John Kelly, Ph.D.
Recovery Research Institute, Massachusetts General Hospital and Harvard Medical School Departments of Psychiatry
During the past 50 years since the birth of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), much has been learned regarding the etiology, epidemiology, typologies, and prevention and treatment of alcohol use disorder and related health and social problems. Research funding from the NIAAA over these years has led to advances in our understanding of the genetic contributions and neurobiological effects of alcohol addiction and how best to safely detoxify, stabilize, and treat individuals suffering from AUD. In more recent years, given the instability and relapse risk observed in the early months and years of salutary change efforts, there has been growing recognition of the need to understand more fully how people achieve initial and sustained remission and long-term stable recovery. The notion of AUD “recovery” has provided the field with a novel guiding framework, but has proved stubborn to operational definition. It is largely recognized by stakeholders and interested and affected parties, that “recovery” is something more than just remission that is characterized by elements of improved functioning and enhanced quality of life that creates added resilience. Many have attempted to provide multidimensional definitions of the dynamic processes involved “recovery”, but explication and measurement of the component parts has proved challenging. This talk will provide context for the current Zeitgeist and focus on “recovery” within the alcohol and drug use disorder field, and discusses the question of the clinical research utility and challenges involved in arriving at an operational definition that is measurable and testable.
Stephen A. Maisto, Ph.D.
Syracuse University, Department of Psychology
My initial reaction to NIAAA’s proposed definition of AUD recovery was that it has the potential to advance the field because of its several strengths, including that it is: an attempt to create a standardized definition of recovery that is conceptually-based and easily operationalized; includes a drinking criterion, any heavy drinking, that has been shown empirically to be an improved consumption criterion compared to abstinence per se; and takes the view that recovery is part of the dynamic process of AUD change over time. The field’s reaction likely will be mixed, dependent on stakeholders. The most positive reactions likely will be from researchers for reasons just identified, but other stakeholders, especially the 12-step community, will object to considering quality of life factors more ancillary rather than central to the definition. The definition aligns unevenly with my past research on AUD remission and relapse. It is consistent in considering recovery part of a dynamic change process. Inconsistencies are in using a narrow biomedical conceptual base and including essentially a dichotomous heavy drinking or not criterion as part of the definition. Main areas for further research based on my previous studies include developing the proposed definition toward one that is standardized, multidimensional (biopsychosocial), and easily operationalized, and that features a more nuanced heavy drinking criterion.
Constance Weisner, Ph.D.
Kaiser Permanente
Unhealthy alcohol use and alcohol use disorders are highly prevalent and critical health conditions. As such, addressing the spectrum of alcohol use, problems, disorders, and recovery is fundamental to health care; this is similar to ongoing measurement in health care of other health conditions. As a field, health services research examines how people access health care services, how they use care, and what happens to patients as a result of this care. It studies these from the perspective of patients, as well as clinicians and health policy. This is a highly useful context for studying recovery. Doing so is most efficient by measurement of alcohol use as part of the process of obtaining health care. The definition of recovery as “a process through which an individual pursues both remission from AUD and cessation from heavy drinking is highly relevant to health services.” This presentation addresses the importance of this definition for health systems – the usefulness of measurement and definitions -- how it can be used by clinicians as part of care, as well as for health policy. We discuss why measuring drinking, rather than focusing on AUD is the most important approach for clinical care, as clinicians can see the relationship of changes in drinking to other health outcomes. We discuss what non-drinking outcomes should be a focus of recovery – such as improvements in physical and mental health. For example, clinicians are concerned about changes in drinking that affect other health conditions (e.g., hypertension, diabetes, weight). As health care delivery moves to using electronic health records, we discuss how can they be used to measure remission and recovery and how can they be used to facilitate clinicians addressing alcohol. What is the most important and helpful to them? To measure drinking and remission over time, how can EHRs be used to develop alcohol registries, and how can registries be used for health services, clinical, and policy research – as well as clinical use – to understand remission and recovery.
Katie Witkiewitz, PhD,
University of New Mexico
Four decades ago the “controlled drinking” controversy roiled the alcohol field. Data have subsequently accumulated indicating that non-abstinent alcohol use disorder (AUD) recovery is achievable, but questions remain whether it is sustainable long-term. In the current roundtable I will present findings from two clinical trials for alcohol use disorder (AUD), Project MATCH and the COMBINE study, in which we examined whether non-abstinent recovery at three years following AUD treatment was associated with better functioning up to 10 years following treatment. In both studies, recovery was defined by latent profile analyses based on psychosocial functioning and alcohol consumption three years following treatment. Alcohol consumption, mental and physical health, and quality of life measures were assessed up 10 years following treatment. Results indicated four latent profiles at three years following treatment in both studies, characterized by low functioning frequent heavy drinking, low functioning infrequent heavy drinking, high functioning heavy drinking, and high functioning infrequent non-heavy drinking. Latent recovery profiles were significantly associated with outcomes up to ten years following treatment. The two high functioning profiles at three years had the highest level of psychological functioning at ten years post-treatment, regardless of alcohol consumption level. Abstinence at three years did not predict better psychological functioning at ten years. Based on two independent studies we conclude that non-abstinent AUD recovery is possible and is sustainable for up to 10 years following treatment. The current findings align with recent proposals to move beyond relying on alcohol consumption as a central defining feature of AUD recovery.
Jalie A. Tucker, Ph.D., M.P.H.
University of Florida – Gainesville
Historically, recovery research has been conducted from a clinical perspective emphasizing abstinence, and most AUD treatments use a program theory incorporating these assumptions. However, natural recovery is the dominant recovery pathway in the AUD population, and 40 years of natural recovery research has revealed variability in processes and outcomes that remains poorly connected to AUD services. (1) Most individuals with AUD never receive treatment; associations among AUD severity, help-seeking, and recovery are complex; and help-seeking influences are not wholly redundant with behavior change influences. (2) Improved functioning and wellbeing are not highly correlated with drinking practices, indicating that domains for defining recovery require expansion. (3) Low risk drinking is a more common outcome of natural than treatment-assisted recovery attempts, in part because most treatments are abstinence-based. (4) Longitudinal natural recovery research has found that low risk drinking outcomes are associated with distinct variability in drinking practices and monetary spending patterns that increase access to valued non-drinking rewards after initial cessation of heavy drinking. Individuals who achieved stable moderation had distinctive shifts of higher overall value compared to those who abstained or relapsed; this adds to evidence that moderation entails different behavioral regulation processes than abstinence and relapse, which were similar. Overall, natural recovery research highlights the need to consider variability in AUD problem severity, help-seeking, and recovery patterns in defining “recovery,” explicating behavior change mechanisms, and guiding services across the AUD spectrum.
Christine Timko, Ph.D.
Stanford University
This presentation will discuss NIAAA’s definition of recovery in the context of research on 12-step mutual-help organizations, such as Alcoholics Anonymous (AA), and the recovery experiences of AA members. NIAAA’s definition requires remission from alcohol use disorder and cessation from heavy drinking, with improvements in well-being. In keeping with AA’s program of “total abstinence,” AA research has focused on the primary outcome of abstinence as well as mechanisms of behavior change such as social network abstinence support. The experience of recovery described by AA members focuses on sobriety, but also on a spiritual transformation (a radical change in character, identity, and interpersonal relationships) whereby the individual comes to feel peace, joy, and freedom by engaging in constructive activity and practicing acceptance, honesty, and humility (White, 2010). There are overlaps and gaps between NIAAA’s recovery definition, researchers’ operationalization of AA outcomes, and AA members’ recovery experiences.
Her talk will present these approaches and consider how they can align and inform each other, using a framework of measuring change mechanisms and recovery components, examining their associations, and identifying factors associated with increased mechanism levels. There may be common factors associated with increases in mechanisms (e.g., provision of support, goal direction, structure, and monitoring) and change processes that facilitate recovery (e.g., increased self-efficacy, self-confidence, and effective coping skills), as described in both research and lived experience, across 12-step programs, alternative mutual-help organizations, and treatments (Moos, 2007, 2008). The framework also needs to consider that recovery’s definition and determinants vary across populations identified by demographics, alcohol use severity, time in recovery, other aspects of health, and community-environment characteristics. Researchers can use common measurement approaches across studies, while settings such as mutual-help organizations, and populations such as AA members, maintain tailored recovery definitions.