RESEARCH ANALYSIS and UTILIZATION SYSTEM Relapse and Recovery in Drug Abuse DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration Relapse and Recovery in Drug Abuse Editors: Frank M. Tims, Ph.D. Carl G. Leukefeld, D.S.W. Division of Clinical Research National Institute on Drug Abuse NIDA Research Monograph 72 1986 DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse, and Mental Health Administration National Institute on Drug Abuse 5600 Fishers Lane Rockville, Maryland 20857 For sale by the Superintendent of Documents, Congressional Sales Office U.S. Government Printing Office, Washington, DC 20402 NIDA Research Monographs are prepared by the research divisions of the National institute on Drug Abuse and published by its Office of Science. The primary objective of the series is to provide critical reviews of research problem areas and techniques, the content of state-of-the-art conferences, and integrative research reviews. Its dual publication emphasis IS rapid and targeted dissemination to the screntific and professional community. Editorial Advisors MARTIN W. ADLER, Ph.D. MARY L. JACOBSON Temple University School of Medicine National Federation of Parents for Philadelphia, Pennsvlvania Drug-free Youth Omaha, Nebraska SYDNEY ARCHER, Ph.D. Rensselaer Polytechnic lnstitute Troy, New York REESE T. JONES, M.D. Langley Porrer Neuropsychiatric lnstitute RICHARD E. BELLEVILLE, Ph.D. San Francisco, California NE Associates, Health Sciences RockviIle, Maryland KARST J. BESTEMAN DENISE KANDEL, Ph.D. College of Physicians and Surgeons of Alcohol and Drug Problems Association Columbia University of North America New York, New York Washington, D.C. GILBERT J. BOTVIN, Ph.D. Cornell University Medical College HERBERT KLEBER, M.D. New York, New York Yale University School of Medicine New Haven, Connecticut JOSEPH V. BRADY, Ph.D. The Johns Hopkins University School of Medicine RICHARD RUSSO Baltimore, Maryland New Jersey State Department of Health Trenton, New Jersey THEODORE J. CICERO, Ph.D. Washington University School of Medicine St Louis, Missouri NIDA Research Monograph Series CHARLES R. SCHUSTER, Ph.D. Director, NIDA THEODORE M. PINKERT, M.D., J.D. Acting Associate Director for Science, NIDA Parklawn Building. 5600 Fishers Lane, Rockville, Maryland 20857 Relapse and Recovery in Drug Abuse This monograph is based upon papers and discussion from the RAUS Review Conference on Relapse and Recovery in Drug Abuse which took place on September 19 and 20, 1985, in Rockville, Maryland. The review was sponsored by the Office of Science and the Division of Clinical Research, National Institute on Drug Abuse. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this material is permitted only as part of a reprinting of the entire publication or chapter. For any other use, the copyright holder's permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. The U.S. Government does not endorse or favor any specific commercial product. Trade or proprietary names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. Opinions expressed in this volume are the views of the authors and do not necessarily reflect the official position of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. DHHS Publication No. (ADM)90-1473 Alcohol, Drug Abuse, and Mental Health Administration Printed 1986, Reprinted 1988, 1990 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, Biosciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts iv Preface The Research Analysis and Utilization System (RAUS) is designed to serve four functions: Collect and systematically classify the findings of all intramural and extramural research supported by the National Institute on Drug Abuse (NIDA); Evaluate the findings in selected areas of particular interest and formulate a state-of-the-art review by a panel of scientific peers; Disseminate findings to researchers in the field and to administrators, planners, instructors, and other interested persons; Provide a feedback mechanism to NIDA staff and planners so that the administration and monitoring of the NIDA research program reflect the very latest knowledge gleaned from research in the field. Since there is a limit to the number of research findings that can be intensively reviewed annually, four subject areas are chosen each year to undergo a thorough examination. Distinguished scientists in the selected field are provided with copies of reports from NIDA-funded research and invited to add any information derived from the literature and from their own research in order to formulate a comprehensive view of the field. Each reviewer is charged with writing a state-of-the-art paper in his or her particular subject area. These papers, together with a summary of the discussions and recommendations which take place at the review meeting, make up a RAUS Review Report in the NIDA Research Monograph Series. Relapse and recovery are two related areas which are central to drug abuse treatment and research. This view of drug addiction and dependence as chronic, relapsing disease is supported by both v research and clinical experience. Recent research shows that many drug abusers have relatively short "addiction careers" and suggests that with a better understanding of relapse (and its prevention), we may be able to assist clients more effectively in reaching a state of recovery. The meeting on which this monograph is based took place September 19-20, 1985, at the National Institute on Drug Abuse. Its focus was on: (1) a review of available theoretical perspectives; (2) reviews of long-term studies of treated samples to assess patterns of relapse and recovery over protracted time spans; (3) understanding relapse and recovery through examination of controlled studies and shorter term followup research; and (4) implications of research for clinical practice. The meeting was jointly chaired by Frank M. Tims, Ph.D., and Carl G. Leuke- feld, D.S.W. Ms. Jacqueline P. Ludford, Chief, Research Analysis Branch, Office of Science, is coordinator of NIDA's RAUS system. vi Contents Preface v Relapse and Recovery in Drug Abuse: An Introduction Frank M. Tims and Carl G. Leukefeld 1 Theories of Relapse and Recovery and Their Implications for Drug Abuse Treatment Donald R. Wesson, Barbara E. Havassy, and David E. Smith 5 The Drug Dependence Syndrome Concept as an Organizing Principle in the Explanation and Prediction of Relapse Thomas F. Babor, Ned L. Cooney, and Richard J. Lauerman 20 Acquisition, Maintenance, Cessation, and Reacquisition: An Overview and Behavioral Perspective of Relapse to Tobacco Use John Grabowski 36 Relapse and Recovery in Substance Abuse Careers James F. Maddux and David P. Desmond 49 Multivariate Description of Alcoholism Careers: A 10-Year Followup Colin Taylor, David Brown, Anni Duckitt, Griffith Edwards, Edna Oppenheimer, and Margaret Sheehan 72 Relapse and Recovery Among Opioid Addicts 12 Years After Treatment D. Dwayne Simpson and Kerry L. Marsh 86 The Process of Smoking Relapse Thomas H. Brandon, Stephen T. Tiffany, and Timothy B. Baker 104 Commitment to Abstinence and Relapse to Tobacco, Alcohol, and Opiates Sharon M. Hall and Barbara E. Havassy 108 vii Explaining Relapse to Opiate Addiction Following Successful Completion of Treatment William E. McAuliffe. Barry Feldman, Rob Friedman, Elaine Launer, Elizabeth Magnuson, Carl Mahoney, Susan Santangelo, and William Ward 136 Relapse to Use of Heroin, Cocaine, and Other Drugs in the First Year After Treatment Robert L. Hubbard and Mary Ellen Marsden 157 Smoking Cessation and Relapse Among Cardiac Patients George E. Bigelow, Cynthia S. Rand, Janet Gross, Thomas A. Burling, and Sheldon H. Gottlieb 167 Clinical Implications of Relapse Research Bruce J. Rounsaville 172 Relapse and Recovery: Some Directions for Research and Practice Carl G. Leukefeld and Frank M. Tims 185 List of NIDA Research Monographs 191 viii Relapse and Recovery in Drug Abuse: An Introduction Frank M. Tims and Carl G. Leukefeld From the treatment perspective, relapse and recovery are key issues. The high rate of relapse is an especially frustrating problem, and the notion of a "cure" remains elusive. Substance abuse careers are episodic, with periods of abstinence, reduction of use, and relapse the prevailing pattern, often with the course of events being influenced by external factors such as availability of drugs and societal pressures. Given the patterns of relapse and remission, a variety of interpretations of the nature of substance abuse as a disease condition, how it should be treated, and what the goals of treatment should be, have evolved. High relapse rates among substance abusers remain old news. Numerous studies have documented that high relapse rates prevail across classes of substances--for example, Marlatt (1979) has found that the average time from abstinence to relapse varies from 4 to 32 days for