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Remission from addiction

What if I were to tell you that many people with significant alcohol and drug problems quit on their own? Would you believe me? If it were true, what would that mean for how we perceive addiction and how we treat it?

There is good evidence in support of the idea that the majority of people with addiction eventually go into remission at some point in their lives. According to SAHMSA in 2013, 70% of the US population drank alcohol, 10% of which met the criteria for alcohol dependence. A large study found that remission from substance dependence is achieved in the vast majority of individuals over time.

Adapted from Lopez-Quintero et al., 2011

This figure shows the increasing probability of remission from alcohol, nicotine, cocaine, and cannabis addiction the further one gets from the onset of addiction. To make things simpler, let’s just focus on alcohol (filled in circles) for the moment, especially since it conveniently represents approximately the mean of remission from the four drug addictions.

Clearly, remission increases as a function of time since onset. While only three percent of individuals alcohol-dependent go into remission in the first year, the probability increases year after year. You’ll notice that remission from alcohol dependence is around 25% at five years, 40% at ten , and just over 50% after 20 years.

The study was not interestested in how many of these individuals were in treatment, but Gene Heyman, a neuroscientist at Harvard, points out from other studies that typically about 15-30% ever use treatment. In another study, about 50% of individuals who went into remission utilized treatment. From this, we can assume that at least half, if not more of the individuals that achieved remission from addiction did so without treatment. Finally, remission at the time of interview doesn’t mean that person won’t relapse (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 are the symptoms? The qualifying criteria in this particular study come from the DSM IV, in which a person has to answer yes to 3 out of 7 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, subsequently added to the new DSM (version 5). 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.

If most people quit, then is addiction such a big deal after all?

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 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. In reality, it’s more complicated than the dichotomy of choice vs. disease, but the distinction can be lost in media headlines and interpreted incorrectly.

I do agree that the definition of addiction needs to be retooled, but if we’re just going to get locked up on semantics, then we need to make that 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. So, I do want to get hung up on semantics for a bit, while at the same time, trying 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.”

Okay, that’s pretty straightforward, right? Actually, I think this is where some of the incorrect assumptions begin. Take a look at this article trying to us natural recovery as evidence that addiction is not a chronic disease. The author misconstrues it as progressive and a life sentence. True, 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 interrupting or indeed just modifying a vital function, like the brain, and in the case of addiction, the reward system. Some might say that the qualities of addiction are a part of normal functioning but just exaggerated. I sometimes crave chocolate, but does that mean I’m addicted to chocolate? No, but if the craving for chocolate were so intense as to cause compulsive consumption that disrupted my so-called normal life, while at the same time increasing my tolerance for chocolate that I need an increasing number of candy bars to satisfy that craving, and after the sweet chocolate-y goodness leaves 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 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, 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 to reconcile this? Simple. The changes 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. There’s evidence showing that the brain does indeed recover.

how do we make sense of the remission statistics?

The data and figures discussed above tell us something critical, 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 investigated the cycle of treatment, recovery, and relapse. The majority of individuals transitioned from one point to another. Encouragingly, there was an increase of those transitioning into recovery over the three-year period, but there was also a transition from recovery to relapse, as well. Only 10% of those in recovery at six months continued to stay there, but only 16% of those using at six months continued in that phase. The movement among the different phases demonstrated the chronic cycle of addiction over the years studied.

Are some individuals more addicted to drugs and alcohol than others?

Historically, we’ve been taught that once a person crosses a line, she cannot cross back. The data indicate to me that this isn’t true, but perhaps there’s reason to think that one person can be better or worse off than others. The data indicates to me that this is true. Circumstances play a large part in this, 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 a occurring on a spectrum, from mild to moderate to severe. Several factors play into the severity rating, but one of these is 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, but 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 disgust with current situation. As I have pointed out before, influenced by 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 worse outcomes, essentially, 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, for instance, and addiction 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 caught in a chronic relapse/recovery cycle, we need to do a better job of understanding the underlying reasons for why. Perhaps there’s a psychological problem that needs to be addressed. Perhaps there’s issues related to SES, like employment or education. Perhaps use has become so compulsive, that neurobiological changes need to be addressed. There’s not a ‘one size fits all’ approach. There’s no magic bullet. There are reasons for baffling behavior, and we need to take time to understand why for each and every person before hoping to treat it. I know. 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 because 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 that missteps will deter future ones to add in these important arms.

Thankfully, some are taking matters into their own hands, like at the Massachusetts General Hospital, where Nalan Ward understands the need for more comprehensive care. She says, “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 able to deal with the small percentage of individuals who will never remit or are stuck in the recovery/relapse cycle. And if she understands that, 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. In other words, maybe it’s time that rather than more studies, we need more action based on the results from studies we already have.