Continuing “Very Heavy Drinking” and Also Meeting An Improved Definition of Recovery?

In their 2020 Commentary published in The Journal of Addiction Medicine (a journal of the American Society of Addiction Medicine aka ASAM), Kelly and Bergman state that:

“Individuals with regular and increasing very heavy alcohol consumption cannot be considered as maintaining ‘recovery’ due to toxicity and intoxication-related risks”. 

Why did they publish a commentary about recovery and very heavy drinking being incompatible?

The commentary by Kelly and Bergman is their response to an article published earlier in 2020 in the same journal.  It’s an article by Witkiewitz and others titled, “Can Individuals With Alcohol Use Disorder Sustain Non-abstinent Recovery?  Non-abstinent Outcomes 10 years After Alcohol Use Disorder Treamtent.”  In their article Witkiewitz and colleagues state,

“Nonabstinent AUD recovery is possible and is sustainable for up to 10 years after treatment.  The current findings align with recent proposals to move beyond relying on alcohol consumption as a central defining feature of AUD recovery.” 

Among other points, Kelly and Bergman note:

  • A recovery definition should not entirely remove abstinence from alcohol use from the list of all recovery indicators
  • Level of functioning regardless of amount of drinking should not become the sole indicator of the presence and level of recovery, as the Witkiewitz paper asserts.
  • Classifying someone as “in recovery” should include consideration of “potential collateral damage to close significant others” as a factor. 
    • They go on to say that classifying someone continuing with ongoing very heavy drinking as “in recovery” would seemingly ignore the information close significant others could provide about the person’s level of function
  • Those who are abstinent, but still struggling in psychosocial function per the Witkiewitz et. al. recovery definition, would be excluded by that definition from qualifying as “in recovery”. 
    • They go on to say this ironic and unintended consequence of a psychosocial function only recovery definition would promote stigmatization of the abstinent who are experiencing psychosocial struggles.

It looks to me like this is a full-blown open discussion of a recovery definition by academic researchers in the top peer-reviewed literature.  I don’t think the discussion is over with, and it should be fascinating. 


I could say a lot of things about a recovery definition that ignores the presence of drinking and that even ignores drinking at the level of very heavy drinking.  And I could say a lot of things about the Kelly and Bergman response.  For now, however, I’ll go a different direction and make some comments of my own that apply to the topic overall:

  1. I wish Kelly and Bergman would simply say “damage” or “additional damage” instead of “collateral damage” when describing the mental and emotional trauma experienced by those in the home, caused by someone who continues to drink.  To me, “collateral” makes family members sound peripheral rather than sound like people.
  2. The Dry Drunk Syndrome can be terrifying for everyone experiencing it – drinker and family members alike.
  3. Symptom suppression is not enough.  Recovery must be in the “do-direction”.
  4. Very heavy drinking is a danger to self and others. 
  5. It’s interesting to see a recovery definition that seems to come from the perspective of research data alone and removed from clinical experience and lived experience. 
  6. If we are coming at this from a clinical perspective, I wish we would include a focus on prognosis.  That is to say, how do we expect the person to do?  Or, “Are people getting better, or not?”  To me, that is the central question. 
  7. For example, if we are dying now or later from continuing cigarette smoking while drinking nothing, or drinking less, or showing improved psychosocial function, while meeting a new and improved recovery definition, while we continue our very heavy drinking, are we content with that?

For those that are interested, I’ll note that the Kelly and Bergman commentary has already produced a formal and published letter to the editor from Witkiewitz and colleagues. All three references are down below.


I might post more on this down the road.


References

Kelly JF, Bergman BG. A Bridge Too Far: Individuals With Regular and Increasing Very Heavy Alcohol Consumption Cannot be Considered as Maintaining “Recovery” Due to Toxicity and Intoxication-related Risks. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000759. Epub ahead of print. PMID: 33060467.

Witkiewitz K, Wilson AD, Roos CR, Swan JE, Votaw VR, Stein ER, Pearson MR, Edwards KA, Tonigan JS, Hallgren KA, Montes KS, Maisto SA, Tucker JA. Can Individuals With Alcohol Use Disorder Sustain Non-abstinent Recovery? Non-abstinent Outcomes 10 Years After Alcohol Use Disorder Treatment. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000760. Epub ahead of print. PMID: 33060466.

Witkiewitz K, Wilson AD, Pearson MR, Roos CR, Swan JE, Votaw VR, Stein ER, Edwards KA, Tonigan JS, Hallgren KA, Montes KS, Maisto SA, Tucker JA. A Bridge to Nowhere: Resistance to the Possibility of Some Heavy Drinking During Recovery and the Potential Public Health Implications. J Addict Med. 2021 Feb 10. doi: 10.1097/ADM.0000000000000796. Epub ahead of print. PMID: 33577228.

5 thoughts on “Continuing “Very Heavy Drinking” and Also Meeting An Improved Definition of Recovery?

  1. Thanks for the summary, I too noticed this research conflageration with considerable interest. I very much appreciate your fifth point, about a definition coming exclusively from data. The issue as I see it is that few institutions make real inclusion of lived experience part of their research. Any definition ‘about us without us’ isn’t nearly as helpful to clinicians or to people in recovery as one that stands up to the ‘sounds about right’ consensus of people in recovery. There is an urgent need to include this kind of experience in the research, it saves lives by expediting the translation of the science from theoretical to practice.

  2. Thanks much for your thoughtful comments. You bring two more points to mind for me and I’ll go ahead and share them briefly. One of them is a first-hand story I was told by a respiratory therapist who also has a graduate degree in public health, and volunteers as a Parkinson’s advocate given their interest in neurodegenerative disorders (and family experience with that disease). The short version is that the advocacy gathering included a scheduled visit to a bench-science research site for neurological problems in Parkinson’s disease by people with Parkinson’s who are also formal advocates in the effort. Guess what? When the researchers met the people with the disorder the researchers were delighted to finally meet some patients to whom they dedicate their lives in doing the work of research. It really opened my eyes though to hear that a patient asked a bench scientist “Wonderful about movement questions, but do you investigate gut motility?” In short, what gets noticed by looking gets the research interest but the researcher didn’t know the problem of gut motility and was glad to be told. Of course, the patient knew (the clinical target that could be made a research target) because they live with the experience. The other thought is the idea of research data or lived experience input from those that refuse to participate, drop out, don’t do well, or are otherwise not included due to the problem itself. That is to say, learn from those that didn’t make it. Again, thanks for your thoughtful input. Peace.

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