Drink does not drown care, but waters it, and makes it grow fasterBenjamin Franklin
When we consider the things that make us vulnerable to addiction – trauma, poverty, lack of opportunity, stress, stigma, genetics and environment, it’s no surprise that relapse and the development of problems with other substances occur after treatment. These problems don’t resolve quickly, if at all.
The attempt to soothe cares, pain and distress with alcohol, the permitted drug, is understandable. I hear stories every week from my patients about their experiences of putting down one substance and picking up alcohol (or other drugs) only to find their problems worsening.
In their recently published study, Greg Rhee and Robert Rosenheck have helped to quantify this risk this a bit more. They sought to estimate how common alcohol use disorder (AUD) was in those who had recovered from other substance dependence.
As the authors say, individuals who use one substance ‘are recognised to be at greater risk of using other, often multiple, substances’. Previous research suggested that ‘alcohol use, especially heavy drinking, may be overlooked and underestimated among patients recovering from substance misuse’. Alcohol consumption has also been linked to increased risk of relapse back to the drug of choice, but it has been difficult to quantify risks.
What they did
The researchers took a look at data from just over 2000 adults who had previously suffered from substance use disorders (e.g. opiates, cocaine and other stimulants) but who were now in recovery. They divided this group into three – those who had no history (past or present) of alcohol use disorder (AUD), those who had a past, but not current, history of AUD and those who currently met the criteria for AUD. Then they looked at relevant factors for all three categories, such as other diagnoses, demographics and quality of life indicators.
Interestingly, the largest group in the sample was those with cannabis use disorder (60%), followed by cocaine use disorder (31%) and stimulant use disorder (21%) with only 17% having an opioid use disorder.
More than three quarters had either a current (29%) or a past, but recovered (48%), AUD. Less than a quarter (23%) had no history of AUD. Those who had a current medical or mental health problem were more likely to have a current AUD. They were also less likely to be married and more likely to be a bit younger.
What does it mean?
It means that a significant proportion of the people recovering from non-alcohol substance use disorder seem to be at risk of AUD.
Alcohol use disorder is the most common co‐occurring lifetime substance disorder among those recovered from substance use disorderRhee and Rosenheck 2020
Although the distribution of the problem substances in this population would certainly seem not to be typical of a Scottish treatment population, limiting generalisability (there are other limitations listed in the paper), there are lessons here.
Statutory treatment provision here has been criticised as focussing on opioid treatment in a service-user group who are often suffering from problem poly-substance use. This is a broad generalisation, but could we do better, given the evidence on poly-substance use risk seen in our drug-related deaths data? In particular, based on this study, it looks like we need to look at alcohol risks. Service users need and deserve to have information about this.
What would help is to have clear policies, practice and education to try to reduce risk, to screen for AUDs, to treat co-occurring AUDs and to allow service users to hear peer experiences on the issue. Some of this is happening already – in my place of work, this comes up again and again and is a topic in our educational programme.
This study helps us begin to put some flesh on the bones of the issue and ought to inform policy and practice.
Rhee TG, Rosenheck RA. Alcohol Use Disorder Among Adults Recovered From Substance Use Disorders. Am J Addict. 2020 Jul;29(4):331-339. doi: 10.1111/ajad.13026.
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