iCAAD INSIDERS: Guest Blog28 Nov 2017
Can Recovery be Measured?
Written by Dr Constant Mouton,
MBChB, FCPSychSA, Psychiatrist KNMG
Medical manager Triora Clinics
When looking at the websites of recovery centres around the globe or when reading papers on different treatment modalities, percentages for long-term recovery rates are often given to measure the success of a programme. The question is, what was measured? What do relapse numbers tell us about recovery? And can recovery from addiction be measured at all?
Perhaps the best place to start thinking about the question of measuring recovery is by looking at what someone is recovering from. For the purposes of this article, it would be an addiction. The short definition of addiction according to the American Society of Addiction Medicine (ASAM) is as follows:
"Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviours.
Addiction is characterised by the inability to consistently abstain, impairment in behavioural control, craving, diminished recognition of significant problems with one's behaviours and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death." (ASAM)
Remission or recovery?
Remission is “the partial or complete disappearance of the clinical and subjective characteristics of a chronic or malignant disease. Remission may be spontaneous or the result of therapy. In some cases, remission is permanent, and the disease is cured.” (Mosby’s 2009).
Regarding addiction, remission is, therefore, the partial or complete disappearance of the clinical and subjective characteristics of the chronic disorder of addiction. Remission can be spontaneous or the result of treatment (in its various forms). When the disorder of addiction is in remission the preferred term is “in recovery”.
Because of the chronicity of addiction, permanent remission from addiction requires constant effort from the patient suffering from the disorder. Similar to other chronic diseases like asthma or diabetes, addiction cannot be cured, and the term “long-term recovery” is preferred.
Recovery is a process, not an event. The process/path of recovery is all the steps and efforts of an individual suffering from addiction towards sobriety, a life free from use/pathological behaviour.
What is the goal? Abstinence or sobriety
Most people use the terms abstinence and sobriety as synonyms, but there is a difference.
Abstinence from an addiction is the term used for the act of not doing, consuming or having what is wanted or enjoyable.
Sobriety, on the other hand, is more comprehensive and refers to "the natural state of a human being" meaning that neither intoxicants nor addictive behaviour influences healthy thoughts or behaviour. In self-help groups, the word sobriety describes a person in good physical, mental, and spiritual health. One would say that this is similar to being in recovery or remission of the whole disease of addiction.
Lapse or relapse?
The process of relapsing can be described as a series of events that may or may not be followed by the return to the frequency of the behaviour that is seen as addictive. In other words, every step towards returning to the original behaviour is seen as the process of relapsing.
There is a fundamental difference between a 'lapse' and a 'relapse'. A lapse (often referred to as a ‘slip'), is a temporary (usually one-off) return to a previous behaviour that one is trying to control or quit. It is a breach of abstinence but not of sobriety. Relapse, on the other hand, is a full-blown, pathological return to a pattern of behaviour that one is trying to control or quit (Marlatt and Donovan, 2005). In the case of relapse, there is a breach of sobriety and a patient is no longer in remission/recovery.
A lapse can turn into a relapse, but not always as a patient in recovery will apply knowledge and methods learned in therapy to return to healthy behaviour following a regime in which recovery can be maintained.
The example often used is if a patient with a food addiction strays from their diet and has a one-off chocolate indulgence, but then immediately returns to their diet, that is seen as a lapse. The reason is that, even though there were signs and symptoms of addiction seen in this patient, the patient was able to apply treatment principles to return to the recovery process without returning to being ill again. A relapse would be returning to full-blown food addiction with behaviours such as craving, buying and consuming candy in a way that affects health and functioning.
In medical terms relapse is to return to a state of illness after a period of being healthy, "disease-free," without symptoms, or in a state of remission. In other words, only once a patient is fulfilling diagnostic criteria (for example the DSM-5 criteria or others) for the illness of addiction, can we say that a patient has had a relapse. Merely having a one-off lapse is a breach of abstinence, not of remission.
It is important also to realise that the terms lapse and relapse not only refer to (re)lapsing into the behaviour or using the substance known in the first addiction but refers to all addictive behaviours. One can, therefore, relapse into alcohol addiction from being in remission from cocaine addiction, or relapse into internet/gaming addiction while recovering from drug addiction.
Long-term recovery rates
When researching relapse rates in addiction, authors often use different criteria. Most often researchers refer to no use of a substance within a year of treatment as a marker of recovery. Others will use no more than five lapses in one year as a marker of recovery. Both these measurements refer to abstinence rates and counts lapses but say nothing about relapses.
When measuring recovery rates, it is necessary to exercise caution when determining what to measure.
- If the outcome to be measured is total abstinence then one would estimate how many patients had no lapse during a specific time. Any use of any substance (or addictive behaviour) within that year would then count negatively.
- If the outcome one wants to measure is recovery then one would measure how many patients had no relapse during a specific period. Once again any addictive behaviour will then count negatively.
So what does this mean?
When it comes to recovery statistics, relapse rates for drug addiction are comparable to relapse rates in people who suffer from hypertension, asthma and diabetes, according to the National Institute on Drug Abuse:
30 to 50 percent of people with type 1 diabetes fail to stick with their treatment plan.
50 to 70 percent of people who have asthma fail to take their meds or make recommended lifestyle changes.
50 to 70 percent of people with chronic high blood pressure don’t take their hypertension medication as directed.
40 to 60 percent of people addicted to drugs will relapse from their plan of treatment.
When looking at research papers on addiction or merely assessing treatment programmes for success rates, caution is advised. Although the focus is often on measuring one-year abstinence rates, one-year relapse rates or claims of "long-term abstinence", these only give limited information to the reader on the success of the treatment. These numbers should always be looked at within the framework of the population studied. Factors like exclusion criteria from treatment, socio-economic status, age, race, gender, family structure, heritage, resilience of participants, and many more should be considered before comparing treatment modalities.
Other meaningful measures might be Quality of Life (QOL), Drug-Taking Confidence Questionnaire (DTCQ), Purpose in Life scale (PIL), measurement of resilience, recovery of the family or whether those treated by a centre would advise loved ones to follow the same treatment.
As for an individual's recovery? This is a profoundly personal process of learning, changing, adjusting and growing towards a more meaningful life. As recovery is a journey, not a destination, perhaps it is better to experience and live the process instead of focusing too closely on measuring the miles.
2. Mosby's Medical Dictionary, 9th edition, Elsevier, 2009.
3. Gale Encyclopedia of Medicine. (2008).
4. Laudet AB. What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of substance abuse treatment. 2007;33(3):243-256.
5. Marlatt, G. A., & Donovan, D. M. (2005). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: Guilford Press.
6. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 284(13):1689-1695, 2000.