Year 1 of recovery when some of the severity of withdrawal from alcohol has long since abated and some recovery tools have been learnt.

The fact that this impulsivity continues to contribute to relapse and mortality may suggest it is a trait state in alcoholics and possibly a vulnerability to later alcoholism also.

In effect, it illustrates the role impulsivity plays as a pathomechanism in alcoholism, i.e. it is a psychological mechanism that drives addiction and alcoholism forward to it’s chronic endpoint.

Again research shows us how we can learn about a pathology from the recovery from it!

 

impulse control.preview

“Abstract

Background

Although past research has found impulsivity to be a significant predictor of mortality, no studies have tested this association in samples of individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes. The current study addressed these issues in a mixed-gender sample of individuals seeking help for alcohol-related problems.

Results

…higher impulsivity at baseline was associated with an increased risk of mortality from Years 1 to 16; higher impulsivity at Year 1 was associated with an increased risk of mortality from Years 1 to 16, and remained significant when accounting for the severity of alcohol use, as well as physical health problems, emotional discharge coping, and interpersonal stress and support at Year 1. In addition, the association between Year 1 impulsivity and 15-year mortality risk was moderated by interpersonal support at Year 1, such that individuals high on impulsivity had a lower mortality risk when peer/friend support was high than when it was low.

Conclusions

The findings highlight impulsivity as a robust and independent predictor of mortality.

Introduction

…personality traits related to impulsivity (e.g., low conscientiousness) have been identified as significant predictors of poor health-related outcomes including mortality (Bogg and Roberts, 2004; Roberts et al., 2007). Although there is a well-established association between disinhibitory traits and alcohol use disorders (AUDs) (Labouvie and McGee, 1986; McGue et al., 1999;Sher et al., 2000), to our knowledge, no studies have tested these traits as predictors of mortality among individuals with alcohol-related problems or examined moderation of this effect via socio-contextual processes.

Predictors of Mortality Risk among Individuals with Alcohol Use Disorders

Relative to the general population, individuals with AUDs are more likely to die prematurely (Finney et al., 1999; Johnson et al., 2005; Valliant, 1996). Accordingly, several longitudinal studies have aimed to identify the most salient risk factors for mortality in this population (for a review, see Liskow et al., 2000)

…more reliance on avoidance coping, less social support, and more stress from interpersonal relationships increase the risk of mortality among individuals with AUDs (Finney and Moos, 1992; Holahan et al., 2010; Mertens et al., 1996; Moos et al., 1990).

Impulsivity and Risk for Mortality: Relevance for Individuals with Alcohol Use Disorders

Despite the litany of variables that have been examined as predictors of mortality among individuals with AUDs, tests of the significance of individual differences in personality are noticeably absent from this literature. In the clinical and health psychology literatures, however, personality traits have long been identified as possible risk factors for mortality (Friedman and Rosenman, 1959), with low conscientiousness emerging as one of the most consistent, trait-based predictors of poor health and reduced longevity (Kern and Friedman, 2008; Roberts et al., 2007). Conscientiousness is a broad domain of personality reflecting individual differences in the propensity to control one’s impulses, be planful, and adhere to socially-prescribed norms (John et al., 2008).

(previously) no studies in this literature have tested impulsivity as an independent predictor of mortality in a sample of individuals with alcohol-related problems. This is a surprising omission, given that impulsivity is a well-established risk factor for alcohol misuse (Elkins et al., 2006; McGue et al., 1999; Sher et al., 2000) and therefore may be an especially potent predictor of mortality among individuals with AUDs. Furthermore, the role of impulsivity as an independent predictor of mortality risk among individuals with AUDs is relevant from the standpoint of the stage of the alcohol recovery process.

Thus, we sought to examine the impulsivity-mortality link at baseline and one year after participants had initiated help-seeking for their alcohol use problems. At baseline, participants were in a state of distress due to their problematic alcohol use, whereas at Year 1 most participants had obtained help for their alcohol-related problems and reduced their drinking (Finney and Moos, 1995).

Given prior research on acute clinical states and self-report assessments of personality (e.g., Brown et al., 1991; Peselow et al., 1994;Reich et al., 1987), we hypothesized that individuals’ self-reports of impulsivity at Year 1 would be less a reflection of their alcohol problems – and therefore more likely to be independently linked to mortality risk – than their reports at baseline, which may be more closely associated with concurrent alcohol use and problems (i.e., state effects).

Discussion

…impulsivity at baseline was a significant predictor of mortality risk from Years 1 to 16; however, this effect was accounted for by the severity of alcohol use at baseline. In contrast, impulsivity at Year 1 was associated with an increased risk of mortality over the subsequent 15 years…

In addition, a significant interaction was observed between impulsivity and peer/friend support at Year 1, which suggested that, among individuals high on impulsivity, the mortality risk may be reduced for those high on support from peers/friends. Collectively, these findings highlight impulsivity as an independent risk factor for mortality in AUD samples…

…It is also conceivable that, given participants were in a state of crisis at baseline, their reports of their impulsive tendencies at that time partly captured “state” effects (e.g., psychiatric distress from concurrent substance use; withdrawal symptoms) and therefore were less an indication of their typical or “characterological” pattern of impulsivity, independent of alcohol use. However, at Year 1, most participants had reduced their drinking and were not in a state of crisis; thus, their reports at that time may have been a better reflection of their “trait-like” pattern of impulsivity, which in turn may be a more robust independent predictor of long-term outcomes such as mortality. Accordingly, future studies that seek to test impulsivity as an independent predictor of mortality among individuals with AUDs should consider the stage of the alcohol recovery process.

Moderation of the Impulsivity-Mortality Link via the Social Context

The results of the moderator analyses suggest that the effects of impulsivity on mortality may become manifest through interactions between traits and socio-contextual process (Friedman, 2000). That is, the dire effects of impulsivity on risk for mortality may not reach fruition for individuals who are able to maintain a strong peer support network. Conceivably, by virtue of their strong bond with a high-risk individual, such peers may have sufficient leverage to discourage expression of the individual’s impulsive tendencies and encourage consideration of the long-term consequences of his/her actions.

Such a perspective is consistent with evidence from the AUD treatment-outcome literature that social support networks are a key mechanism by which Alcoholics Anonymous (AA) and other psychosocial treatments can improve long-term drinking-related outcomes (Humphreys and Noke, 1997; Kaskutas et al., 2002).

Furthermore, from the standpoint of treatment, the present findings suggest that interventions for AUDs may benefit from an ecological perspective that considers the contexts in which dispositional tendencies, such as impulsivity, become expressed in individuals’ everyday lives. Notably, based on prior work with this sample, longer duration in AA and alcohol treatment was associated with a decline in impulsivity (Blonigen et al., 2009). In combination with the present findings, it appears that formal and informal help for AUDs may include “active ingredients” that can help curtail expression of impulsive tendencies (e.g., social integration, peer bonding; Moos, 2007,2008) and buffer the otherwise deleterious impact of such tendencies on health and longevity.

References

1. Blonigen, D. M., Timko, C., Moos, B. S., & Moos, R. H. (2011). Impulsivity is an Independent Predictor of 15-Year Mortality Risk among Individuals Seeking Help for Alcohol-Related Problems. Alcoholism, Clinical and Experimental Research, 35(11), 2082–2092. doi:10.1111/j.1530-0277.2011.01560.x

What recovers in Recovery? – Cognitive Control over emotions?

 In recent blogs we have called for an increase in research into the neurobiology of recovery to add to the extensive research already published on the neurobiology of the addiction cycle.
There has been extensive research into the neurobiology of addiction, most of this has focused on reward and motivation networks of the brain.  In effect this suggests there is a pathological wanting in addicts, an excessive motivation towards drug taking over all other rewarding activities.
This view does not fully consider that this pathological wanting is in itself a product of dysregulated stress systems in the brain, many the product of neglect, abuse and maltreatment in childhood. These stress factors are also reflective of the role of emotional distress in the addiction cycle . This distress is we feel a product of the emotion processing and regulation deficits commonly seen in all addictive behaviours such as alcohol and substance addiction, eating and gambling disorders and sex addiction etc (and often reflective of childhood maltreatment).
In fact , this emotion processing and  regulation deficit is also apparent in certain children of alcoholics and may be a vulnerability to later alcoholism as these children demonstrate a deficit in impulsivity (common to alcoholics and addicts) and a decision making profile based on choosing now over later (short term gains based) and which recruits more subcortical and motor expressive (compulsive) parts of the brain rather than cortical and reflective/evaluative parts of the brain.
This means they make decisions to alleviate the distress of decisions (as undifferentiated emotions appear to be distressing) not via evaluative processes). This has obvious consequence for decision making over a life span.
This emotion dysregulation is also seen in active addicts and alcoholics and at the endpoint of addiction there is a fairly complete reliance of this compulsive decision making profile, which begs the question, does the decision making deficits seen in at risk children simply get worse in the addiction cycle via the neuro toxic effects of substance abuse?
This emotion (and stress) dysregulation also potentiates reward (makes things more rewarding) so alcohol is seen as more stimulating than for non risk children. This vulnerability may lead to the need  to regulate, especially negative, emotions ( and low self esteem ) via the stimulating and highly rewarding effects of alcohol make perpetuate the addiction cycle to it’s chronic endpoint where chronic emotional distress acts as a compulsive stimulus to the responding of chronic alcohol and drug use.
This emotion dysregulation also seems to play a huge part in relapse – so it begs the question does this emotion regulation improve in time via recovery, particularly long term recovery?
In the next two blogs we look at how the emotion regulation areas of the brain become reinforced, strengthened by the process of recovery or in other words we appear to develop the brain capacity for controlling and regulating our emotions more adaptively and this reduces the stress/distress which often prompts relapse.
Personally, I can wholeheartedly say, that the one main aspect I have developed in my recovery has been the awareness and skills in regulating/controlling emotions. Via recovery I have learnt to identify, label, describe by verbalising and sharing with others how I feel. This processes and regulates the emotions that used to cause me so much distress.
I have also developed a more acute awareness of the the emotional expression and needs of yours. These were previously aspects of my life which were completely lacking and frustrating/confusing as a result.
By emotionally engaging in with the world, by becoming more emotionally literate, I can converse with the world in a way that was previously beyond my capabilities.
The research we look at in the next two blogs asks the question – is cognitive control over emotions, lacking in active addiction, one of the main brain functions that improve in recovery?
A core aspect of alcohol dependence is poor regulation of behavior and emotion.
Alcohol dependent individuals show an inability to manage the appropriate experience and expression of emotion (e.g., extremes in emotional responsiveness to social situations, negative affect, mood swings) (1,2). Dysfunctional emotion regulation has been considered a primary trigger for relapse (1,3) and has been associated with prefrontal dysfunction.
While current alcohol dependence is associated with exaggerated bottom-up (sub-cortical) and compromised top-down (prefrontal cortex) neural network functioning, there is evidence suggesting that abstinent individuals may have overcome these dysfunctional patterns of network functioning (4) .
Neuro-imaging studies showing chronic alcohol abuse to be associated with stress neuroadaptations in the medial prefrontal and anterior cingulate regions of the brain (5 ), which are strongly implicated in the self-regulation of emotion and behavioral self-control (6).
One study (2) looking at how emotional dysregulation related to relapse, showed compared with social drinkers, alcohol-dependent patients reported significant differences in emotional awareness and impulse control during week 1 of treatment. Significant improvements in awareness and clarity of emotion were observed following 5 weeks of protracted abstinence.
Another study (7) which did not look specifically at emotional regulation but rather on the recovering of prefrontal areas of the brain known to be involved also in the inhibition of  impulsive behaviour and emotional regulation showed that differences between the short- and long-abstinence groups in the patterns of functional recruitment suggest different cognitive control demands at different stages in abstinence.

In one study, the long-term abstinent group (n=9) had not consumed cocaine for on average 69 weeks, the short-term abstinent (SA) group (n=9) had an average 0f 2.4 weeks.

Relative to controls, abstinent cocaine abusers have been shown to have reduced metabolism in left anterior cingulate cortex (ACC) and right dorsolateral prefrontal cortex (DLPFC), and greater activation in right ACC.
In this study  the abstinent groups of cocaine addicts showed more elevated activity in the DLPFC ; a finding that has also been observed in abstinent marijuana users (8).
The elevation of frontal activity also appears to undergo a shift from the left to right hemisphere over the course of abstinence.  The right is used more in processing (labelling/identifying) of emotion.
Furthermore, the left inferior frontal gyrus (IFG) has recently been shown to be important for response inhibition (9) and in a task similar to that described here, older adults have been shown to rely more on left PFC (10). Activity observed in these regions is therefore likely to be response inhibition related.
The reliance of the SA group on this region suggests that early in abstinence users may adopt an alternative cognitive strategy in that they may recruit the LIFG in a manner akin to children and older adults to achieve behavioral results similar to the other groups.
In longer,  prolonged abstinence a pattern topographically typical of normal, healthy controls may emerge.
In short-term abstinence there was an increased inhibition-related dorsolateral and inferior frontal activity indicative of the need for increased inhibitory control over behaviour,  while long-term abstinence showed increased error-related ACC activity indicative of heightened behavioral monitoring.
The results suggest that the improvements in prefrontal systems that underlie cognitive control functions may be an important characteristic of successful long-term abstinence.
Another study (11) noted the loss of grey matter in alcoholism that last from 6–9 months to more than a year or, in some reports, up to at least 6 years following abstinence (12 -14).
It has been suggested cocaine abuse blunts responses in regions important to emotional regulation (15)
Given that emotional reactivity has been implicated as a factor in vulnerability to drug abuse (16)  this may be a preexisting factor that  increased the likelihood of the development and prolonging of drug abuse
If addiction can be characterized as a loss of self-directed volitional control (17),  then abstinence (recovery) and its maintenance may be characterized by a reassertion of these aspects of executive function (18)  as cocaine use has been shown to reduce grey matter in brain regions critical to executive function, such as the anterior cingulate, lateral prefrontal, orbitofrontal and insular cortices (19-24) .
The group of abstinent cocaine addicts (11) reported here show elevations in  (increased) grey matter in abstinence exceeded those of the healthy control in this study after 36 weeks, on average, of abstinence .
One possible explanation for this is that abstinence may require reassertion of cognitive control and behavior monitoring that is diminished during current cocaine dependence.
Reassertion of behavioral control may produce a expansion (25)  in grey matter  in regions such as the anterior insula, anterior cingulate, cerebellum, and dorsolateral prefrontal cortex .
All brain regions implicated in the processing and regulating of emotion. 
References
1. Berking M, Margraf M, Ebert D, Wupperman P, Hofmann SG, Junghanns K. Deficits in emotion-regulation skills predict alcohol use during and after cognitive-behavioral therapy for alcohol dependence. J Consult Clin Psychol. 2011;79:307–318.
2.  Fox HC, Hong KA, Sinha R. Difficulties in emotion regulation and impulse control in recently abstinent alcoholics compared with social drinkers. Alcohol Clin Exp Res. 2008;33:388–394.
3..Cooper ML, Frone MR, Russell M, Mudar P. Drinking to regulate positive and negative emotions: A motivational model of alcohol use. J Pers Soc Psychol. 1995;69:990
4. Camchong, J., Stenger, A., & Fein, G. (2013). Resting‐State Synchrony in Long‐Term Abstinent Alcoholics. Alcoholism: Clinical and Experimental Research37(1), 75-85.
5. Sinha, R., & Li, C. S. (2007). Imaging stress- and cue-induced drug and alcohol craving: Association with relapse and clinical
implications. Drug and Alcohol Review, 26(1), 25−31.
6. Beauregard, M., Lévesque, J., & Bourgouin, P. (2001). Neural correlates of conscious self-regulation of emotion. Journal of
Neuroscience, 21(18), RC165
7. Connolly, C. G., Foxe, J. J., Nierenberg, J., Shpaner, M., & Garavan, H. (2012). The neurobiology of cognitive control in successful cocaine abstinence. Drug and alcohol dependence121(1), 45-53.
8.  Tapert SF, Schweinsburg AD, Drummond SP, Paulus MP, Brown SA, Yang TT, Frank LR. Functional MRI of inhibitory processing in abstinent adolescent marijuana users.Psychopharmacology (Berl.) 2007;194:173–183.[PMC free article]
9. Swick D, Ashley V, Turken AU. Left inferior frontal gyrus is critical for response inhibition. BMC Neurosci. 2008;9:102.[PMC free article]
10. Garavan H, Hester R, Murphy K, Fassbender C, Kelly C. Individual differences in the functional neuroanatomy of inhibitory control. Brain Res. 2006;1105:130–142
11. Connolly, C. G., Bell, R. P., Foxe, J. J., & Garavan, H. (2013). Dissociated grey matter changes with prolonged addiction and extended abstinence in cocaine users. PloS one8(3), e59645.
12. Chanraud S, Pitel A-L, Rohlfing T, Pfefferbaum A, Sullivan EV (2010) Dual Tasking and Working Memory in Alcoholism: Relation to Frontocerebellar Circuitry. Neuropsychopharmacol 35: 1868–1878 doi:10.1038/npp.2010.56.
13.  Wobrock T, Falkai P, Schneider-Axmann T, Frommann N, Woelwer W, et al. (2009) Effects of abstinence on brain morphology in alcoholism. Eur Arch Psy Clin N 259: 143–150 doi:10.1007/s00406-008-0846-3.
14.  Makris N, Oscar-Berman M, Jaffin SK, Hodge SM, Kennedy DN, et al. (2008) Decreased volume of the brain reward system in alcoholism. Biol Psychiatry 64: 192–202 doi:10.1016/j.biopsych.2008.01.018.
15, Bolla K, Ernst M, Kiehl K, Mouratidis M, Eldreth D, et al. (2004) Prefrontal cortical dysfunction in abstinent cocaine abusers. J Neuropsychiatry Clin Neurosci 16: 456–464 doi:10.1176/appi.neuropsych.16.4.456.
16.  Piazza PV, Maccari S, Deminière JM, Le Moal M, Mormède P, et al. (1991) Corticosterone levels determine individual vulnerability to amphetamine self-administration. Proc Natl Acad Sci USA 88: 2088–2092. doi: 10.1073/pnas.88.6.2088
17.  Goldstein RZ, Volkow ND (2002) Drug addiction and its underlying neurobiological basis: neuroimaging evidence for the involvement of the frontal cortex. Am J Psychiatry 159: 1642–1652. doi: 10.1176/appi.ajp.159.10.1642
18. Connolly CG, Foxe JJ, Nierenberg J, Shpaner M, Garavan H (2012) The neurobiology of cognitive control in successful cocaine abstinence. Drug Alcohol Depend 121: 45–53 doi:10.1016/j.drugalcdep.2011.08.007.
19.  Liu X, Matochik JA, Cadet JL, London ED (1998) Smaller volume of prefrontal lobe in polysubstance abusers: a magnetic resonance imaging study. Neuropsychopharmacol 18: 243–252 doi:10.1016/S0893-133X(97)00143-7.
20.  Bartzokis G, Beckson M, Lu P, Nuechterlein K, Edwards N, et al. (2001) Age-related changes in frontal and temporal lobe volumes in men – A magnetic resonance imaging study. Arch Gen Psychiatry 58: 461–465. doi: 10.1001/archpsyc.58.5.461
21. Franklin TR, Acton PD, Maldjian JA, Gray JD, Croft JR, et al. (2002) Decreased gray matter concentration in the insular, orbitofrontal, cingulate, and temporal cortices of cocaine patients. Biol Psychiatry 51: 134–142. doi: 10.1016/s0006-3223(01)01269-0
22.  Matochik JA, London ED, Eldreth DA, Cadet J-L, Bolla KI (2003) Frontal cortical tissue composition in abstinent cocaine abusers: a magnetic resonance imaging study. NeuroImage 19: 1095–1102. doi: 10.1016/s1053-8119(03)00244-1
23.  Lim KO, Wozniak JR, Mueller BA, Franc DT, Specker SM, et al. (2008) Brain macrostructural and microstructural abnormalities in cocaine dependence. Drug Alcohol Depend 92: 164–172 doi:10.1016/j.drugalcdep.2007.07.019.
24.  Ersche KD, Barnes A, Jones PS, Morein-Zamir S, Robbins TW, et al. (2011) Abnormal structure of frontostriatal brain systems is associated with aspects of impulsivity and compulsivity in cocaine dependence. Brain 134: 2013–2024 doi:10.1093/brain/awr138.
25.  Ilg R, Wohlschlaeger AM, Gaser C, Liebau Y, Dauner R, et al. (2008) Gray matter increase induced by practice correlates with task-specific activation: A combined functional and morphometric magnetic resonance Imaging study. J Neurosci 28: 4210–4215 doi:10.1523/JNEUROSCI.5722-07.2008.

The Road to Recovery

Following on from our recent blog on “So what is Recovery?” we now look at the process of recovery itself and important changes that contribute to successful recovery.

Many recovering persons report quitting drugs because they are ‘sick and tired’ of the drug life. Recovery is the path to a better life but that path is often challenging and stressful.

However, the main message from this study (1) is that those individuals who manage to get to 5 or more years abstinence have an 86% chance of long term recovery !

Not only do the recovering persons benefit in many ways but families and societies also see major benefits of recovery too. The initial cost of recovery, i.e. if via treatment facilities, is offset by increased employment, less penal costs, financial contributions to society of recovering persons etc.

Not only does it make ethical, moral and medical sense to spend much more on treatment facilities it makes makes very obvious financial sense.

“Although substance use disorders are increasingly recognized as chronic relapsing conditions that often span decades and require multiple episodes of treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001; Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos 2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome 2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996), approximately 60% of the people with lifetime substance disorders do eventually reach a state of sustained abstinence (Cunningham 1999a, 1999b; Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).

This has led to multiple calls to define and better understand and study “recovery” in terms of not only abstinence but improvements in health, mental health, coping, housing, social and spiritual support, illegal activity, and vocational engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen, and White 2006; Laudet, White, and Storey [in press]; White 2005).

Using data from 1,162 adults living in a large metropolitan area who sought substance abuse treatment in 1998 and who were subsequently interviewed annually between Years 2 and 8 (greater than 94% follow-up rate each year), this study addresses the following four questions:

1. How do health, mental health, and coping vary by duration of abstinence?

2. How do illegal activity, incarceration, employment, and family income vary by duration of abstinence?

3. How do housing, clean and sober friends, recovery environment, self-efficacy to resist relapse, and social and spiritual support vary by duration of abstinence?

4. How does the likelihood of sustaining abstinence another year vary by the duration of abstinence?

Health, mental health, and coping. Abstinence is generally associated with better health, mental health, and coping. Among people in the community, less substance use is associated with lower rates of chronic health and psychiatric problems, which are in turn associated with high societal costs and death (Mokdad et al. 2004).

Abstinence is also associated with less “avoidance” coping styles, such as cognitive avoidance and emotional discharge, as well as more “approach” coping styles, such as logical analysis, seeking guidance, problem solving, seeking alternative rewards, and positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos 2005).

Abstinence has generally been associated with reductions in illegal activity, incarceration, poverty, and improvements in vocational activity. Reductions in substance use are associated with relatively rapid reductions in illegal activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).

Although this often involves some period of residential treatment or incarceration, such costs are typically offset by reductions in other costs to society, increased employment, and increased productivity (Bray et al. 2000; French, Salome, and Carney 2002; McCollister and French 2003; Rajkumar and French 1997; Single et al. 1998).

Abstinence is generally associated with being housed and having some friends, fewer problems in the recovery environment, and more personal, family, social, and spiritual support.

Risks (e.g., substance use among family, friends, and victimization) and protective factors (e.g., treatment and self-help participation, peers in recovery) in the recovery environment and self-efficacy to resist relapse were also among the major predictors of transitions from using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte et al. 2001; Scott et al. 2005b).

The general association between relapse and stress has also been found to be moderated by the extent of support one gets from self-perceived personal strengths, family, and social peers (Jessor, Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996; Procidano and Heller 1983; Schutte et al. 2001).

We found no studies to date using the “duration of abstinence” to predict the likelihood of sustaining abstinence for another year. However, a recent extensive review by Moos and Moos (2007) found one or more of four dozen studies reporting that the odds of sustaining abstinence was positively associated with abstinence self-efficacy, approach coping styles, vocational engagement, income, having clean and sober friends, and having social and spiritual support and inversely related to an avoidance approach coping style.

Findings – This study demonstrates that duration of abstinence is related to changes in other aspects of recovery but at different rates and times.

Use of coping mechanisms started out high and decreased as the number of years of abstinence increased, suggesting that the high rates of these coping strategies previously reported by others (see Moos and Moos 2007) may actually be a characteristic of early abstinence. Mental health problems peaked during 1 to 3 years of abstinence and decreased thereafter.

The rapid decrease in illegal activity and illegal income sustained across varying lengths of abstinence was consistent with the literature given that many of the crimes were drug related. Following 1 year of abstinence, the number of days worked and legal income generated significantly increased and days with financial problems decreased. After 3 years of abstinence, there were also significant reductions in the percentage of families living below the poverty line, which indicates continued gains in financial status.

Consistent with the literature, the duration of abstinence was associated with reduced environmental risks and increased number of clean and sober friends, level of social support, spiritual support, and self-efficacy to resist relapse.

The odds of sustaining abstinence increased dramatically during the first 3 years and then leveled off. Among people with 5 or more years of abstinence, there was still some risk of relapse (14%) – but equally a 86% chance of remaining in recovery!

Consistent with earlier findings by Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al. [in press]) that women were more likely to enter and stay in recovery.

Implications for Practice, Policy, and Research

Findings suggest the need for a shift from focusing on acute episodes of treatment to the management of recovery during longer periods of time.

Most of the drug abuse treatment research to date has focused on reducing days of use or abstinence in the first 6 to 12 months after treatment (Dennis and Scott [in press]; Prendergast et al. 2002). More health services research is needed on managing long-term recovery, both in terms of how to deliver it in ways that are both effective and cost effective for multiple years. This includes research on ways to integrate these other kinds of services, minimize some of the negative trends (e.g., the early peak in mental health problems), and accelerate the positive trends (e.g., more positive recovery environment and vocational activity).

Conclusion

Although much of the research on substance abuse treatment outcomes has focused on abstinence in the first 6 to 12 months after treatment, this article suggests that initial abstinence and the initial time period do not fully represent the changes associated with long-term recovery. This research shows that risk of relapse is particularly problematic in the first 3 years of abstinence and never completely goes away, suggesting the need for promoting strategies and programs that support the long-term management of recovery.

References

1. Dennis, M. L., Foss, M. A., & Scott, C. K. (2007). An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Evaluation Review, 31(6), 585-612.