I’m constantly referencing this study in my writing, so I figured I should post up the main information from it here. The study is an analysis of data from 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions, or NESARC for short. This data is relevant because it comes from a survey representative of the US population as a whole – unlike many addiction studies which only survey people who go through treatment programs. Those studies often find that people relapse quickly without continued treatment, leading to the erroneous assumptions that addicts can’t quit without treatment, or that addiction is a chronic disease, and especially that abstinence is necessary and that successful moderation is rarely attainable – among other nonsense. But what we find when we broaden our scope, like in this study, is that the majority of people with Substance Dependence (as defined in the APA’s DSM-IV) actually quit on their own without any sort of treatment or 12-step involvement. Here is the most important table from the study, so you can look at the numbers yourself:
It’s important to realize that this is representative of the general population. They are questioned about past substance use and diagnosed with the DSM-IV criteria for Substance Dependence. This study proves a few key points that directly contradict the common knowledge about addiction:
Point #1: Most People Cease to Be Substance Dependent
Figure 2
The fact is that at any given time, of people who could be classified as Dependent in a time prior to the past year, only 25% of them are still dependent. That leaves the other 75% as no longer Dependent. This one fact proved by this study offers a lot of hope for those with substance use problems. The odds are that you are three times more likely to end your addiction than you are to continue your addiction! We know this from the data above and in Figure 2 (shown to the right).
Point #2: You Have A Better Chance of Ending Your Addiction If You Are Never Exposed To Treatment Programs or 12-Step Programs.
The study breaks the total group down into those who have received treatment (including 12-step group involvement) and those who haven’t ever received treatment. If you look at the numbers I highlighted in blue on the table above you’ll see that 23.8% of those who were never treated are still dependent – yet 28.4% of those who have been treated are still dependent. This means your chance of resolving your substance use problem may be better if you simply avoid treatment!
The recovery culture claims that you cannot end your addiction without treatment or 12-step meetings, but the facts show that a higher percentage of people end their dependence without ever getting this kind of “help”. Moreover, in raw numbers, most people stop without treatment. If you look at the table you’ll see that the total number of people participating in the study is 4,422, of which 1,205 have been exposed to treatment, and 3,217 have never been treated. That means that in this study, 2,451 people ended their dependence without treatment, while only 862 ended their dependence with treatment. Another way to express this – 73.9% of those who end their Substance Dependence do so without treatment!
Point #3: Long-Term Success Is More Likely Without Treatment
If you look at the numbers I highlighted pink in the table above you’ll see that they represent success rates at various intervals since onset of dependence. What this means is when we look at the first number, for example, we learn that 64.9% of people who have received treatment, and whose addiction started sometime in the past 5 years, are still dependent. The interesting thing about this is that the number is exactly the same for untreated individual whose addiction began in the past 5 years! So in the early years, there is no difference in outcome whether you get treatment or not! The numbers stay close for people whose problem started 5-9 years ago (with the untreated group doing slightly better), but when we get to the group whose substance problem began in the range of 10-19 years ago we start to see a massive gap between the the treated and untreated subgroups – at this point we see that only 9.4% of the untreated group are still dependent, while at the much higher rate of 27.3%, those who attended treatment and 12-step meetings are nearly three times as like to have been dependent in the past year! What does this say about your long term chances of success in the conventional recovery culture? This group is no anomaly either, when we get to those whose problems started 20 or more years ago we see the untreated group doing great with only 4.3% still dependent, while the treated group is now doing more than 3 times worse with 13.6% still dependent.
The recovery culture has advocated longer and longer stays in treatment, to the point that they’re now telling people to mortgage their homes to pay for a full year of inpatient treatment, and then coming up with all sorts of “aftercare” plans for out patient treatment, sober living houses, long-term pharmaceutical treatments, and a lifetime of 12 step meetings. Meanwhile, the facts are the facts, and the numbers above prove that they should really be advising us to stay away from treatment for the rest of our lives, if we want long term success. But if you want a life of “recovery”, maybe you should stay in treatment.
Point #4: Moderate Use Is A Possible and Probable Outcome For Resolution of Substance Dependency
In the table above, the groups of numbers directly below those highlighted blue represent non-abstinent recovery from Substance Dependence. A large number of people fit into this gray area where they are drinking, but not to a threshold that qualifies them as addicted. The categories are defined in the study as follows:
Five categories of past-year status were used in this analysis:
1. Still dependent: had 3+ positive criteria for alcohol dependence in the past 12 months.
2. Partial remission: did not meet the criteria for alcohol dependence in the past 12 months, but reported 1+ symptoms of either alcohol abuse or dependence.
3. Asymptomatic risk drinker: past-year risk drinker (see definition above) with no symptoms of either abuse or dependence in the past 12 months.
4. Low-risk drinker: past-year drinker with no symptoms of either abuse or dependence and who was not classified as a past-year risk drinker.
5. Abstainer: did not consume any alcohol in past year.
People with PPY alcohol dependence were classified as being in full remission in the past year if they were in categories 3, 4 or 5. They were classified as being in recovery if they were in categories 4 (non-abstinent recovery, i.e. NR) or 5 (abstinent recovery, i.e. AR).
It should be mentioned that the Partial Remission category has a relatively low threshold, in that respondents may fit the category by reporting only one symptom of the DSM-IV Substance Abuse and Substance Dependence criteria – i.e. – if you drink, and you have an argument with a family member about drinking – then that would be a “symptom” of Substance Abuse, and you would be considered to be in partial remission. But who’s to say the fact that you got into an argument with a family member means that you are anywhere near “dependent” on a substance? Many in this category could be safely considered moderate users.
Also, you should know that “Asymptomatic Risk Drinkers” are those who didn’t have any symptoms of abuse or dependence, but drank at these levels: for men- drank more than 14 drinks per week on average or had 5 or more drinks in one day at least once in the past year. For women – drank more than 7 drinks per week on average or had 4 or more drinks on a single day in the past year. Notice that you don’t even have to drink every day or drink the 7 or 14 drinks per week, you can be considered an asymptomatic risk drinker in this study if you have one day of somewhat heavy drinking. So – pop open five beers over the course of a 4th of July picnic, or finish off a bottle of champagne on New Year’s Eve, and bingo, you’re an asymptomatic risk drinker.
I bring all this up not to criticize the study, but only to show that the lines in between “Still Dependent” and “Abstinent” aren’t so clear. What is clear, is that there are a large number of people who fall between these two poles, and thus a large number of “moderate” drinkers. This is important to realize, since the recovery culture doesn’t allow for moderation as a success story – they believe it’s abstinence or nothing, and in fact they actively teach people that once they’ve been Substance Dependent, a single drink will rapidly escalate them back into full blown substance dependence. The facts show that this clearly isn’t the case. Moderation is possible, and indeed a probable outcome for people experiencing DSM-IV Substance Dependence.
The numbers also suggest that the all or nothing message of the recovery culture is a powerful one – for better or for worse. The percentage of abstainers in the treated group is nearly 3 times that of the “never treated” group (35.1% vs 12.4% respectively), which some may look at in isolation, and declare that treatment is clearly successful. But, with 28.4% still dependent, the path of treatment produces nearly 20% more failures than the path of no treatment (23.8% still dependent). This is not shocking, when you consider that those who attend treatment are taught in no uncertain terms, repeatedly, that a single drink will lead to a complete loss of control over drinking. Likewise, the “never treated” individual has less exposure to the all or nothing recovery message that a single drink will lead to full alcoholic breakdown/relapse, and accordingly, more of them fit into the area between the 2 poles of dependency and abstinence. When we sum up the 3 middle categories (2, 3, & 4 on the list above), we see that 63.8% of the “never treated” group fit into the middle, while only 36.5% of the treated group fit into these middle categories. While the all-or-nothing message may push more people towards abstinence, it may also push more people towards full blown Substance Dependence. Furthermore we may interpret the subcategory data relating to time since onset of dependence as evidence that the all-or-nothing message delays progress, as I discussed in point #3 that in the long run, as we look at people who are further and further away from the time when their substance dependence started, the percentage of treated individuals who are still dependent (13.6%) is more than 3 times higher than the percentage of “still dependent” in the never-treated group (4.3%). They start out with identical success rates, but over time, the untreated group clearly does better – what happens in between for the treated group is debatable, but I believe the all-or-nothing message sends them on a roller coaster ride between periods of struggling to painfully hold onto abstinence one day at a time, followed by explosions of full blown “addiction”. Were they able to accept a something in between these two poles, they might just live and learn, and get to a happier life free of Substance Dependence sooner, as the never treated individuals seem to do at a better rate.
Some may take issue with my further interpretations of this data, and they may have legitimate points, which is why I posted the table for you to look at and judge on your own, and cited the source below. The basic point though, I believe holds strong: most people recover from substance dependence, with or without treatment.
Source: Recovery from DSM-IV alcohol dependence: United States, 2001–2002 Deborah A. Dawson, Bridget F. Grant, Frederick S. Stinson, Patricia S. Chou, Boji Huang & W. June Ruan Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
Limitations
This study doesn’t give us all the answers, but it’s one of the most solid pieces of information we’ve got in the world of addiction. There is plenty more information I’d like to know, but this is still enough to draw some very important conclusions from. With that said, there are limitations I should make you aware of in the interest of full disclosure. It doesn’t count people who are currently institutionalized i.e. prisoners. Nor does it account for deaths caused by substance use. With that said, the number of substance use caused deaths actually ranks very low as compared to other causes of death – one number I was able to find from the CDC said that there were about 38,000 deaths attributed to drugs/alcohol (not including tobacco) in the year 2006. In that same year, the NSDUH showed that there were approximately 22,613,000 people with DSM-IV Substance Abuse or Dependence. 38,000 is such a small part of that number as to be completely insignificant to the data we’re considering in this study – .0016% – and that death rate includes accidental pharmaceutical poisonings unrelated to substance abuse. Nevertheless, this is a limitation of the study. Also, the present study focuses only on alcohol use. I would rather find a similar study which focuses on use of all substances, but the NIAAA who carried out this study is dedicated to studying alcohol. The NIAAA has been open-minded, and conceded in recent years that treatment isn’t necessary or always effective; their sister agency which studies illicit drugs, the NIDA, is not so open minded. They are much more vocal about the necessity of treatment and aggressively promoting the brain disease theory of addiction – I doubt such a study comparing treated and untreated drug abusers will be forthcoming from them. With that said, alcohol and illicit drugs affect the brain in nearly identical ways, they are used for the same reasons, they effect people’s lives in the same basic ways (with the exception of the illegality of drugs and the extra consequences that imposes), quitting drugs or alcohol is achieved in the same way, and both addictions are “treated” in the same way professionally (except for the exceptions some make in separating drug addicts from alcoholics in an attempt to preserve the fragile egos of some alcoholics). So, it’s not everything I want in a study, but personally, I feel the data is applicable to drug use problems as well as alcohol (liquid drug) use problems.
While I hear you on the all or nothing perspective being problematic, but you are assuming that all addicts are created equal because they meet criteria based on the DSM-IV. Its most likely that those who go to treatment are more ill than those who don’t. I do think that its possible for people to return to moderation after meeting the basic criteria for dependence. However, if my life had spiraled so out of control that I lost much of what made me human and a substance was involved, I’d be pretty scared to ever ingest anything ever again. I do happen to be a substance abuse counselor, so I maybe somewhat biased… my folks ask me if they need to stay abstinent forever… my answer is much like what I have written and I ask them if they want to risk it. Its up to them in the end. I’m just a person with some data to offer.
“I’d be pretty scared to ever ingest anything ever again. I do happen to be a substance abuse counselor, so I maybe somewhat biased… my folks ask me if they need to stay abstinent forever… my answer is much like what I have written and I ask them if they want to risk it. Its up to them in the end. I’m just a person with some data to offer.”
Are you offering “data” or fear and self-doubt?
-Steven
Numbers can be twisted to make anything seem credible. What I see here is someone condemning treatment. This is what causes people to die you moron! I am a person in recovery from drugs, and yes alcohol is a drug. My life was twisted from multiple decades of abuse. I tried the Army and couldn’t quit, I only attained brief periods of abstinence and every time I returned to active addictionit only got progressively worse. Every corner of my life was negatively impacted by addiction spiritually, financially, emotionally and physically I was damaged. I knew I was a hopeless addict I spent almost 40 years wreaking havoc in the lives around me and I knew I was meant to die an addict. I finally worked up the courage to kill myself and I did! I was resuscittated and sent to treatment it was in treatment that I learned of Narcotics Anonymous. By completely immersing myself in Narcotics Anonymous (a 12 step program) I have now achieved the longest period of abstinence that I have ever known. You are an idiot whose beliefs will send people back to active addiction and eventually jails, institutions and death. You shouldn’t be down playing treatment you should be promoting any form of treatment that a person like me chooses to achieve his/her goals of abstinence. I would revel in the opportunity to meet an asshole like you. This would give me the opportunity to practice patience, tolerance and forgiveness spiritual principles I learned about in Narcotics Anonymous. Have a great day and I thank god for people like you to keep the fire inside me alive. God Bless the rooms of Narcotics Anonymous, the 12 steps, sponsors, homegroups and service these are the things that keep me clean!!!!!!!!!!!!!!!!!!!!!!
I don’t think I really need to reply to this, but I can’t resist highlighting a quote from it:
“I would revel in the opportunity to meet an asshole like you. This would give me the opportunity to practice patience, tolerance and forgiveness spiritual principles I learned about in Narcotics Anonymous.”
My emphasis added.
-Steven
“You shouldn’t be down playing treatment you should be promoting any form of treatment that a person like me CHOOSES to achieve his/her goals of abstinence.”
I can’t make things bold to show my added emphasis, so CAPSLOCK does it…
I believe all of the philosophy on this site is about choice. Martin, if you are now sober, you chose to be. NA or AA may have provided support, tips, etc., but they did not stop you from falling into a destructive pattern again – you chose to change.
Dear Mr Slate,
Great to see someone willing to think outside the box, although it is perhaps injudicious to jump to absolutist conclusions from a single, cross-sectional and (as you correctly identify) methodologically flawed study with indistinct categorisations.
Point 1: The data you quote represents past-year status or period prevalence. It does not represent lifetime risk, for a condition which commonly (usually) recurs.
Point 2: Causation and correlation are different things. For instance, severity would feasibly be associated with treatment-seeking, as one possible confounder.
Point 3:See point 2 and point 1.
Point 4: I think the jury is still out on whether, at the population level, abstinence or harm-reduction is preferable with regards to alcohol (Ritter, 2006).
Looking at the same table in isolation, I might choose to conclude:
1. People who have had some form of treatment are 3 times more likely to be abstinent (although we don’t know for what proportion of the sample this is the goal)
2. The majority of those ‘never treated’ are either still dependent or in ‘partial remission’.
3. Those ‘never treated’ are 2.4 times more likely to fall into the category of drinking at risky levels.
4. Those never treated are more likely to be drinking in an unsafe fashion (ie. categories 1, 2 or 3).
Personally, I would agree with your core philosophy of empowering addicts in recovery, and that there is MUCH room for improvement in how we conceptualise, understand, prevent and assist people in recovery, however they may choose to define their own recovery process. Change is needed.
Constructive and open-minded research, debate and transparency will help us get there. Current treatment models are profoundly flawed, I’d agree. We, perhaps, need to think more of the role of comorbidity in recovery, given that this is the expectation, not the exception (Minkoff, 2001)
References:
Minkoff K. Developing Standards of care for individuals with co-occurring psychological and substance use disorders. Psychiatr Serv.2001;52:597–599
Ritter A., Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006; 25: 611–24
Yours faithfully,
Dr Mathew Carter
Australia
Thanks for the engaging comments Dr Carter.
First, I would reply by saying that I haven’t formed my opinions on this one study alone, it just happens to be a particularly noteworthy example, and one of my personal favorites. This study is of course a snapshot of past year substance use status as of the time the data was collected – which could cause one to wonder “was this just the state of things in 2002?” However, a similar study was done (by the same researcher) of data collected in the 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES), and the results were nearly identical.[1] The fact that the data of snapshots taken 10 years apart is nearly identical, is a powerful indicator of its significance. To some degree, this addresses your opening and Point 1.
Beyond this, I would recommend Gene Heyman’s Addiction: A Disorder Of Choice, which contains a great review of the most relevant research which points to the same conclusions – that addiction isn’t “chronic”; that self-change is the norm; that treatment isn’t necessary, nor necessarily effective; and that abstinence isn’t necessary, nor the most likely resolution to the problem. I don’t have the book in front of me, and can’t remember all the studies covered, but the Epidemiological Catchment Area Study from the 80′s comes to mind as an example. Bottom line, there’s a lot of research out there which points to the same conclusions I’ve come to here; my opinions aren’t based on this study alone.
On Point 1 “The data you quote represents past-year status or period prevalence. It does not represent lifetime risk, for a condition which commonly (usually) recurs.” – I think pairing this study with the NLAES study [1] strongly suggests that people tend to age out (or mature out) of addiction. That is, in snapshots taken 10 years apart, people who are surveyed at a longer interval since onset of dependence are far more likely to be recovered. If it was a lifelong or “chronic” disease, then we shouldn’t see this trend, and we certainly shouldn’t see it in 2 studies ten years apart.
In NLAES, of those for whom dependence began within the past 5 years, 57.1% were still abusing or dependent on alcohol. In those for whom dependence began 20 or more years ago, only 12.4% percent were still abusing or dependent. In NESARC (the study covered on this page), on a similar measure, 64.9% of the ’5 years or less since onset’ group are “still dependent” while only 6.9% of the ’20 years or more since onset’ group are still dependent. In both studies there are also ’5-9′ and ’10-20 years since onset’ groups whose numbers evidence a steady decline of dependence with time since onset. Here’s a powerful trend shown in 2 similar studies 10 years apart.
On Point 2 “Causation and correlation are different things” – my point exactly. When the same percentage of people are changing their habits without treatment, this data calls into question the entire notion that treatment causes recovery. Granted though “severity would feasibly be associated with treatment-seeking, as one possible confounder”, may be a good point – but as to whether it nullifies my points, I don’t think it does. Certainly the treated population runs the gamut in severity, from my experience. But what is severity anyways? – I find it to be very subjective and contextual. I’ve met people who have 3-5 glasses of wine once a week who have been to rehab and feel like their drinking is a very severe problem – and who am I to say otherwise? From their point of view, or context, it is severe.
What would be traditionally considered an extremely severe substance use problem, say injecting heroin on a daily basis, has also proven to be a habit which people are able to solve on their own without treatment – if you’re familiar with the famous study of Vietnam era veterans – it showed that the vast majority quit using heroin without treatment!
Then there’s some data from Project MATCH, which was the US government’s most expensive study of treatment to date, which strongly indicates that treatment has little to no effect. Although the lead researchers didn’t include a control group (which is ridiculous considering their budget), they wound up with an accidental control group anyways. A research report released in 2005 based on the MATCH data [2], found a significant number of subjects who went through intake, failed to attend even a single treatment session, yet were subsequently followed up with. It was found that these untreated subjects improved at a rate nearly equal to the treated subjects! In this study, everyone is a treatment seeker, and in fact by at least one measure (number of drinks per drinking day) the untreated group’s problem was somewhat more “severe” than those who attended the treatment to begin with. On the idea that treatment “causes” recovery, the researchers also noted that improvement for all groups happened in the first week before treatment, and that for the group receiving 12 weeks of treatment, there was only a 4% improvement over those following 12 weeks! If treatment was the cause, surely there would be a steady and dramatic rise in success throughout the 12 weeks (or maybe a huge jump at the end – but 4% total? come on!).
These researchers [2] also mentioned that selection effects may come into play. Consider that the relative improvement of all groups in this study could be attributed to the fact that they were simply “ready, willing, and able” to change their habits, so they sought out treatment – because that’s what we’re all told by our cultural institutions we must do if we want to change such a habit. Or more simply – people who are going to quit, often choose to get treatment while they proceed to quit. If this is a real factor (which I believe it is), then that would confound our results as well, this time definitely giving undue credit to treatment.
I’m not sure why you included point 3, or whether it is a ‘point.’
On Point 4 – Believe it or not, I’m not a “Harm Reduction” advocate. Although I agree with some of its advocates’ premises, it includes a wide range of policies, ideas, and treatment approaches which I do not agree with or endorse. I am however an advocate of each person using whatever amount of substances that brings them what they want out of life – and I am an advocate of the belief that moderation is a completely acceptable goal. This is because:
1) I’ve seen no objective (or even partially objective!) evidence that a “loss of control” exists.
2) Evidence such as the above, which shows that people with past substance use problems have clearly demonstrated that a moderate usage outcome is possible and probable.
Based on this – I would never propose to tell someone that they’re doomed to failure without abstinence. Such claims, if believed, decrease the quality of life of those who would be happier with moderate use, and may lead many of those to flip back and forth between extreme levels of substance use and abstinence – believing a middle ground is non-existent, while still desiring to use substances. That’s a dangerous self-fulfilling prophecy to create.
On your list of conclusions:
“1. People who have had some form of treatment are 3 times more likely to be abstinent (although we don’t know for what proportion of the sample this is the goal)”
Agreed. Although as you said, we don’t know how many hold that as a goal. How many were convinced that this should be their goal? How do we know it is the proper goal? Would they be happier with moderation? Does the demand of abstinence lead to the lower rates of change seen in the long run with the treated group?
It seems to be an arbitrary judgment to assume that abstinence is better than moderation.
To look at the table “in isolation” as you said you would, is still to bring your own premises to it, just as I have. The difference in abstinence rates alone is only significant if you hold the opinion that abstinence is better than a moderate level of use – I do not hold that opinion – and I’m not sure how we could make that blanket judgment for people.
“2. The majority of those ‘never treated’ are either still dependent or in ‘partial remission’.”
As I discussed in the piece, the “partial remission” criteria is suspect. Going back to Dawson’s earlier NLAES study [1] – there are only 3 categories, rather than the 5 categories listed in the more recent one. In the earlier study, the categories were listed as: alcohol abuse or dependence; abstinence; and drinking without abuse or dependence. Fully half of the study population fit into that last category. It’s notable that the more recent study (NESARC) broke that last category up into three categories: partial remission; asymptomatic risk drinker; and low-risk drinker. I don’t know in which stage of the process, and by who’s design this change in study design happened – but it clearly changes the character of the results – which may have been intentional. Again though, you already have my criticism of the partial remission category in the original post.
“3. Those ‘never treated’ are 2.4 times more likely to fall into the category of drinking at risky levels.”
True, although I don’t know that “risk drinking” is bad, or a bad outcome, as defined in the study. Again, see my criticism of this category (and “partial remission”) in the original post above under “Point #4″ – the threshold for “risk drinking” is very low.
4. Those never treated are more likely to be drinking in an unsafe fashion (ie. categories 1, 2 or 3).
See my criticisms above. I don’t know that it’s actually “unsafe” or that even if it is riskier, that it’s not a level of risk the participants are happy with. It should be noted that we all happily take on risk regularly in our everyday lives because it’s worth the rewards – such as driving a car. The exposure to risk can’t be considered on it’s own to be “bad” without also considering the relative rewards to the person exposed to the risk – this would be a massive error of “context-dropping” – but then the entire recovery culture, with it’s demand for abstinence is guilty of dropping context and making judgments about what is or isn’t proper behavior for other people.
I think much of this comes down to one’s opinions of the various categories and standards involved. I’m willing to grant some credence to the DSM’s “Alcohol Dependence” diagnostic criteria as a good description of what a substance use problem usually looks like – but at the same time, I think it casts a pretty wide net – so if you no longer fit into it, it’s extremely likely that you no longer have much of a problem. Thus with that wide net, I think it’s unfair to characterize those who fall into the other categories of ‘partial remission’ and ‘asymptomatic risk drinker’ as not recovered.
-Steven Slate
[1] Dawson, D.A., Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, 20, 771-779, 1996
[2] Robert B Cutler and David A Fishbain, Are alcoholism treatments effective? The Project MATCH data. BMC Public Health. 2005; 5: 75.
Steven,
Thanks for your considered reply.
We agree that if someone in recovery defines their goal as low level / controlled drinking and they can achieve that and maintain it, great.
We disagree on whether “risky level drinking’ and “partial remission/partial dependence” are desirable outcomes or not, hence we will draw different conclusions from the same data. These types of drinking have clearly established causative relationships with cardiovascular disease, depression, various cancers and injuries to self and others. (Fergusson, 2009; Rehm, 2003)
What constitutes treatment is a broad umbrella. A body of evidence including longitudinal prospective follow-up, much less prone to errors of bias and confounding than a single retrospective snapshot, does show those not ‘in treatment’ relapse more at 3 years (Monahan, 1996; Moyer, 2002; Weisner, 2003; Moos, 2006)
The successful remission rates that you conclude from a *cross-sectional* dataset have been debunked by longterm (10+ years) longitudinal research proving the majority of those who remit without treatment will relapse (Moos, 2006; Klingemann, 2004). It is thought that those who succeed without treatment have greater social capital and a lesser history of alcohol related sequalae, producing a self-selection bias that can be misinterpreted as a causal relationship. (Moos, 2006)
Your company sells CBT-based treatment programs. Surely you must agree that *some* treatments do help *some* people in recovery significantly, in achieving their goal to reduce or cease drinking?
-Mathew Carter
Refs:
Fergusson DM, Boden JM, Horwood LJ. Tests of Causal Links Between Alcohol Abuse or Dependence and Major Depression. Arch Gen Psychiatry. 2009 March 1, 2009;66(3):260-266.
Klingemann H, Aeberhard M. [Biographies and addiction careers 1988–2002. Longitudinal case analyses on male and female self-healers]. Abhaengigkeiten 2004;2: 52–63
Monahan S, Finney J. Explaining abstinence rates followingtreatment for alcohol abuse. A quantitative synthesis of patient, research design, and treatment effects. Addiction 1996;91: 787–805.
Moos RH. Rates and predictors of relapse after natural and treated remission from alcohol use disorders. Addiction. 2006;101(2):212.
Moyer A, Finney JW. Outcomes for untreated individuals involved in randomized trials of alcohol treatment. J Subst Abuse Treat 2002;23: 247–52.
Rehm J. Alcohol as a risk factor for global burden of disease. European addiction research. 2003;9(4):157.
Weisner C, Matzger H, Kaskutas LA. How important is treatment? One-year outcomes of treated and untreated alcohol-dependent individuals. Addiction 2003;98: 901–11
Matthew,
I think we will definitely have to agree to disagree on those categories, my reasons having already been covered above. Also, I just can’t bring myself to decide whether the various trade-offs involved with different levels of substance use are worth it or not for any individual. An analogy may help to explain myself here. The cast of MTV’s Jackass suffer all manner of injuries due to their stunts. I would never want to suffer such injuries. But to them, it’s worth it, for whatever reasons – fame, money, ego, bragging rights, machismo, etc. The various scars they’re left with could certainly be considered an unfavorable outcome by many, but all that really matters is whether it was worth it from their own judgment. Likewise, someone may risk cancer by drinking, but they may view the risk as “worth it” when compared against whatever rewards they receive. So I think we have an honest philosophical disagreement here.
I’m fine making my conclusions with a retrospective snapshot (and especially, considering that I’ve seen other snapshots coming up with nearly identical results). To distrust it, would be like distrusting demographic sales records indicating how many people downloaded a Justin Bieber song in the past month: The records would likely show far more 14 year olds than 40 year olds would have downloaded the teeny bopper’s tunes. However, you would have me believe that an equal number of 40 year olds are downloading Justin Bieber tracks, but we just didn’t happen to catch them at a time when they did so.
On This: “The successful remission rates that you conclude from a *cross-sectional* dataset have been debunked by longterm (10+ years) longitudinal research proving the majority of those who remit without treatment will relapse (Moos, 2006; Klingemann, 2004)” and “those not ‘in treatment’ relapse more at 3 years.”
I’m not able to track down or access the Klingemann study (and I happen to appreciate some of his work), but the Moos study is highly suspect. These aren’t just untreated self-changers who are relapsing after 3 years – specifically, they are people who sought treatment, but didn’t get it within the first year after seeking it. He doesn’t seem to give the numbers of how many got treatment after the first year, but indicates that some portion of them did – yet we’re now counting them as untreated self-changing relapsers? That study design is too strange for me to conclude that self-changers have a higher rate of relapse from it.
My company doesn’t sell a CBT based treatment, but I don’t fault you for misunderstanding. First, we don’t “treat” anyone, because we don’t view addiction as a disease – thus we have no therapists, psychiatrists, doctors, or counselors. Second, our program is purely educational, and not at all therapeutic. Third, we agree with one premise of CBT, but we go so far beyond that, that it would be highly inaccurate to say our program is CBT based. CBT has an empowering message to a degree, but it tends to promote reactivity – the power of one’s thought is always placed only in reference to external things and events (this may also have the side effect of paradoxically instilling an external locus of control). Our Cognitive Behavioral Education (CBE) curriculum is designed to go beyond reactivity, and teach proactivity – so that among other things, people can learn to stop being ruled by circumstance and move on with their lives – so they can move towards building the life they want, rather than running away from a life they don’t want.
I wouldn’t argue with any individual’s personal experience of whether a treatment helped them or not – except to say that all change is self-change, and they should give themselves the credit. You might think that a certain counselor, or treatment activity of some kind helped you to change – and if it helped you to realize something or look at things differently or whatever, then sure, it helped you. But I would argue with people who say that treatment is necessary or works on a whole- because I don’t believe it does, statistically – to the degree that it does “work”, in accordance with the data presented in NESARC and other studies, it’s only taking credit for change that would’ve occurred without it. That is, if 75% change with treatment, and 75% change without it – then it’s a wash. It’s like (and I know this is an imperfect comparison, because a cold is an actual illness) giving people a homeopathic remedy to get over a cold, and then attributing their recovery to it – even though they would’ve gotten over the cold on their own – and even though there is no evidence that any greater percentage of people get over colds with your remedy than without it. There may be some helpful practices in the treatment world here and there, but they’re far outweighed by the unhelpful and counterproductive practices in my opinion.
The concession I will make to medicine, is that detox can be necessary, and helpful. But this has nothing to do with a long term change in one’s behavior which is supposedly addressed in “treatment.”
-Steven
I should also say that in the Moos study, this seems extremely noteworthy:
“A total of 121 of the 628 baseline participants (19.3%) had died by the 16-year follow-up.”
A 19.3% death rate over 16 years seems HUGE to me. Maybe I’m wrong, idk. But it’s so notable, that you’d think the researcher would let us know which percentage of those who died received treatment or didn’t receive treatment. I don’t bring this up to disqualify anything you’ve said, I just bring it up to say: WOW, I really want to know more about that. Did he address this somewhere and I just missed it?
-Steven
Steven,
I suspect we’d both agree that much of the research in this area is methodologically unsound and of questionable use. As flimsy as a house of cards, in many respects.
Dusting off my doctor’s hat, I’m pleased to note your perspective on the specific and limited role of detox in the short term, particularly with regards to alcohol, as the grand mal seizures that can occur in that first couple of weeks can be fatal. Unfortunately the medications we on occasion use to prevent such seizures are themselves very addictive, as you probably know!
Personally, thanks for clarifying the role of your program, my own experience is similar, that personal empowerment is the key to recovery.
When we break a leg we may need a crutch, to start walking again, but after a while the crutch slows us down.
I look forward to reading more of your blog.
Best wishes,
Mathew Carter
Perth
Australia
“does show those not ‘in treatment’ relapse more at 3 years”
Addiction is not a disease. Relapse is not the appropriate term, but used by 12 Step proselytizers to legitimize their faith-healing. Moreover, why is it any of your business how someone chooses to live their life? I ask that you please refrain from responding with the ‘argument from authority’ typical of the quacks in your profession.
Ryan,
As a fan of constructive dialogue, I’m going to forgive the aggressive/passive-aggressive tone and respond.
I’m not, personally, a fan of 12-step programs, in terms of their dogmatic and religion based approach, and I do think we should scrutinise and dissect the 12-step model closely.
I do speak as an ex-clinician, and I agree that the medical/biological model is not much use in addiction.
I do speak as a multidisciplinary researcher.
I also speak from personal experience. I’m sorry that you took offence at the terms I use to understand recovery, as I see it and as I have lived it.
-Mathew
Sorry for misunderstanding. Most if not all clinicians and treatment professionals I’ve encountered on and off venues that consider pathways for “recovery” from addiction would not agree with you! As an exAA myself I must admit to my immense appreciation for websites such as this that tend to validate my very negative experience in “recovery.” Again I apologize for assuming your stance and my passive-aggressive retort. To say the least, I have immense anger towards the addiction and mental health industries, especially following the intentional death of a close family member after undergoing such “treatment.” I am pleasantly surprised at your apparent open-mindedness and wonder why I have never met or heard of a “treatment professional” (clinician) such as yourself who do not endorse the 12 Step methodology. Very scary stuff! Is attending over 1000 meetings and compliant with all dogmatic requirements for membership serve as familiarity sufficient to scrutinize the 12 Step “approach.” I feel inclined to pose more questions to an ex-clinician of your stature but will pause for the moment. My “disease” is getting tired and I am preparing for the 3 year benchmark which your study warns is the time I will “relapse.”
Ryan,
I am sorry to hear of your loss.
That’s very kind of you to offer an apology, but it’s not really necessary, I’m pretty thick skinned
, and I don’t claim any stature in particular, just an open and inquiring mind, as I suspect both you and the blog author also have, this is arguably more valuable in understanding or achieving this nebulous concept of “recovery” than any collection of post-nominals, in my personal opinion.
Your duration of involvement with AA far exceeds what mine was, and you understand what AA is like from the inside far better than me. We have alternatives available to many here in Australia, although AA is still the only type of peer support accessible to many people.
The 3 year cut-off in that study was probably arbitrary, it’s a trend more than a discrete time-frame.
Best wishes
Thank you for your considerate response. I was worried of being labeled and rediagnosed as “passive-agression” has already been pathologized in the DSMV! Yes, my sister was very near to me. She had an inquiring mind too, but was told by certified physicians that it was a symptom of a “disease” that can’t be observed under a microscope but required soul surgery administered by “old-timers” who may or may not have been convicted felons or rapists. It hurts so much sometimes to think about. Best wishes your way too.