Nonabstinence in recovery(?) from what?

Several months ago, The Journal of Addiction Medicine published an article on the prevalence of alcohol and other drug use among adults “in recovery.”

It drew from the 2022 National Survey on Drug Use and Health and looked at the prevalence of alcohol and other drug use among people who answered yes to the following questions:

Do you think you ever had a problem with your own drug or alcohol use?
At this time do you consider yourself to be in recovery or recovered from your own problem with drugs or alcohol use?.

The article notes that 71.3% of respondents who answered “yes” to the first question also answered “yes” to the second.

The focus of the article is that 65.2% of the people who answered “yes” to both questions and reported past-month AOD use.

A couple of things are noteworthy about question one:

It’s not asking about a specific diagnosis. It’s inquiring about a type of problem which could range from a mild, time-limited condition that causes no functional impairment, to a severe, debilitating, chronic, and life-threatening condition.
It’s not asking if they’ve ever been diagnosed, it’s asking them if they believe they ever had these types of problems. It relies on subjective self-assessment and reporting.
It’s going to capture a massive range of clinical and nonclinical self-assessed problems.

With respect to question two, it characterizes these people as “self-identified” as in recovery. (This characterization has been widespread in recovery advocacy and recovery prevalence research since these surveys began more than a decade ago.) This characterization seems accurate and misleading.

A few things are noteworthy about question two:

It doesn’t define recovery.
It asks if they consider themselves to be in recovery, whatever that means to them.
- It’s important to note that some of the more severe and chronic forms of drug and alcohol problems are characterized by periods where the person mistakenly believes they’ve resolved the problem and are effectively managing it.
It forces respondents into a binary yes/no response. If they believe they no longer have a problem, their only reasonable response is “yes”, which isn’t quite the same thing as identifying as in recovery or recovered.

Imagine this focused on mood, eating, or cancer and used similar questions to determine the prevalence of depression, eating disorders, or cancer and recovery from them.

If we were to take a similarly inclusive approach with cancer, an illness experience whose diagnosis and resolution can also be identity-altering, an analogous pair of questions might look something like:

Do you think you ever had a problem associated with cancer or elevated risk for cancer? (e.g., basal cell carcinoma, lymphoma, polyps, etc.)
At this time, do you consider yourself to be in recovery or recovered (survivorship) from your health problem associated with cancer?

If we were to take a similarly inclusive approach with eating disorders, an illness experience also often accompanied by denial, an analogous pair of questions might look something like:

Do you think you ever had a problem with food?
At this time, do you consider yourself to be in recovery or recovered from your problem with food?

If we were to take a similarly inclusive approach with Major Depression, an illness experience with elements that are a universal part of the human experience that are often confused with the diagnosis, an analogous pair of questions might look something like:

Do you think you ever had a problem with depressed mood?
At this time, do you consider yourself to be in recovery or recovered from your mood problem?

What would these surveys tell us about recovery from cancer, Anorexia Nervosa, Bulimia Nervosa, or Major Depression?

What would we expect people who respond “yes” to the first question to have in common?

What commonalities would we expect people who answer yes to question 2?

Would these people share an identity?

If advocacy establishes these people as a group in the culture’s framework for understanding the problem, what misunderstandings are likely to emerge? What stigmas will be inadvertently reinforced or generated?

What would these groups tell us about the individual and population-level experiences and solutions for these problems?

Noting that “Most US adults who self-identified as ‘in recovery’ were nonabstinent”, the authors conclude that their “Findings support calls to integrate harm reduction, treatment, and recovery support services and reconceptualize recovery in addiction policy and practice.”

Imagine we surveyed people who reported believing that they once had a problem with food and have recovered from that problem. And imagine that most people who answered yes to both questions reported something like occasional overeating. Would that be cause for systemic changes in care delivery, and reconceptualization of recovery in eating disorder recovery policy and practice? I wouldn’t imagine so.

The conclusion represents the zeitgeist but the most troubling thing for me is the move from this extremely vague self-identified “problem” and “recovery” to a call for reconceptualizing recovery in addiction policy and practice. Not drug and alcohol problems, but addiction.

Seeing population-level patterns of self-reported problems and resolution may have significant public health benefits, but it’s hard for me to see this survey providing a lot of insight into addiction or recovery from addiction.