Natural Recovery from Alcohol and Drug Dependence. Catriona Matheson Academic Primary Care, University of Aberdeen, May 2015

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1 Natural Recovery from Alcohol and Drug Dependence Catriona Matheson Academic Primary Care, University of Aberdeen, May 2015 Key points The volume of the literature was large and the quality generally good. Factors influencing achieving natural recovery were: having a supportive family/partner, concern about the impact on work or children, having health problems/concerns, fear of affecting the health or well-being of others, the ability to have a non-drinking friendship network was important. Background There has being growing interest in the phenomenon of natural recovery from alcohol and drug dependence. Over the last 25 years there has been a growing body of literature on this topic that has developed from acknowledging the existence of natural recovery to assessing the size of identifying determinants or predictors of natural recovery. It is accepted that there is much that treatment and support services might be able to learn from the natural recovery literature to give better support to those in treatment. This review aimed to answer two questions: 1. What are the key characteristics of those who recover naturally from alcohol (and drugs?) dependence? 2. What helps or hinders natural recovery? Methods An electronic database search was carried out using MEDLINE and SCOPUS. Databases were initially searched from 1990 to November Titles and abstracts were searched using the concepts of natural recovery with addiction, substance related disorders, illicit drugs and opioids. The search was limited to human studies in the English language. Studies relating to gambling, smoking or student groups were excluded. 1

2 Results The search initially retrieved 24 titles from Medline and 64 from Scopus. Following a review of titles and abstracts, 21 were identified within the inclusion criteria. Of these, eight related to alcohol only and 10 to other substances or a mixture of drugs and alcohol. Furthermore, 18 covered characteristics and features of natural recovery including identification of sub-groups and three covered interventions to assist natural recovery. Alcohol Characteristics: Eight (one in Spanish, leaving seven) Drugs (and alcohol) characteristics: 10 Interventions: Three all alcohol In addition, from the grey literature, a Scottish Government Report: The Research For Recovery: A Review of the Drugs Evidence Base (Best et al 2010) was identified. The focus of this review was on recovery from drugs but some of the papers included covered drugs and alcohol because the literature does not always differentiate. Due to the potential volume of literature a further revised search was undertaken to identify quantitative studies on alcohol and to identify further papers on drugs since 2009, when the review above was undertaken. The terms natural remitters and natural remission were added to the search terms. This identified one further paper for inclusion. This review covers eight papers: seven on alcohol characteristics and one on substance dependence more generally which was published since the review. Intervention studies are not included. 1. Environment Events Surrounding Natural Recovery from Alcohol-Related Problems Tucker et al (1994) (abstract only) This relatively small quantitative study from California, USA explored the impact of environmental events on natural recovery. It compared 21 abstinent and 18 active problem drinkers who had not received any treatment, and recovered alcoholics who had abstained for an average of six years. During structured interviews, events were assessed over a three-year period that began two years before abstinence was achieved and one year after. Recovered participants were compared with events during a matched three-year interval for active drinkers, which equated the groups on the length of recall. Recovered participants showed heightened health concerns and a relatively stable work situation during the year preceding initial abstinence. Following abstinence there was a reduction in health events and a decrease in legal events and total negative events across the 2

3 three years surrounding resolution. Authors concluded that changes in several areas of functioning evolve over time to motivate initial abstinence and then to maintain continued resolution. 2. The Challenge of Sobriety : Natural Recovery without Treatment and Self-Help Groups. (Burman, 1997) This qualitative study from the US sought to identify the motivations and strategies used to achieve abstinence without seeking help. It was a qualitative, exploratory study with a purposive sample of 38 former drinkers who met the following criteria: i) they considered themselves to have severe problems due to alcohol, ii) had been abstinent for one year, and iii) had not had any treatment or attended a self-help group. A semi-structured open interview was used. Findings were analysed using grounded theory in which emerging themes were identified. Findings revealed a common thread which led to the decision to change their alcohol use: Having too much to lose which might have been family and meaningful relationships, a career, good health. Terrifying fears of being injured, death or causing an injury to others whilst drunk. Determination to be a positive role model for children. Spirituality and belief in prayer or keeping promises to loved ones. Strategies used: avoidance of alcohol environments, getting rid of alcohol from their house, altering lifestyles and friends, seeking alternative pleasurable activities and changing jobs. Supportive significant others were recognised as positive reinforcers. Observing others such as family members quitting naturally had a positive effect. 3. Natural Recovery in a community based sample of alcoholics: study design and descriptive data (Russell et al, 2001) This quantitative study followed up people with a lifetime diagnosis of alcohol abuse or dependence from four previous community surveys in Erie County, New York. Those who were screened as not having been in treatment were selected and invited for interview. A range of tests and an interview were undertaken. Participants were categorised into those in recovery, problem drinkers and hazardous drinkers. Natural recovery was defined as non-hazardous drinking for the 12 months prior to interview. The final sample for analysis was 221 people. Regression analysis was undertaken to test for differences relating to natural recovery. The following factors were associated with natural recovery: 3

4 being older and being married, having higher self-esteem and less avoidant coping styles. Furthermore natural recoverers had fewer drinking and drug using network members and fewer family members in their social networks. No significant difference was evident with: race, sex, education, income, family history of alcoholism, major depression or symptoms of depression or indications of antisocial personality. 4. Gender Differences in Natural Recovery from Alcohol Dependence (Bischof et al 2000) (abstract only) This German study explored gender differences in natural recovery. A quantitative design was used in which a sample of 38 women and 106 men who had remitted from alcohol dependence (DSM-IV) without formal help, were compared. A standardized interview assessed reasons for not seeking help, and triggering mechanisms and maintenance factors of remission. Females prior to remission, experienced lower extents of social pressure to change drinking behaviour, drove less often under the influence of alcohol, revealed less satisfaction with life domains and reported a higher impact of health problems on the remission process. Females also informed fewer individuals about their former drinking problems. This study indicated there are gender differences in factors that trigger behaviour change to stop drinking as well as the maintenance of natural remission. 5. Types of Natural Recovery from Alcohol dependence: a cluster analytic approach. Bischof et al (2001) This German study from the same research group explored the extent that severity of dependence and social support are related to natural recovery. Previous research to this point had not found differences in these factors which the authors felt was due to the wide heterogeneity in the samples. They aimed to identify clusters or subtypes of natural remitters. A quantitative approach was used in which 178 natural remitters were identified through the media (newspaper articles, radio and television). Natural recovery was defined as being abstinent for the previous 12 months and previously meeting the DSM IV criteria for lifetime alcohol dependence and having never had treatment. Alcohol quantity and frequency of use was assessed and computed into average daily alcohol consumption. Triggering mechanisms were assessed. These were identified from previous literature and included: life events and relationship problems in three domains (work, partnership and health). A range of questionnaires were used to assess factors considered to be maintenance 4

5 factors i.e. mental health, post-remission coping, temptation and self-efficacy and social support (covering support provided by partners, family, friends and others). The study identified three sub-types of natural remitters: 1. High severity of dependence, low alcohol related problems and low social support. (LPLS) 2. High severity of dependence, high alcohol related problems and medium social support. (HPMS) 3. Low severity of dependence, low alcohol related problems and high social support. (LPHS) There were significant differences between groups in the following domains: 1. LPHS had higher satisfaction with life domains prior to and after remission. 2. HPMS gave more emphasis on the impact of partnerships, financial and legal events than the other groups. This group also informed more people about their alcohol problems and revealed more support from partners and friends. 6. Stability of Sub-types after two years. Bischoff et al (2007) The same German study group then followed the trajectories of these three sub-groups over a two year period to determine longer term outcomes. They found that differences between the subgroups in social support diminished over time. However the LPLS had less social support from friends compared to LPHS and had higher rates of relapse and utilisation of formal help than other sub-groups. 7. Influence of Psychiatric co-morbidity in Alcohol-Dependent Subjects in a Representative Population Study on Treatment Utilisation and Natural Recovery Bischof et al (2005) The same German group also used a large population survey in Germany (n=4075 responders, 70%) to assess whether there was a link between psychiatric co-morbidity on axis I non-psychotic disorders and experience of natural recovery. No link was found and authors concluded that remission without formal help was equally prevalent among co-morbid and non co-morbid alcohol dependent individuals. 8. Remission from substance dependence: Differences between individuals in a general population longitudinal survey who do and do not seek help 5

6 Grella et al (2013) This US study examined associations between remission from alcohol or other drug use (AOD) and other health outcomes with higher levels of social support and stress. Researchers built upon previous data on remission of those with AOD disorders in Wave 2 (2004-5) from the longitudinal National Epidemiological Survey on Alcohol and Related Conditions (NESARC) who had AOD disorders in the past 12 months in Wave 1 (2001-2). Data were available on 1262 people Findings showed that critical factors aiding recovery include lower levels of substance use and mental health disorders and higher levels of employment and social support resources, whether or not individuals seek help. Females with high stress levels and poorer physical and mental health were less likely to seek help and although women seeking help were more likely to have multiple dependencies; those who had sought help at baseline were more likely to be in remission at followup. Methodological points The quality of papers included in this brief review was generally good. Due to the nature of natural recovery, identifying the group to be studied is challenging and tended to rely on population surveys or previous samples or use of the media for quantitative studies and snowball samples for qualitative studies. The terms of the search were kept tight to limit the volume of research. Recovery definitions were consistent across studies i.e. abstinence from alcohol (or drugs) in the previous 12 months. Similarly natural recovery was consistently defined as no formal help in the form of treatment or other support or self-help groups. This maximises the strength of the evidence synthesis. Evidence Synthesis These studies of the characteristics of those who achieve natural recovery from alcohol dependence provide corroborative evidence of the characteristics of natural recoverers although the same concepts were often expressed in slightly different ways. See appendix 1 for how terms were mapped onto each other. Motivation and ability to change behaviour to achieve abstinence were influenced by a range of social factors that were grouped into what was often described as social capital i.e. having a supportive family/partner, concern about the impact on work or children. Other factors identified were: having health problems/concerns or fear of affecting the health or well-being of others. 6

7 Furthermore having the ability to have a non-drinking friendship network was important. The concept of reaching rock bottom was not particularly evident. Four studies looked into the effect of sub-groups and found there were gender differences in those achieving natural recovery (note gender difference in being able to achieve natural recovery was not studied). Grella s study noted women were less likely to seek help if they had co-morbid issues in particular but if they did, they were more likely to be remitters. There was no difference in axis I psychiatric co-morbidity. There were found to be three classifications according to severity of dependence and social support with those receiving higher social support having better life satisfaction. Those with high alcohol related problems were more likely to report the possible consequences of this in terms of financial legal events and the influence of partners. The evidence from a couple of studies suggests that the factors that motivate change are often externally focussed (family, work, children) and these may evolve into different factors that help motivate continued abstinence which are more internally driven. Conclusion Natural recovery is helped by a lower level of dependence, strong social capital i.e. family, employment and non-drinking friendship groups. There is evidence of gender differences that needs further exploration. Psychiatric co-morbidity did not appear to influence recovery. Natural recovery drivers can move from being external to being internal as individuals start to recognise their social capital. 7

8 References Included Studies Bischof G. Rumpf HJ. Hapke U. Meyer C. John U. Gender differences in natural recovery from alcohol dependence Journal of Studies on Alcohol 61(6):783-6, 2000 Nov Bischof G. Rumpf HJ. Hapke U. Meyer C. John U. Types of natural recovery from alcohol dependence: a cluster analytic approach Addiction 98(12): , 2003 Dec Bischof G. Rumpf HJ. Meyer C. Hapke U. John U. Stability of subtypes of natural recovery from alcohol dependence after two years Addiction 102(6):904-8, 2007 Jun Bischof G. Rumpf HJ. Meyer C. Hapke U. John U. Influence of psychiatric comorbidity in alcoholdependent subjects in a representative population survey on treatment utilization and natural recovery Addiction 100(3):405-13, 2005 Mar Burman S. The challenge of sobriety: natural recovery without treatment and self-help groups Journal of Substance Abuse 9:41-61, 1997 Grella CE. Stein JA. Remission from substance dependence: Differences between individuals in a general population longitudinal survey who do and do not seek help Drug and Alcohol Dependence 133(1): , 2013 Tucker JA. Vuchinich RE. Gladsjo JA. Environmental events surrounding natural recovery from alcohol-related problems Journal of Studies on Alcohol 55(4):401-11, 1994 Jul Russell M. Peirce RS. Chan AW. Wieczorek WF. Moscato BS. Nochajski TH. Natural recovery in a community-based sample of alcoholics: study design and descriptive data Substance Use& Misuse 36(11): , 2001 Sep Studies not Included but of Relevance Gladsjo JA. Tucker JA. Hawkins JL. Vuchinich RE. Adequacy of recall of drinking patterns and event occurrences associated with natural recovery from alcohol problems Addictive Behaviors 17(4):347-58, 1992 (methodological) Granfield R. Cloud W. Social context and "natural recovery": the role of social capital in the resolution of drug-associated problems Substance Use & Misuse 36(11): , 2001 Sep (DRUGS in Review) 8

9 Heather N. Kissoon-Singh J. Fenton GW. Assisted natural recovery from alcohol problems: effects of a self-help manual with and without supplementary telephone contact British Journal of Addiction 85(9): , 1990 Sep (Intervention) Schroder KE. Tucker JA. Simpson CA. Telephone-based self-change modules help stabilize early natural recovery in problem drinkers Journal of Studies on Alcohol & Drugs. 74(6):902-8, 2013 Nov (Intervention) Sobell LC. Sobell MB. Leo GI. Agrawal S. Johnson-Young L. Cunningham JA. Promoting self-change with alcohol abusers: a community-level mail intervention based on natural recovery studies Alcoholism: Clinical & Experimental Research. 26(6):936-48, 2002 Jun (Intervention) Perez Gomez A. Sierra Acuna DR. Natural recovery and treatment recovery from drug and alcohol abuse] [Spanish], Adicciones. 19(4):409-21, 2007 (SPANISH) 9

10 Appendix 1: Mapping of terminology Study 1 heightened health concerns relatively stable work situation health concerns work implications Study 2 Having too much to lose which might have been family and meaningful relationships, a career, good health. Health and work implications Terrifying fears (health related) Health concerns Determination to be a positive role model for children. Social network Spirituality and belief in prayer or keeping promises to loved one. Supportive partners and family supportive family Study3 being older being married, having higher self-esteem less avoidant coping styles. fewer drinking and drug using network members fewer family members in their social networks. supportive family Self esteem Coping personality non drinking networks Following abstinence Study 3 a reduction in health events decrease in legal events and total negative events 10