Recovery/Remission from Substance Use Disorders An Analysis of Reported Outcomes in 415 Scientific Reports, 1868-2011 William L. White, MA Philadelphia Department of Behavioral Health and Intellectual disAbility Services Great Lakes Addiction Technology Transfer Center Recovery/Remission from Substance Use Disorders: An Analysis of Reported Outcomes in 415 Scientific Reports, 1868-2011 Published by the Philadelphia Department of Behavioral Health and Intellectual disAbility Services and the Great Lakes Addiction Technology Transfer Center Great Lakes Addiction Technology Transfer Center Jane Addams College of Social Work University of Illinois at Chicago 1640 West Roosevelt Road, Suite 511 (M/C 779) Chicago, Illinois 60608-1316 Philadelphia Department of Behavioral Health and Intellectual disAbility Services 1101 Market Street Philadelphia, PA 19107 March, 2012 This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by William L. White and jointly published by the Philadelphia Department of Behavioral Health and Intellectual disAbility Services and the the Great Lakes Addiction Technology Transfer Center (GLATTC) under contract number 5 UD1 TI013593-0, with SAMHSA Center for Substance Abuse Treatment (CSAT). Donna M. Doolin, LSCSW, served as the ATTC Project Officer/Public Health Advisor. The views, opinions, and content of this publication are those of the author and do not necessarily reflect the views, opinions, or policies of SAMHSA or CSAT. No official support from or endorsement by any of the agencies for these opinions or for particular resources described in this document is intended or should be inferred. The guidelines in this document should not be considered substitutes for individualized client care and treatment decisions. All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA/CSAT. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Great Lakes ATTC. For more information on obtaining copies of this publication, call (312) 996-0966. Produced under a grant funded by the Center for Substance Abuse Treatment Substance Abuse and Mental Health Services Administration U.S. Department of Health and Human Services Center for Substance Abuse Treatment, 5600 Fishers Lane Rockwall II, Suite 618, Rockville, Maryland 20857, 301.443.5052 Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the agency. Grant No. 5 UD1 TI013593-0 Recovery/Remission from Substance Use Disorders: An Analysis of Reported Outcomes in 415 Scientific Reports, 1868-2011 Table of Contents Executive Summary ...................................................................................................................... 1 Conclusions and Recommendations .................................................................................... 3 Acknowledgments ................................................................................................................. 5 About the Author ................................................................................................................... 5 Introduction ................................................................................................................................... 7 The Challenges of Recovery Measurement ................................................................................. 8 A Problem of Population Diversity .............................................................................................. 12 Methodology ............................................................................................................................... 16 Community Studies ..................................................................................................................... 18 Clinical Studies ........................................................................................................................... 33 Clinical Studies (Adult Recovery Rates) ..................................................................................... 34 Clinical Studies (Adolescent Recovery Rates) ........................................................................... 45 Measuring Recovery Prevalence in Philadelphia ....................................................................... 48 Discussion .................................................................................................................................. 49 Conclusions and Recommendations .......................................................................................... 55 References ................................................................................................................................. 61 Appendices Appendix A: Recovery Prevalence Studies Among Community Populations .......................... 101 Appendix B: Recovery/Remission Rates in Adult Clinical Studies .......................................... 115 Appendix C: Recovery/Remission Rates in Adolescent Clinical Studies ................................. 153 – i – Tables Table 1: Cessation Patterns among Youth and Young Adults in 2009: .................................. 18 Lifetime versus Past-Year Use Rates Table 2: Extrapolated Remission Estimate From Substance Use .......................................... 21 Disorders for U.S. Adults Based on ECA Study Table 3: Substance Use Disorder Remission/Recovery Estimate .......................................... 22 based on the National Comorbidity Survey Table 4: Alcohol Use Disorder Recovery Estimate based on National ................................... 23 Health Interview Table 5: Estimated Population in Remission from Alcohol Use Disorders ............................. 24 Table 6: Estimated Population in Remission from Drug Use Disorders ................................. 24 Table 7: Extrapolations of NESARC Data for Projections of National .................................... 25 AUD Remission Estimates Table 8: Summary of Remission Rates and Recovery Prevalence ........................................ 27 Estimates across Studies, 1991-2010 Table 9: Studies Chosen for Analysis by Period of Publication .............................................. 34 Table 10: Remission Probabilities by Drug Choice and Duration of Use .................................. 45 Figures Figure 1: Community Studies, Remission/Recovery Rates ..................................................... 31 Figure 2: Community Studies, Remission/Recovery Rates ..................................................... 32 Published Since 2000 Figure 3: Community Studies Remission and Abstinence Rates ............................................ 33 Figure 4: Recovery/Remission Rate at Last Follow-up, 1868-1959 ........................................ 35 Figure 5: Recovery/Remission Rate at Last Follow-up in the 1960s ....................................... 36 Figure 6: Recovery/Remission Rate at Last Follow-up in the 1970s ....................................... 37 Figure 7: Recovery/Remission Rate at Last Follow-up in the 1980s ....................................... 38 Figure 8: Recovery/Remission Rate at Last Follow-up in the 1990s ....................................... 39 Figure 9: Recovery/Remission Rate at Last Follow-up, 2000-2004 ........................................ 40 Figure 10: Recovery/Remission Rate at Last Follow-up, 2005-2011 ........................................ 41 Figure 11: Reported Remission Rates by Era ........................................................................... 42 Figure 12: Recovery/Remission Rate at Last Follow-up and Abstinence .................................. 43 Rates, 1970s-2000s Figure 13: Reported Recovery Outcomes in the Treatment of Adolescent ............................... 46 Substance Use Disorders – ii – Recovery/Remission from Substance Use Disorders: An Analysis of Reported Outcomes in 415 Scientific Reports, 1868-2011 William L. White, MA Executive Summary The emergence of recovery as an organizing paradigm for addiction treatment and the larger arena of behavioral health care underscores the need to measure both early recovery initiation and stabilization and the prevalence of long-term recovery maintenance. Such measurement is critical in evaluating addiction treatment as a system of care and monitoring broader dimensions of community health. Efforts to measure recovery are challenged by the lack of professional and cultural consensus on the definition and measurement of key constructs (recovery, remission, abstinence, and subclinical/asymptomatic/controlled/moderate use) and by conflicting rates of recovery—rates reported across clinically and culturally diverse populations in studies marked by widely varying methodologies, follow-up periods, and follow-up rates. Of particular import is the wide divergence between portrayals of the natural course of alcohol and other drug (AOD) problems in community populations and portrayals of such problems in clinical populations following specialized addiction treatment. These divergent portrayals constitute the ultimate “apples and oranges” of the AOD problems arena. The question of recovery stability and prevalence is more than an academic one. The constant media onslaught of celebrities heading back to “rehab” after their latest falls from grace has produced a public unsure of exactly what “recovery” means