what is recovery?

How do you know when Medicating becomes Self Medicating?

Posted on by alcoholicsguide

A recent blog in the After the Party Magazine  has raised some very pertinent questions about the issue of co-morbidity in alcoholics and addicts seeking recovery via 12 step groups and suggests the extent of this co-morbidity is much higher than may have been anticipated.

This blog raises important issues but ultimately may leave more questions than it answers?

The blog starts “You hear it in 12-step meetings all the time—people who were once on psych meds discovered they didn’t need them after getting sober and doing the steps. Now they’re evangelizing at every meeting in town about how their problem was really just spiritual. Maybe they were never mentally ill to begin with or maybe the steps really did banish their mental illness right out of their brains. But for me, and plenty of others I know, this isn’t the case.”

The author then continues ” If anyone has any questions about psychiatric meds AA has an official stance that’s in a pamphlet called The AA Member—Medications and Other Drugs. ”

I referred to this pamphlet on Monday’s blog Can you be Sober and in Recovery while on Medication?

As I mentioned then the pamphlet appears to be alerting AA members to the reality that certain members “must take prescribed medication for serious medical problems. However, it is generally accepted that the misuse of prescription medication and other drugs can threaten the achievement and maintenance of sobriety”.

As the author notes this pamphlet states ” “No A.A. member should ‘play doctor’; all medical advice and treatment should come from a qualified physician.”

It also states that “Some of us have had to cope with depressions that can be suicidal; schizophrenia that sometimes requires hospitalization; bipolar disorder, and other mental and biological illnesses.

“A.A. members and many of their physicians have described situations in which depressed patients have been told by A.A.s to throw away the pills, only to have depression return with all its difficulties, sometimes resulting in suicide.

“We have heard, too, from members with other conditions, including schizophrenia, bi-polar disorder, epilepsy and others requiring medication, that well-meaning A.A. friends discourage them from taking any prescribed medication. Unfortunately, by following a layperson’s advice, the sufferers find that their conditions can return with all their previous intensity. On top of that, they feel guilty because they are convinced that ‘A.A. is against pills.’ It becomes clear that just as it is wrong to enable or support any alcoholic to become readdicted to any drug, it’s equally wrong to deprive any alcoholic of medication, which can alleviate or control other disabling physical and/or emotional problems.”

The author then suggest that ” roughly 70% people I meet in AA are on meds. A lot people are quiet about it because they don’t want the backlash…”

Is the prevalence of people taking medication in 12 step groups this high? Or is this a sample bias?

Perhaps many of the people I know in AA have simply been keeping quiet about it? I am not convinced that this figure is accurate, based on my own observations?

If this figure is representative then what co-occurring conditions are these recovering people medicating?

There are obviously a host of co-occurring conditions  that recovering people suffer from – from physical, such as back pain, to epilepsy, to anxiety disorders to depression, bi-polar, borderline personality disorder, post traumatic stress disorder, schizophrenia …in fact the list goes on.

Is it  thus reasonable of us in AA and other 12 step groups to expect that all members are medication free or that the 12 steps can treat all co-occurring conditions?

It has been suggested in a AA survey  that over 60% of recovering individuals in 12 step groups seek outside professional help for co-occurring difficulties which suggest that the trajectory of alcoholism and addiction is not straightforward and includes other co-occurring problems which may add to the severity of psychological symptoms experienced.

A very pertinent question is whether these co-occurring conditions are parallel problems or are additional problems that affect one’s addiction recovery.

By this I mean if one suffers, as I do, from PTSD, do PTSD symptoms also add to relapse vulnerability, for example. I can say for myself that the two times I have had issues with relapse have been prompted by manifestation of PTSD symptoms, such as flashbacks.

For me, at least, my co-occurring condition of PTSD affects my recovery from alcoholism and substance addiction. It is inseparable – in fact my PTSD and childhood maltreatment has contributed to my addiction.  Although it doesn’t necessarily follow that my choice of  treatment, e.g. 12 step recovery will straighten out all the factors that contributed to this addiction.

Equally the 12 step and associated fellowship and program for living may help manage this condition too?

I have not relapsed in a decade so the 12 steps etc must be helping with co-occurring conditions as these conditions have to potential to prompt relapse?

I will explain this further, below, in relation to the various sponsors I have had in recovery.

I do not medicate for this condition nor have I sought outside help although I  have considered outside help many times. Perhaps I am edging closer to that.

Equally I believe the process of recovery has helped me recover from PTSD, has made me aware of triggers, etc.

How prevalent is PTSD in addiction? Do others suffer in recovery from this co-occurring condition too?

Approximately 35% to 50% of people in addiction treatment programs have a lifetime diagnosis of posttraumatic stress disorder (PTSD), and 25% to 42% have a current diagnosis (Back et al., 2000; Brady, Back, & Coffey, 2004; P. J. Brown, Recupero, & Stout, 1995; Cacciola, Alterman, McKay, & Rutherford, 2001; Dansky et al., 1996;Jacobsen, Southwick, & Kosten, 2001; Mills, Lynskey, Teesson, Ross, & Darke, 2005;Ouimette, Ahrens, Moos, & Finney, 1997).

Is this the case in 12 step groups?

In order to examine the extent of co-morbidity in recovery I will briefly run through some of the sponsors I have had in recovery, and their co-occurring conditions – self acknowledged or not.

First sponsor – bi polar, not medicated, but also treated via outside professional help – accepts that he will occasionally have very dark days as part of his recovery. His choice is not to medicate as he feels it is a chemical straightjacket although he accepts the right of others to take medication for this condition.

Second sponsor – borderline personality disorder – not medicated – has sought professional outside help.

Third sponsor – no co-occurring conditions  – but would suggest his religiomania contributes to his absolute conviction that recovering people do not need medication of any sort that God can heal everything.

Fourth and fifth  sponsors both PTSD but not fully acknowledged nor treated outside of 12 steps.

All in long term recovery of 12 plus years.

From this very small survey it is clear that there is a common co-occurrence with other conditions, acknowledged or otherwise. There is also extensive childhood abuse of various types.

All of them have not or do not take medication. They may be in some way also be treated by the 12 steps.

I have also sponsored a person with  schizophrenia who needs to take medication because of returning psychosis if he fails to take medication.

What I am saying is that some individuals with obvious co-occurring conditions also choose not to medicate as well and feel their general “recovery” is treated by the steps and fellowship, often together with outside help. Having a co-occurring condition does not mean one automatically takes medication for this condition? Many do not?

This is why I queried the “70%” are on meds above. I do not necessarily disagree that those suffering co-morbid conditions is the majority but would query why so many take medication?

Are some of these on medication assisted treatment to curb urges and cravings too?

In terms of so-called co-occurring disorders such as anxiety and mood disorders such as generalized anxiety disorders (GAD) and major depression (MDD), research has shown that these symptoms often dissipate in the early weeks of recovery.

This had led researchers like Mark Shuckit to call these substance induced disorders and to suggest that co-occurring disorders such as GAD and MDD are distributed in recovery populations as they are in normal population at around 15% prevalence.

This is why I think some 12 steppers are “anti med” as they often see the symptoms of GAD and MDD dissipate in early recovery and thus believe the steps are treating these disorders successfully.

Although these disorders are but temporary substance induced disorders for many, however, for 15%, at least, these conditions of  GAD and MDD are possibly what they suffer from too in recovery.

Regardless of that caveat if we add this 15% to up to 50% who suffer PTSD and the possibility of the occurrence of other conditions such as borderline, bi polar, etc we get closer to the 62% figure of AA respondents that an AA survey in 2012 states  received some type of treatment or counseling, such as medical, psychological, spiritual, etc., (and 82% of those said it played an important part in their recovery from alcoholism).

Whether these conditions require medication is a matter for the person and their sponsor in discussion with medical professionals and not some layperson “medical expert” as often abounds in AA and other 12 step groups.

The issue here is not simply co-morbidity  but whether this co-morbidity is an intrinsic part of the aetiology of addiction from a vulnerability to a relapse  factor. In other words, have other conditions meshed into the overall condition of addiction? Can they be treated by the same treatment?

Regardless,  they often have to be treated  separately.

To conclude it seems that 12 step groups need to appreciate that co-occurring conditions, self acknowledged or not, play an important part in recovery and relapse as well as in the aetiology of addiction.

How effectively the medication used can be dissected from the condition of addiction is still debatable for many?

In short, many feel being on medication impedes full recovery.

How we define full recovery is open to question? Recovery can be measured using many variables related to quality of life. If medication using members feel their lives are steadily improving then who are we to judge?

Equally just because one suffers a condition does not inevitably mean it must be medicated, some of the examples above have “treated”  their co-occurring conditions via the 12 step program of recovery.

I think ardent fans of the right to medication should appreciate that there is a valid counter argument – they may have the same rights to their point of view as the author of this  blog?

All of us has the right to think as they wish and to express their views also.

Live and Let Live may be apropos, we all have the right to be wrong, Love of others is our code.

Alcoholics are such absolutist thinkers, all or nothing, black and white thinkers at times. Recovery is also considering others and their points of view?

Personally speaking if I sponsor, I take it on a case by case basis.

I have had only one sponsee out of 7 who has been on medication.

It is for sponsor, sponsee and family as well as medical professionals to contribute to the debate on continued medication.

My lasting concern, however is the 70% figure cited in this blog. It does not tally with my experience of recovery.

Another part of the AA pamphlet cited also warns,

“Experience suggests that while some prescribed medications may be safe for most nonalcoholics when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way…”

Again this seems to be alerting us to the question when is medicating actually self medicating?

 

 

This has been my main experience with medication, that those taking them do not always look completely sober.

In order to recovery fully perhaps we have to be fully sober first?

I will continue this discussion in Part 2 of this blog when I discuss also whether considering alcoholism purely as a “spiritual malady” complicates this argument.

In the DSM manual 75% of the disorders contained therein have emotion dysregulation at the centre of their condition. I believe alcoholism and addiction also have although not acknowledged.

Insted DSM states the emotional dysfunction seen in addiction is the result of some of co-morbidites mentioned above. I disagree.

Is it not about time we got our heads together and agreed on what the hell we suffer from?

Isn’t addition an emotional disorder in it’s own right compounded by other co-occurring conditions?

Then we will be in a position to discuss how the 12 steps can treat this condition and related conditions of emotion dysregulation?

The main issue for the blog addressed, is that the author, and many others, cannot understand how a spiritual malady has anything to do with their other conditions, when, in reality, alcoholism is another type of disorder, similar to that with which it often co-occurs .

More on this later…

 

 

 

 

 

 

 

Can you be Sober and in Recovery while on Medication?

Posted on by alcoholicsguide

 

In a recent blog from the Recovery Research Institute http://www.recoveryanswers.org/blog/12-step-mutual-help-and-medication-assisted-treatment/

by  Brandon G. Bergman, Ph.D. 

It was suggested that a survey of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”.

Obviously if these AA members have a respect for the Traditions of AA they would have been responding to the survey as individuals in recovery? As Tradition 10 of Alcoholics Anonymous states:-

“Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.”

This is a very important point. I do not write this blog as an AA member but as a researcher and recovering alcoholic/addict who seeks to combine  neuro-psychological research with the experiential insights I have been given as the result of recovery, albeit with 12 step recovery. I do not speak for AA nor would I wish to. I believe the traditions can be incorporated in our daily recovery like the 12 steps. The traditions are there to protect us from ourselves and gives us guidelines for interacting with the wider world.

Being drawn into public controversy is not good I believe for the health of AA or the recovering individual within AA.

I mention this also because in this article, the author appears to suggest that AA’s  membership has an  official position on Medication-assisted treatment (MAT), including opioid agonists (e.g., Suboxone) and antagonists (e.g., Naltrexone and its monthly depot formulation Vivitrol).

Is this actually the case or is this statement misleading?

I will leave you to decide that? The   official position on MAT is that of the AA pamphlet The A.A. Member — Medications and Other Drugs – which this author suggests “appears to be one of skeptical tolerance”.

Personally I have read through the pamphlet and see no mention of MAT whatsoever.

The pamphlet appears to be alerting AA members to the reality that certain members “must take prescribed medication for serious medical problems. However, it is generally accepted that the misuse of prescription medication and other drugs can threaten the achievement and maintenance of sobriety”.

Among some suggestion listed in this pamphlet are

“• No A.A. member should “play doctor”; all medical advice and treatment should come from a qualified physician. • Active participation in the A.A. program of recovery is a major safeguard against alcoholic relapse. • Be completely honest with your doctor and yourself about the way you take your medicine. Let your doctor know if you skip doses or take more medicine than prescribed. • Explain to your doctor that you no longer drink alcohol and you are trying a new way of life in recovery….”

The pamphlet proceeds to warn

“From the earliest days of Alcoholics Anonymous it has been clear that many alcoholics have a tendency to become dependent on drugs other than alcohol. There have been tragic  incidents of alcoholics who have struggled to achieve sobriety only to develop a serious problem with a different drug. Time and time again, A.A. members have described frightening and sobriety-threatening episodes that could be related to the misuse of medication or other drugs.”

Experience suggests that while some prescribed medications may be safe for most nonalcoholics when taken according to a doctor’s instructions, it is possible that they may affect the alcoholic in a different way. It is often true that these substances create dependence as devastating as dependence on alcohol.

I can not see a “skeptical tolerance” or even a mention here of MAT.

The author then suggests that “broader anti-medication messages may be pervasive” within AA membership.

Although he slightly contradicts this by citing a survey “of almost 300 long-term AA members (average time in recovery 13 years), more than half felt medication to resist alcohol cravings/urges was or might be a good idea, and 17% did not think it was a good idea, but were “OK with it”. That would be a majority are “ok with it”?

The actual study concluded that “it did not find strong, widespread negative attitudes toward medication for preventing relapse among AA members. Nevertheless, some discouragement of medication use does occur in AA. Though most AA members apparently resist pressure to stop a medication, when medication is prescribed a need exists to integrate it within the philosophy of 12-step treatment programs.”

So why say it anti-medication views are pervasive based on this study?

However, one could say they are indeed pervasive based on the next study.

The author then states, “However, in a follow-up survey  with about 130 participants from Project MATCH 10 years after they began the clinical research study, only 16% agreed that 12-step members say it is acceptable to take medications to address drinking problems.”

I found this passage a little confusing so looked at the original survey abstract which states “In general, client perceptions were not favorable about the use of such medications.”

The author then proceeds to mention NA’s  official position “on individuals receiving MAT is welcoming on the one hand, while on the other, is explicitly restrictive and conveys a clear divide between members who are “clean” (i.e., “in recovery”) and those who are “on drug replacement therapy” (i.e., attending meetings but are not “in recovery”).”

NA’s “official position” is outlined in the pamphlet – NA groups and Medication

Drug Replacement

By definition, drug replacement is used for a different reason than prescribed medications for mental or physical health. This distinction makes drug replacement a separate issue for us in NA. When it comes to those who participate in drug replacement, it is helpful to remember that our Third Tradition clearly states that membership in NA is established when someone has a desire to stop using or when they choose to become a member, not when they are clean. No matter what the issue, groups are still charged with the goal of welcoming each person who walks into a meeting.

Some NA members are confused or even intolerant of those on drug replacement due to what they see as a contradiction between drug replacement and the NA principle of complete abstinence.

Some of us are fearful when those on drug replacement want to share or speak on behalf of NA. It may be helpful for all of us to remember that many addicts on drug replacement eventually do get clean, stay clean, and find a way of life they thought was unobtainable before coming to NA. This process doesn’t always occur when an addict attends his or her first meeting—getting and staying clean is often a decision that’s made after attending many meetings over a period of time.

Because NA a is program of complete abstinence, groups do sometimes limit the participation of members on drug replacement to ensure the clarity of the NA message. Yet, we must balance this limited participation with the idea that membership in NA comes with a desire to stop using, not abstinence.

As the Tradition Three essay in It Works: How and Why, reminds us, “Desire is not a measurable commodity. It lives in the heart of each member. Because we can’t judge the sole requirement for membership, we are encouraged to open wide the doors of our meetings to any addict who wishes to join.”

Opening our doors to these members means that groups take the time to discuss this issue and find ways to make everyone feel welcome. Each group is autonomous, and a group’s conscience will ultimately determine the level of participation of those on drug replacement.

Some groups may decide to encourage those on drug replacement to serve as coffee or tea makers, or as a clean-up person, instead of holding leadership positions. These commitments may encourage a desire for complete abstinence through allowing these members to feel a part of NA.

The reality is that some groups already permit those on drug replacement to share and lead meetings, while others do not. Although we may not endorse this level of participation, we can simply acknowledge what exists and consider ways to encourage every member to get clean and find the hope and recovery that are possible in NA. The real question groups are left with is how to honor the NA philosophy of complete abstinence and still welcome addicts in our groups and meetings.

What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom. The only requirement for membership is a desire to stop using. Tradition Three One of the most challenging aspects of this issue is that while an NA group is free to ask those who have used that day to refrain from sharing in the meeting, groups don’t decide what “using” means for an individual member. The use of medication is an issue that many members have strong personal feelings about, but a group is not there to enforce, endorse, or oppose members’ personal opinions.

Any member—those who take medication and those who feel taking medication is inappropriate—has a responsibility to not represent their personal feelings and opinions as the opinions of Narcotics Anonymous as a whole. In NA, we purposely attract people who are ill, unstable, and in need of help. Our challenge is to continue to practice tolerance, patience, and love, so that we create an atmosphere in which those who want to recover can do so.

Many of us have watched as NA meetings become weighed down by disruptions, controversy, and negativity around this issue. Yet, when these challenges are addressed through incorporating the spiritual principles of our program, groups often become stronger and more focused as a result. Recovery is often a demanding process with many ups and downs, and NA groups tend to experience similar challenges. Yet, it is these struggles that allow us to grow as individuals and as groups.

Narcotics Anonymous is here to help addicts find a new way of life, and joining NA means becoming a part of a lively and diverse fellowship. As our First Tradition reminds us, “Our relationships with one another are more important than any issue that may arise to divide us.” Keeping this in mind allows our groups to best serve all addicts seeking recovery in NA.”

However, as the author notes in reference to William White’s observations , “there are no empirical studies of how MAT patients engage with NA or, in parallel, NA members’ perceptions and attitudes toward MAT. In an informal qualitative assessment of MAT-focused online discussion forums (e.g., suboxforum.com), however, he found that some individuals receiving MAT have had positive, live-saving experiences in NA, though the majority experience was one of feeling rejected, confused, or angry, sometimes leading individuals to seek support elsewhere.”

The author concludes that “the medication-skeptical culture in professional 12-step-oriented treatment programs and systems appears to be in transition. Cutting-edge, front-line organizations like Hazelden Betty Ford recognize the power, and evidence, in both linking individuals to MHO-based recovery supports, as well as the need to address opioid use disorders with a comprehensive biopsychosocial approach.”

“They are currently studying pilot outcomes of this new integrated treatment that uses MAT to help patients get into recovery emphasizing 12-step MHO engagement, with an eventual gradual taper once long-term, stable recovery is achieved. It is unclear whether this type of attitudinal shift is also taking place within the community-based 12-step MHO groups themselves.

In the meantime, the limited available data suggests individuals receiving MAT are likely to encounter concerns or outright opposition from 12-step MHO members (with greater anti-medication attitudes in NA). They and their providers and family/friends should be prepared for this. The field would benefit from research studies of MAT patients’ quality of life recovery outcomes, MAT patients’ attitudes about NA, NA members’ attitudes about MAT, and whether and how MAT patients can successfully navigate anti-medication sentiment during their 12-step MHO participation. Also, specific research questions around different opinions about agonists versus antagonists would have important implications on clinical practice. Finally, there are a host of non-12-step MHOs that the field knows far less about from an empirical perspective, like SMART recovery, which, for example, officially supports legally prescribed, evidence-based MAT.”

It is worth noting that AA also has no opinion on treatment centres either. What happens at HalezdenBettyFord is not the concern of AA.

The results of their study or prospective studies do not necessarily have any bearing on 12 step groups either.

There are a number of hugely important issues raised in this article, which is indeed timely.

In part 2 of the is blog I will attend to these points and another article recently posted in the After the Party Magazine.

In order to get to the bottom of this debate we have to ask ourselves some serious questions such as

What is that I suffer from as an addict (what are the underlying conditions)?

How are these underlying mechanism “treated”by 12 step recovery processes? What is recovery?

How would this treatment or recovery be helped or hindered by continued use of MAT – i.e. when is short term use ok and long term not (how do we draw he line between recovery and choosing an easier softer way which does not arrest our condition but may contribute to it’s continued trajectory?)

There may be no hard and fast answer to the last question.

I am not sure we have arrived at a comprehensive theory of addiction which links the cognitive affective mechanisms which mediate the impaired neurobiology of addiction.

As such we seem to rely on neurobiological accounts which have a focus on paradigms such as craving and cue reactivity etc when these are always mediated by factors such as stress and emotion dysregulation?

To conclude we need to ultimately consider recovery tools which address the emotion and stress dysregulation which maintain this disorder and prompts carving and relapse.

Whether MAT straightjackets or facilitates this process to wellness is ultimately the question.

My craving dissipated with full acceptance of my addictive disorder.

Ultimately it is a very personal question too!?

This is often for individuals, and their sponsors and home groups to decide not by “official positions” – to decide for themselves what is in the best interest of recovery within individual groups at a micro level not the macro levels that researchers want 12 step groups to comment on.

Researchers may also consider that it is not always fear that prompts anti medication debates but real concern that certain individuals are engaged in a recovery process. Not to be engaged in a recovery process or reluctant to be has obvious consequences also.

AA and other 12 step groups are ingenious in their structures  that flow from from the 12 steps, to the 12 traditions to the 12 concepts for World Service to help what is essentially group of, at times, fear based control freaks to live properly together, to recover, together. They achieve in that  human terms is the equivalent of learning how to  herd cats!

They are truly remarkable. They are also there to protect us from the however well meaning opinions of others, or otherwise, in the outside world!

The outside world often has not got a clear idea of how these structures protect our recoveries. AA is a network of indepedent groups, a federation in the true sense, of emotionally vulnerable people who only want to help others like them.  This is in fact how these fellowships  grow and recovery

Within these structures we try not take other people’s inventories but only our own. We try not judge but be tolerant of. Groups take their own inventories but not other groups’. in an ideal scenario anyway!

If individuals do not feel welcome in these meetings there are often other groups where they will.

I am stating this because there is an idea of 12 step groups as a monolith when the opposite is true. The liberties of 12 step groups far exceeds any other groups I have ever known. No one is in charge of AA or other groups and it is enshrined in our concepts, traditions and steps that we all,  AA and other 12 step groups included, have the right to be wrong.

It is via our own individual and group consciousness that the best direction that most suits others in need is sought.

We recover by helping others recover.

But ultimately we all have to consider as NA states ” What is most important is that we don’t let our fears get in the way of our group’s ability to carry the NA message of hope and freedom.

We do this I believe by “love and tolerance”  and by showing 12 step recovery to those who may not yet have it.

All our efforts thus must be to facilitate this for others, even if that is facilitated by a group conscience that seems at odds with the acceptance of MAT but hopefully not with our traditions of service.

 

 

 

 

 

 

 

So What is Recovery?

Posted on by alcoholicsguide

So, what does recovery mean? It is total abstinence? Is recovery strictly a question of substance use or is there more to it than that?

This study (1) addressed two primary research questions: (1) Does recovery require total abstinence from all drugs and alcohol? and (2) Is recovery defined solely in terms of substance use or does it extend to other areas of functioning as well?

Many of those in this study who defined recovery as abstinence went on to express the idea that using any mood altering substance would lead back to full-blown relapse.

Recovery meant  in descending order: a new life (22%), well-being (13%), a process of working on yourself (11.2%), living life on life’s terms (accepting what comes – 9.6%), self-improvement (9%), learning to live drug free (8.3%), recognition of the problem (5.4%), and getting help (5.1%).

“I’m in recovery myself because I want to stay clean. And I want to be a responsible person or responsible human being. To do what I was … what I should do or what God put me here to do. And, you know, I got to – I got to remain sober to do these things.”

“To me recovery means getting back what I lost. Myself. I am not talking about materialistic things. I am talking about me.”

“Recovery, I just.. What is it for me? It’s going back to me…

“My definition of recovery is life. Cause I didn’t have no life before I got into recovery.”

 

Qualitative data on recovery definitions provided by the 20.4% of individuals who did not consider themselves in recovery are particularly noteworthy as they echo some of the popular connotations the term ‘recovery’ carries in the general public. Some of the answers were expected, including those of individuals who may have never considered themselves in recovery (e.g., “I wouldn’t know how to define recovery because I’ve never been in it,” “I’ve heard of the term, but I don’t know. What is it? I guess, it’s being committed to being straight”), and individuals who may have relapsed (e.g., “it used to feel free and happy without using”).

About one third of the answers from individuals not in recovery echo the public’s perception that recovery means people are ‘trying’ to remain abstinent: “Someone who is currently on guard about falling off the wagon at any moment.” The idea that for some, recovery suggests a struggle with drugs and/or alcohol is further supported by a number of respondents who indicated that they are not in recovery because they are not experiencing drugs and/or alcohol problems; for example: “Recovery… I don’t know, a glass of wine ain’t nothing to me” and “it’s not a battle for me- I don’t have to recover from anything.” The connotation of recovery as a struggle with substance abuse problems and statements from participants who felt they had overcome their problem suggest that recovery is understood by some as having had a severe problem. This is consistent with the image of AA being a place only for ‘skid row drunks.’

The majority of qualitative recovery definitions among participants who didnot consider themselves in recovery indicated that a specific action … was a necessary part of recovery.

The bulk of the answers implying a specific recovery requirement, however, concerned needing or seeking help – getting treatment and/or participating in 12-step recovery: “Being in treatment and not using drugs or alcohol,” “Abstaining and seeking outside help.” Several answers suggested that recovery implies needing to seek outside help because you cannot quit on your own: “Having trouble quitting, needing help,” “when you get some help, like detox, a program or something-not when you just stop on your own,”…

Benefits of recovery – While participants’ definitions of recovery may speak as much to semantics (i.e., the use of the term ‘recovery”) as to their experience, answers about what is or would be good about being in recovery illuminate the recovery experience itself. Regardless of the term used,significant behavior change takes time, it is challenging and stressful.

The most frequently cited benefit of recovery, mentioned by one third of participants, is that it is a new life, a second chance (“like being born again, not living a state of denial, enjoying life better, whole new wonderful feeling, health, financially”); one quarter (23%) cited being drug-free; other benefits cited in were: self-improvement (22.7%), having direction, achieving goals (17.5%), improved/more positive attitude (17.2%), improved finances/living conditions (16.2%), improved physical and/or mental health (16.1%), improved family life (13%) and having friends/a support network (11%).

Recovery: Process or endpoint? –

One of the more controversial issues when speaking of ‘recovery’ is whether it is process (with no specific endpoint) or a state (i.e., whether one is ever ‘recovered”). This question has potentially critical ramifications especially in terms how recovery is perceived by the public and indirectly, in terms of stigma and discrimination (e.g., prospective employers who view recovery as a lifelong process may be more likely to not hire a prospective worker in recovery for fear he/she will relapse or be unreliable). Findings were reviewed earlier suggesting that the public defines recovery as an attempt to stop using drugs and alcohol, suggesting that it may not be attainable.

Thus while maintaining recovery may be a lifelong process (e.g., maintaining certain practices), it is important to determine whether or not the process is lived as having an end (being recovered). In the US, the view of addiction as a chronic disorder, paired with the strong 12-step influence (“once an addict always an addict”) would suggest that recovery is a never-ending process.

Participants made qualitative statements that speak to whether one ever ‘gets there” – i.e., becomes recovered, suggesting that consistent with the disease model of addiction, recovery is a process with no fixed end point, and that it requires ongoing work

“Recovery is getting back some sort of order in your life, the disease is in remission- it’s not a cure- it has to be maintained daily.”

“Recovery is somewhere people think they’re going to get to and you’ll never get there.”

“I don’t think you ever recover from it, it’s learning how to manage it, stay abstinent & become a productive member of society.”

“you’re never recovered, I mean, it’s always ‘gonna be back there.”

“I think recovery’s a process. Um… for me, it’s just always trying to better myself. Um… and realizing that there may not be an end point, but just a… you know, they always say, like, sometimes it’s better to go through it than to get there.”

“I’m still on this journey because there is hope, you know. There is not a cure. But there is hope.”

“And I keep myself in the right, atmosphere or attitude or what not because there is a whole lot to recovery, you know. It ain’t just getting sober and staying clean. It is like you gotta do a lot of work.”

 

Discussion

Prior exposure to treatment and to 12-step fellowships, both of which encourage embracing abstinence as recovery goal, was significantly associated with defining recovery as total abstinence. Interestingly, both individuals who do and do not consider themselves in recovery embraced abstinence as their definition of recovery. While substance users are often ambivalent about quitting drugs, individuals with a long and severe history of substance use who seek remission may come to the conclusion that total abstinence is required from personal experience with relapses and attempts at controlled use. Most failed remission attempts are based on moderation and abstinence proves more successful (e.g., Burman, 1997; Maisto, et al., 2002). Greater lifetime addiction severity was associated with endorsing abstinence, and some participants who did not consider themselves in recovery indicated that recovery implies struggling and/or needing outside help.

BACK TO ME: DISCOVERY AND RECOVERY

With respect to scope, recovery goes beyond substance use for most. This is consistent with 12-step tenets (e.g., “but sobriety is not enough,” Alcoholic Anonymous, 1939/2001, p. 83). Frequently used expressions to define recovery were ‘a new life,’ ‘a second chance,’ or, life itself. The verb “to recover” is defined as (1) to get back : REGAIN; (2) to bring back to normal position or condition; (3) to make up for; (4) to find or identify again; and (5) to save from loss and restore to usefulness: RECLAIM (Merriam Webster).

Several participants framed this notion as regaining something that was lost – the opportunity of becoming what they were meant to be before they started using drugs and alcohol (section 3.4.2). The Big Book expressed this as “We were reborn” (AA, 1939/2001, p. 63).

NO SUCH THING AS GRADUATING: RECOVERY IS A PROCESS RATHER THAN AN ENDPOINT

Reclaiming oneself is a process of growth and a process of change in attitudes, thinking and behaviors consistent with the rich descriptions and experiences documented by Stephanie Brown (1985).

Recovery as a process should not be interpreted as inconsistent with recovery as abstinence; rather abstinence (a state) is viewed as a requirement of the ongoing process of recovery.

The work of change is what distinguishes recovery from mere abstinence (“You could stop doing anything that you want. It’s about the change that comes in—into it, that’s the recovery part.”). The process aspect of recovery has been reported previously in studies conducted among alcohol- and drug-dependent samples both in the US and abroad (e.g., Blomqvist, 2002; Flynn et al., 2003).

A small-scale study of drug-dependent persons abstinent for an average of 9 years sheds light on the stages of the process(Margolis et al., 2000). Participants reported first passing through a phase almost solely focused on staying abstinent, particularly the first year. Only once this foundation (abstinence) was established could they concentrate on “living a normal life,” where abstinence was no longer the main focus.

Finally, following that transitional period, the individual enters late recovery, a time of individual growth and search for meaning. Our findings on the focus of recovery definitions are consistent with these stages: individuals in remission 18 to 36 months (the transition phase) were more likely to define recovery as a process whereas those in remission three years or longer were more likely to focus on the ‘new life’ aspect of recovery and less likely to define recovery in terms of substance use.

Recovered?

Conceptualizing recovery as a process leads to the question of whether one ever ‘gets there” – whether one is ever “recovered.” This is rarely discussed in scientific literature. Most participants regard recovery as “an ongoing process. There’s no such thing as graduating.” This is consistent with the disease model and with prevalent view of addiction as a ‘chronic’ condition (McLellan, Lewis, O’Brien, and Kleber, 2000; White, Boyle and Loveland, 2002); it is also consistent with reports that resolving addiction often takes multiple attempt and treatment episodes (e.g., Dennis et al, 2005; Laudet & White, 2004).

Other biomedical fields have reached consensus about what clinical ‘remission’ means (e.g., five years disease free in oncology). Whether and when SUD remission ever becomes ‘stable’ in terms of substance use (i.e., when the risk of return to drug use is minimized) remains somewhat unsettled.

Three to five years is the timeframe most commonly used (Finney and Moos, 1991; Flynn et al, 2003; Longabaugh & Lewis, 1988; Timko et al., 2000; Vaillant, 1983/1995) and it corresponds to the experiences of persons in long-term recovery (Margolis et al., 2000). While the risk of relapse does not completely disappear after three or even five years of continuous abstinence (e.g., Hser et al., 2001), it appears to be minimal (e.g., Vaillant, 1983/1995).

1964993_10204413266386253_6586670970955919073_n

Addiction is a chronic condition; there may not be a complete or permanent solution (i.e., the risk of relapse may remain for multiple years) but it can be treated and managed. There are many paths to recovery (e.g., Moos & Moos, 2005) but treatment is most often needed when dependence is chronic and severe.

Our findings suggest that for severely dependent individuals, recovery is a process of change and growth for which abstinence from alcohol and others drugs is a prerequisite.

McLellan and colleagues (2005) have made the argument that “Typically, the immediate goal of reducing alcohol and drug use is necessary but rarely sufficient for the achievement of the longer-term goals of improved personal health and social function and reduced threats to public health and safety—i.e. recovery” (p. 448). This conceptualization of clinical outcome is consistent with the World Health Organization’s conceptualization of health as “a state of complete physical, mental, and social well-being, not merely the absence of disease” (1985, p.34).

The question remains : whether we are willing to pay for positive health (wellness) oriented services for substance dependent populations is unclear.

Present findings suggest that the benefits of recovery are many (improved health, life conditions, social life etc.) and they are highly valued. Quality of life (QOL) among active users is poor and abstinence, especially sustained abstinence, is associated with QOL improvements (e.g.,Donovan et al., 2005; Foster et al., 1999; Laudet et al., 2006; Morgan et al., 2003).

Higher life satisfaction prospectively predicts sustained remission (Laudet, Becker & White, in press; also see Rudolf & Priebe, 2002) and low QOL may heighten relapse risk (Claus, Mannen & Schicht, 1999; Hoffmann & Miller, 1993). Thus the clinical goal of addiction treatment must go beyond fostering reduction in substance use to improving personal and social health.

The addiction field can seek guidance from the mental health field where…in a working definition set forth in the New Freedom Commission on Mental Health: “Recovery refers to the process in which people are able to live, work, learn, and participate fully in their communities” (2003, p.5).

How do clinicians foster recovery? Vaillant (1983/1995) described the conditions necessary to the recovery process as abstinence, substitute dependencies, behavioral and medical consequences, enhanced hope and self-esteem and social support in the form of unambivalent relationships. Persons in recovery consistently cite the support of family and peers (and the need to seek and accept support), spirituality, inner strength and the desire to get better as critical sources of strength (e.g., Blomqvist, 2002;Flynn et al., 2003;Laudet et al., 2002,).

Many clients initiate treatment due to external pressures (family, legal, employment) and may not be initially motivated for change; however, once in the therapeutic environment, even externally motivated clients (e.g., legally mandated) may reflect on their situation and accept the need for treatment (Kelly, Finnney & Moos, 2005). The cessation of substance use is often preceded by a period of cognitive preparation (akin to the contemplation stage Prochaska & DiClemente, 1992 – e.g., Burman, 1997and2003; Sobell et al., 2001); participating in treatment during this period may significantly enhances motivation for change by introducing the notion that behaviors and activities that are not drug-related could have healthier consequences and provide more satisfying reward possibilities (Burman, 2003), thus ‘raising the price’ of subsequent substance use and enhancing the likelihood of abstinence.”

 

There are also the financial implications of spending money on effective treatment for those who wish to recover rather than counting the cost of increased crime, prison sentences, extensive medical care,  etc etc. It makes economic sense to spend money in a preventative sense in addiction, as well as being simply a moral decision  to medically treat those who are chronically ill. First do no harm is part of the Hippocratic Oath. Can we say that spending huge amounts of money on harm reduction, controlled use programs, methadone scripts etc etc is actually “treating” alcoholics and addicts?

To quote Russell Brand, that is “like putting a sticking plaster on a broken soul” – it only sustains the problem not alleviating or treating the underlying conditions.

We can help society and families recover also from the effects of alcoholic and addict behaviour. Recovery involves improved well being for family and society members too.

We have to offer a chance to start over, to have access to a new life much better than we could ever have imagined.

Recovery cannot really be about giving you reduced amounts of whatever is poisoning you, ailing you. It cannot be about substituting one drug for another. Substituting one addictive behaviour for another. It cannot be about yet another chemical straight-jacket or prison.

Recovery has to be about getting better. Improving well being. This is what increased in health when a treatment is successful so why should it be different for addicts and alcoholics.

Many millions of people recover from their addictive behaviours, that is fact! We need to start getting this message out,  “We do recover!”

Recovery is much much better than drinking and drugging ever where. This is what we need to get across.

To be in a fairly constant state of contentment is priceless and something no drug could ever achieve!  

References

1. Laudet, A. B. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33(3), 243–256. doi:10.1016/j.jsat.2007.04.014