By Paul Regier
Would you believe me if I were to tell you that many people with significant alcohol and drug problems quit on their own? If this were true, how would that change the way we perceive addiction and the way we treat it?
As it turns out, there is good evidence to support the idea that the majority of people suffering from addiction eventually go into remission at some point in their lives. According to a recent study, remission from drug dependence is actually achieved in the vast majority of individuals over time. The further one gets from the onset of addiction, the higher the probability is of remission from alcohol, nicotine, cocaine, and cannabis dependence.
Although this study was not interested in how many of these individuals were in treatment, Gene Heyman, a neuroscientist at Harvard, points out from other studies that there are typically around 15 to 30 percent who ever use treatment. In another study, about 50 percent of individuals who went into remission utilized treatment.
Therefore, we can assume that at least half if not more of the individuals who achieved remission from addiction did so without treatment. (Remission at the time of interview doesn’t mean that person won’t relapse though, and some undoubtedly will at some point.)
With that in mind, the data essentially showed that a majority of people go into remission at some point in their lives for at least a year. But, it also shows that a majority of people are dealing with significant alcohol issues almost fifteen years out.
What exactly are the symptoms of remission though?
The qualifying criteria in this particular study come from the DSM IV, in which a person has to answer yes to three out of seven questions. The list basically covers the hallmarks of addiction: tolerance, withdrawal, lack of willpower/habitual behavior, and compulsivity. Crucially missing from the old DSM IV list was craving, now recognized as a key component of addiction (though it has subsequently been added to the new DSM).
Without the criteria of craving, we can’t know whether those labeled as being in remission still experienced some of the effects of addiction. Former smokers may still crave cigarettes for much of their lives, implying a neurobiological change that takes a long time to recover. However, someone would not be considered to have an addiction just for this one criteria, even though craving has been linked to relapse.
Yet to better understand how remission works, let’s think about the very nature of addiction and what it does to our brain and body.
WHAT IS ADDICTION?
Only by a very strict definition does addiction not qualify as a disease. Some scientists use this data, often referred to as spontaneous remission or natural recovery, as a means to debunk the disease model of addiction. While natural recovery makes a compelling case against a very strict definition of brain disease, it doesn’t hold up when considering the actual medical definition of disease, and it doesn’t explain the remaining individuals that continue in spite of everything.
If the public and policy makers are convinced that it’s not a disease, then many may assume it’s a moral failing. We know it’s not a moral failing, because in reality, it’s more complicated than the dichotomy of choice vs. disease. The distinction, however, can get lost in media headlines and interpreted incorrectly.
I do agree that the definition of addiction needs to be retooled. But if we’re going to get locked up on semantics, then we need to make things clear. The problem with the definition of addiction as a brain disease is that it is very often misconstrued as meaning a progressive, irreversible disorder, even in the absence of the drug. Therefore, I do want to get hung up on semantics for a bit as a way to set the record straight. The National Institute on Drug Abuse (NIDA) defines addiction as such:
“… a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.”
That’s pretty straightforward, right? Actually, I think this is where some of the incorrect assumptions begin. Take a look at this article, for instance, which tries to use natural recovery as evidence that addiction is not a chronic disease. The author misconstrues it as progressive and a life sentence. Although that may be the case for some, but not for all.
The medical definition of disease includes the disruption of the normal state of a person either by interrupting or simply modifying a vital function. A disease can interrupt or modify a vital function such as the brain and, in the case of addiction, the reward system. Some might say that the qualities of addiction are an exaggerated part of normal functioning. I sometimes crave chocolate, for instance, but does that mean I’m addicted to chocolate? No, that would not mean I suffer from chocolate addiction.
However, if the craving for chocolate were so intense as to cause compulsive consumption that disrupted my daily life, while at the same time increasing my tolerance for chocolate so much that I need an increase the number of candy bars I consume to satisfy that craving, and after the sweet chocolate-y goodness has left my system, I’m in an agitated, dysphoric state of chocolate withdrawal, then yes, I am addicted to chocolate.
Included in the NIDA definition of addiction is the word “chronic”. The medical definition of chronic is marked by a long duration, frequent recurrence over time, and often progressive. Notice, chronic often includes a progression, but not always, and chronic can mean the presence of some condition even without symptoms. According to the National Center for Health Statistics a ‘long period’ is at least a period of three months. This means that a medical definition of addiction, which is what we’re going for, at the very least is a disruption of normal functioning, caused by an environmental factor that lasts for at least three months.
Thus, chronic disease is a fairly flexible label, and for addiction, it makes sense to me. The tricky part is that the environmental factor is the consumption of a substance, or in other words, choice. How can a disease include the factor of choice? We could parse the two, disease and choice, to say that choice is the thing that introduces the agent, and the disease is the thing that results from the choice. In a sense, this is correct, but there’s no way to get around the fact that behavior is embedded in addiction. How do we reconcile this? Simple.
The changes brought on by drug use occur in the brain, and the brain is necessary for choice. Impairment or dysfunction of brain functions influence choice. Severe impairment will hinder choice, such as whether or not to use drugs or alcohol. This is because consumption of drugs and alcohol causes long-term (i.e. chronic) changes to the brain, especially the reward system. The brain includes many different circuits, and we can localize the effects of drugs to specific circuits, making the case for disease even stronger.
It can be progressive, especially in active users, though obviously not for everyone since people with addiction eventually go into remission on their own, and I’m not sure I believe the incubation effect. I think that abstinence or reduction of drug use to the point of no longer meeting the criteria of dependence should allow the brain to recover, and there’s evidence showing that the brain does indeed recover.
Why Are Some People More Addicted Than Others?
The data and figures discussed above tell us something critical: That there remains a percentage of people that never go into remission. We also know that people in remission don’t always stay in remission. One study investigating the cycle of treatment, recovery, and relapse found that the majority of individuals transitioned from one point to another. Encouragingly, there was an increase of those transitioning into recovery over a three-year period, but there was also a transition from recovery to relapse, as well.
Yet there is another key question we need to ask in order to help us better understand the factors of remission: Why are some individuals more addicted to drugs and alcohol than others?
Historically, we’ve been taught that once a person has crossed the line, she cannot cross back. The data indicates to me that this isn’t true. However, data does suggest that perhaps there’s reason to think that one person can be better or worse off than others. Circumstance play a large part in this, for instance, but the new classification of addiction also tells us something. The DSM IV came out in 1994, with the text-revised (TR) version appearing in 2000. The DSM V just came out (you can compare the criteria for alcohol addiction here). Since the release of version IV, we’ve learned much more about addiction, hence the new definition.
Addiction is now thought of as occurring on a spectrum, from mild to severe. Several factors play into the severity rating, with one of them being biological. Robbins and colleagues explain the progression of addiction, starting from voluntary action to more habitual action and eventually compulsion. These behavioral changes are accompanied by underlying changes in the brain, essentially dopaminergic projections shifting from the ventral striatum to the dorsal striatum. Critics will say that this is a normal, evolved process, and it is. However, there’s the idea that the nature of drugs cause this circuitry to overvalue drugs and cause dysfunction. Additionally, progression along the severity line includes changes in homeostasis, increasing tolerance and withdrawal, both of which are driven by biological mechanisms.
Beyond biological factors, there were key environmental factors associated with less chance of remitting, such as education and income. Underlying both of these factors is socioeconomic status (SES), where lower SES individuals tend to have less access to quality resources. Of note, what caused people to want to quit were things like changes in goals, social pressures, and a disgust with their current situation. According to writers like Carl Hart, SES is a major part of addictive behavior. His argument is that if people in lower SES situations had better options and resources, there would be less addiction in the inner cities.
Another thing to consider is that essentially, worse outcomes were associated with the presence of other psychiatric issues. Gene Heyman wrote about this in his book, noting, paradoxically, that treatment seekers generally fair worse than those who do not seek treatment. The reason he says, is that people seeking treatment usually have other mental health diagnoses. Thus, both depression and addiction, for instance, need to be treated in order to successfully get someone well.
MATCHING TREATMENT WITH SPECIFIC ISSUES
The good news is that these studies indicate that most people will remit at some point in their lives, and for them addiction isn’t a lifelong condition. The bad news is that some will never go into remission, and many that go into remission will relapse. For those who never remit and/or those who are caught in a chronic relapse/recovery cycle, we need to do a better job of understanding the underlying reasons for why this happens.
Perhaps there’s a psychological problem that needs to be addressed. Perhaps there’s issues related to SES, like employment or education. Perhaps substance use has become so compulsive that neurobiological changes need to be addressed. There’s no ‘one size fits all’ approach, there’s no magic bullet, and there are reasons for baffling behavior. We need to take time to understand why for each and every person before hoping to treat it. This, however, is easier said than done.
The MATCH study investigated the effectiveness of 12-Step facilitation (TSF), cognitive behavioral therapy (CBT), and motivation interviewing (MI). Participants all generally did favorably well in achieving abstinence or reducing the number of drinks they had, even though the point of the study was to match specific people with specific treatment types. The study reported that abstinence was better at three years for TSF compared to CBT (but not MI), and that individuals with better support networks did better in TSF. Additionally, individuals with more anger issues did better in MI.
The idea came from a good place, but it largely failed in its primarily goal: to match specific people with specific treatments. Part of this is probably due to the fact that TSF, CBT, and MI are all behavioral therapy treatments. Where was the control group to compare relative treatment? Since we know that remission rates increase over the years, we don’t know if overall treatment success was due to treatment or natural recovery. Where was the medication? We know, for example, that Naltrexone and Topiramate are effective for alcohol-use disorders. Where was the consideration of environmental factors and resources to account for SES? Where was Contingency Management, which provides rewards for not using, potentially addressing the reward circuitry issue? These studies are so expensive, unfortunately, that missteps can deter future ones from adding in these important details.
Some are taking matters into their own hands, like at the Massachusetts General Hospital, where hospital director Nalan Ward understands the need for more comprehensive care. According to her: “It’s a complicated … population with psychosocial needs complicated by unemployment, no stable place to live, legal issues … these are the kind of patients we see.”
If she understands that, she’ll be better equipped to deal with the small percentage of individuals who will never remit or are stuck in the recovery/relapse cycle. And if she does so, hopefully others will too, as her section of the hospital could be a shining example for how to show improvement for these individuals dealing with a chronic disorder. So instead of conducting more studies, perhaps it would be more effective if we become more active based on the results from those studies that we’ve already had.