Recovery attempts – how many times?

Addiction is normally framed as a chronically relapsing disorder, but a recent research paper from John Kelly and colleagues challenges us to think again. We actually don’t know as much as we might about recovery trajectories and, in terms of the number of attempts needed, there may be grounds for greater hope.

Previous research

Kelly and his colleagues point to groundwork done by other researchers which fits in with the chronic relapsing description. More than 50% of those starting addiction treatment in the USA do not complete it, 58% have had at least one previous treatment episode and more than 50% of those leaving treatment for alcohol or other drug problems relapse within 90 days.

Smoking cessation attempts have been much better studied – the number of quit attempts before successfully stopping long term is reported to be between 6 and 30 depending on the research method. Kelly and his colleagues point out that it would be good know the equivalent number of recovery attempts for alcohol and other drugs. If it takes 30 attempts to get into stable recovery, that could well act as a disincentive to trying.

Previous research has been limited because it’s pretty much focused on treatment populations. A 2005 study by Dennis and colleagues following up 1,200 patients going through publicly funded treatment found that for those achieving a year or more of abstinence, the median time from first use to last use was 27 years and from first treatment episode to last use was nine years. Feels a bit gloomy.

This research

Kelly and colleagues set out to pin down how many recovery attempts people have on average before successfully resolving an alcohol or other drug problem. They also wanted to identify the things that predicted the number of attempts and look at the relationship between the number of attempts and quality of life in recovery.

They identified 2000 people from a survey database who identified as having resolved an alcohol or other drug problem and asked them how many prior serious recovery attempts they had made. The answers were illuminating.

One of the main findings was how skewed the data were. Attempts could be as low as one or as high as one hundred. It looks like a relatively small group of people had very high numbers of attempts which means that the average number of attempts identified (5.35) is misleading. The median (bang in the middle) number was 2. The modal (most common) number of serious recovery attempts was 1.

There was no association between number of recovery attempts and age, sex, education, or household income. Those who had been diagnosed with depressive or anxiety disorders or who had received treatment or recovery support services including inpatient, outpatient mutual help, or any support service, reported a greater number of recovery attempts.

The researchers suggest that a higher number of recovery attempts needed before alcohol and other drug problems are resolved is ‘independently related to greater psychological distress, but not other indices (e.g., quality of life, happiness; self-esteem), regardless of how long one has been in recovery, prior service use, or the presence of other psychiatric comorbidity.’

The authors theorise that there could be a group of individuals who have ‘suffered from either a greater burden of or sensitivity to stress.’ This group could have found that recovery-related changes were more challenging or ‘perhaps represents those who have found a way to stay in recovery despite a greater burden of sensitivity to stress.’

For most people, the number of serious recovery attempts needed is actually quite low, but with certain subgroups (i.e., likely those with higher severity/ chronicity/comorbidity and lower recovery capital), requiring more attempts to achieve success. Yet, it is these more severe subgroups that are perceived as the norm, when the opposite is in fact true.

The authors point out some limitations in their methodology – the cross sectional nature, the reliance on self-reporting and the non-specific term ‘serious attempts’.

What does it mean?

It’s clear that those who identify as having resolved their problems with alcohol and other drugs are a diverse group – some not having to go to treatment or access mutual aid at all, some managing to resolve their problems with few attempts and some having to have multiple attempts.

Targeting our highest intensity interventions (e.g. structured psychological therapies or residential rehabilitation) to the most vulnerable may short circuit the number of attempts needed and help them achieve their goals faster. For this we need a staged series of treatment interventions that are highly individualised (as the authors point out) and that are joined up – a recovery-oriented system of care in other words. And resources to deliver this.

Here’s the authors’ hopeful bottom line:

The median number of recovery attempts, however, was surprisingly low and may offer hope to those struggling with alcohol and other drug problems.

How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults John F. Kelly, Martha Claire Greene, Brandon G. Bergman, William L. White, Bettina B. HoeppnerAlcohol Clin Exp Res. 2019 Jul; 43(7): 1533–1544.  Published online 2019 May 15. doi: 10.1111/acer.14067

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