Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy

Highlights

• Little is known regarding the prevalence and pathways to alcohol and other drug (AOD) problem resolution.

• 9.1% of the United States (US) adult population (22.35 million) has resolved a significant AOD problem.

• About half use some form of professional or informal external assistance; half do not.

• Most common services are mutual-help groups; outpatient treatment.

• Compared to unassisted pathway use, assisted pathway use is associated with greater severity.

Abstract

Background

Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision.

Method

Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of “assisted” (i.e., treatment/medication, recovery services/mutual help) vs. “unassisted” resolution pathways; 3) correlates of assisted pathway use. Participants (response = 63.4% of 39,809) responding “yes” to, “Did you use to have a problem with alcohol or drugs but no longer do?” assessed on substance use, clinical histories, problem resolution.

Results

Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as “in recovery”; 53.9% reported “assisted” pathway use. Most utilized support was mutual-help (45.1%,SE = 1.6), followed by treatment (27.6%,SE = 1.4), and emerging recovery support services (21.8%,SE = 1.4), including recovery community centers (6.2%,SE = 0.9). Strongest correlates of “assisted” pathway use were lifetime AOD diagnosis (AOR = 10.8[7.42–15.74], model R2 = 0.13), drug court involvement (AOR = 8.1[5.2-12.6], model R2 = 0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR = 0.3[0.2–0.3], model R2 = 0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR = 0.7[0.5–0.9]) and those with opioid problems were more likely (AOR = 2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2 < 0.03).

Conclusions

Tens of millions of Americans have successfully resolved an AOD problem using a variety of traditional and non-traditional means. Findings suggest a need for a broadening of the menu of self-change and community-based options that can facilitate and support long-term AOD problem resolution.

Introduction

The rise in opioid use disorders and opioid overdose deaths in the past 10 years in the US (Rudd et al., 2016a, Rudd et al., 2016b) has occurred within the larger context of a mounting burden of disease, disability, and premature mortality attributable to alcohol and other drug (AOD) use disorders more broadly (Grant et al., 2017, Mokdad et al., 2004, Rehm et al., 2014, Mokdad, 2016). While national concerns are typically focused around the prevalence and impact of these clinically-defined disorders, as noted in the recent Surgeon General’s Report (SGR) on Alcohol, Drugs, and Health (Office of the Surgeon General, 2016), from a broad public health and safety perspective it is important also to recognize that many people who misuse substances actually do not meet diagnostic criteria for an AOD disorder (e.g., based on the diagnostic and statistical manual of mental disorders; [DSM]) but can still suffer from significant problems. For example, more than 66 million Americans report past-month hazardous/harmful alcohol consumption (i.e., consuming 5+ standard drinks within two hours), increasing risk of motor vehicle crashes, other accidents, social problems, violence, and alcohol-poisonings. While only a minority of these individuals meet the diagnostic threshold for alcohol use disorder, this type of harmful alcohol consumption accounts for three-quarters of the yearly economic burden attributable to alcohol (Center for Behavioral Health Statistics and Quality, 2016). Also, in 2015, 12.5 million individuals reported past-year misuse of a pain reliever–increasing risk for a variety of consequences including overdose–but only 2.9 million met diagnostic criteria for a DSM prescription medication disorder (Office of the Surgeon General, 2016). Given the public health and safety burden conferred by this broad population of individuals engaging in various degrees of problem use, understanding more about them and how they resolve such problems is important, regardless of whether or not they meet criteria for an AOD disorder, per se. As such, the current paper takes a population-level, public health perspective in examining how individuals resolve a wide range of AOD problems.

In fact, an important emphasis of the SGR (Office of the Surgeon General, 2016) was highlighting the large knowledge gaps regarding how people resolve this broad array of problems, often referred to in popular and professional discourse as recovery (Betty Ford Institute Consensus Panel, 2007). Epidemiological studies have documented estimates of DSM III remission (e.g., Regier et al., 1990) and high rates of DSM IV remission among those with prior alcohol dependence, with large proportions achieving remission status without the use of any external services (e.g., treatment/mutual-help groups; NESARC, Dawson et al., 2006, Dawson et al., 2007, Lopez-Quintero et al., 2011). Studies examining DSM IV drug (i.e., non-alcohol) dependence remission are less common than those on alcohol dependence remission, though these studies too have documented high rates of remission and slightly smaller proportions achieving this remission status without seeking formal treatment (McCabe et al., 2016). Other large-scale internet-based studies, that have targeted more explicitly those who once had a problem with alcohol/drugs but no longer do (e.g., the “What is Recovery” study; Kaskutas et al., 2014) have focused on how people in recovery define recovery, their demographics and histories, and the types of services they used to help them recover (Kaskutas et al., 2014, Subbaraman and Witbrodt, 2014). Such studies have contributed important new knowledge about the prevalence of remission (especially for more severe alcohol use disorders; i.e., dependence) and the phenomenology of those in recovery. These studies, however, have not yielded national probability-based prevalence estimates of the proportions of US adults successfully resolving a broad array of AOD problems, nor the proportion of these individuals that self-identify as being “in recovery”, estimates specifically called for in the SGR (2016).

Indeed, the value of self-defined problems and their satisfactory resolution has become increasingly more apparent in clinical and public health policy during the past 40 years. There has been a move away from the more clinical “provider-centered” definition of problems and problem resolution, toward “patient-centered” definitions, and recently to a more holistic, “person-centered” perspective (National Academies of Sciences, Engineering, and Medicine, 2017). This person-centric perspective of what constitutes a problem and problem resolution has been particularly true in addiction and mental health, since AOD problems are typified by heterogeneous and dynamic phenotypic expression that can be resolved through a variety of different bio-psycho-social therapeutic inputs (Papadimitriou, 2017). In fact, AOD problem resolution fits well with the biobehavioral principle of “equifinality” (Bertalanffy, 1968), which states that there can be several different pathways that lead to the same developmental endpoint (i.e., problem resolution). For prevalent AOD problems, for example, these salutary endpoints have been shown to come about through unassisted means (“natural recovery”) as well as “assisted” means (e.g., formal treatment, mutual-help organization participation (Sobell et al., 2000, Moos and Moos, 2006). For others, a more natural problem resolution process of “maturing out” is observed to occur as other developmental demands compete for priority (e.g., marriage, children, work; Lee et al., 2013, Lee et al., 2015a, Lee et al., 2015b, Verges et al., 2012, Winick, 1962). Little is known, however, about this large heterogeneous population of individuals and how they resolve and overcome this broad array of AOD problems.

Here we present findings from the first national probability-based sample of US adults who self-identify as having resolved a significant AOD problem. Specifically, this paper provides estimates of: 1) AOD problem resolution prevalence; 2) lifetime use of “assisted” (i.e., formal treatment/medications, recovery support services/mutual help organizations) vs. “unassisted” resolution pathways; and, 3) correlates of assisted pathway use. Greater knowledge of how different types of individuals engage with the resolution process, particularly from the perspective of service utilization, as well as the demographic and clinical correlates of using services or not (i.e., assisted vs unassisted), could inform clinical, public health, and policy discourse and ultimately strategies to better address endemic AOD problems.