Addiction recovery: Its definition and conceptual boundaries

Redefining recovery: Accounts of treatment experiences of dependent cannabis users in Nigeria

BACKGROUND

Research on addiction recovery describes recovery as a process leading to cessation of drug use. Few researchers have explored alternative views of recovery, and the interplay of individuals' agency and social context in the recovery process. This study explored situated understandings of recovery among cannabis users that emphasized process and contingency.

METHODS

We conducted the study in Uyo, Akwa Ibom State in Nigeria. Participants were current (street-involved) cannabis users aged 21 to 34 (n = 97), recruited through time-location sampling. The study collected data through in-depth, individual interviews, which study staff transcribed, coded, and analyzed thematically.

RESULTS

Participants' accounts indicated a quest for treatment as a means of recovery and redemption (i.e., repairing an identity damaged by dependent cannabis use). Relapse affected recovery when participants defined the latter as abstinence. Framing recovery this way showed the effects of social and structural factors on individual agency and treatment experiences. Yet some participants' accounts highlighted a redefinition of recovery as a process ("recovering"), measured by such outcomes as reduced drug use and improved overall well-being.

CONCLUSIONS

Reframing recovery, as some participants' accounts in our study capture, speaks to the need for treatment programs that are informed by the principles of harm reduction and health promotion. Instead of foisting a singular treatment goal defined as total abstinence onto drug users seeking treatment, treatment should be attuned to the experiences and life circumstances of users and support them in achieving their recovery goals.

The Continuum of Recovery from Alcohol Dependence: From Addiction Remission to Complete Mental Health

BACKGROUND

Few representative studies have examined optimal mental health among those with a history of alcohol dependence (AD).

OBJECTIVES

In a representative sample of Canadians with a history of AD, to determine prevalence of, and factors associated with 1) remission from AD, 2) the absence of Substance Dependence and Psychiatric Disorders (SDPD) in the past year, and 3) complete mental health (CMH).

METHOD

Secondary analysis of a publicly available Statistics Canada database, the 2012 Canadian Community Health Survey-Mental Health (820 adults with AD history; 19,945 without AD). Lifetime AD, past-year remission from AD, and previous 12-month absence of SDPD were determined using World Health Organisation Composite International Diagnostic Interview (WHO-CIDI) measures. Individuals are classified as being in CMH if they possessed social and psychological well-being, happiness or life satisfaction and absence of SDPD.

RESULTS

Over 70% of those with a history of AD were in remission, 52% were without past-year SDPD, and 38% of respondents were in CMH. Positive outcomes were more common among married respondents, older individuals, those with higher level of social support, and those who had never had major depressive disorders or generalised anxiety disorders.

CONCLUSION

The majority of Canadians with a history of AD achieve remission and a significant proportion achieve CMH. However, targeted outreach is warranted for the most vulnerable with a history of alcohol dependence, including younger respondents and those with low levels of social support or a history of mental illness.

Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1922451.

Opioid-induced structural and functional plasticity of medium-spiny neurons in the nucleus accumbens

Opioid Use Disorder (OUD) is a chronic relapsing clinical condition with tremendous morbidity and mortality that frequently persists, despite treatment, due to an individual's underlying psychological, neurobiological, and genetic vulnerabilities. Evidence suggests that these vulnerabilities may have neurochemical, cellular, and molecular bases. Key neuroplastic events within the mesocorticolimbic system that emerge through chronic exposure to opioids may have a determinative influence on behavioral symptoms associated with OUD. In particular, structural and functional alterations in the dendritic spines of medium spiny neurons (MSNs) within the nucleus accumbens (NAc) and its dopaminergic projections from the ventral tegmental area (VTA) are believed to facilitate these behavioral sequelae. Additionally, glutamatergic neurons from the prefrontal cortex, the basolateral amygdala, the hippocampus, and the thalamus project to these same MSNs, providing an enriched target for synaptic plasticity. Here, we review literature related to neuroadaptations in NAc MSNs from dopaminergic and glutamatergic pathways in OUD. We also describe new findings related to transcriptional, epigenetic, and molecular mechanisms in MSN plasticity in the different stages of OUD.

Untargeted Metabolomics: Biochemical Perturbations in Golestan Cohort Study Opium Users Inform Intervention Strategies

Objective: Over 50 million people worldwide are estimated to use opioids, of which ~30 million use opiates (opium and its derivatives). Use of opiates has been associated with a variety of adverse complications such as neurological and behavioral outcomes, addiction, cancers, diabetes, and cardiovascular disease. While it is well known that opiates exert their neurobiological effects through binding with mu, kappa, and delta receptors to exert analgesic and sedative effects, mechanistic links to other health effects are not well understood. Our study focuses on the identification of biochemical perturbations in Golestan Cohort Study (GCS) opium users.

Methods: We used untargeted metabolomics to evaluate the metabolic profiles of 218 opium users and 80 non-users participating in the GCS. Urine samples were obtained from adult (age 40–75) opium users living in the Golestan Province of Iran. Untargeted analysis of urine was conducted using a UPLC-Q-Exactive HFx Mass Spectrometry and a 700 MHz NMR Spectrometry.

Results: These GCS opium users had a significantly higher intake of tobacco and alcohol and a significantly decreased BMI compared with non-users. Metabolites derived from opium (codeine, morphine, and related glucuronides), nicotine, and curing or combustion of plant material were increased in opium users compared with non-users. Endogenous compounds which differentiated the opium users and non-users largely included vitamins and co-factors, metabolites involved in neurotransmission, Kreb's cycle, purine metabolism, central carbon metabolism, histone modification, and acetylation.

Conclusions: Our study reveals biochemical perturbations in GCS opium users that are important to the development of intervention strategies to mitigate against the development of adverse effects of substance abuse.

Recovery in Special Emphasis Populations

Special emphasis populations in the current context can be defined as groups experiencing health disparities resulting in elevated risk to health, safety, and well-being from drinking alcohol. Individuals from marginalized minority populations often encounter barriers to accessing and receiving effective alcohol treatment due to social inequities and disadvantaged life contexts, which also may adversely affect recovery from alcohol use disorder (AUD). Recovery from AUD often involves the adoption of a stable non-drinking lifestyle (sobriety), increased health and well-being, and increased social connection. Although there has been considerable work on AUD epidemiology among special emphasis populations, little research exists directly examining recovery among racial/ethnic minority populations and/or sexual and gender minority populations. The current narrative review hopes to spark scholarly interest in this critically neglected area. This article opens with a review of special emphasis populations and their alcohol-related risks. Next, definitions of recovery, Alcoholics Anonymous, and culturally adapted recovery models for racial/ethnic minority populations are explored. This is followed by a discussion of factors that may particularly influence recovery among marginalized minority populations. This narrative review concludes with a discussion of research priorities for promoting health equity through studies focused on understanding and supporting recovery from AUD among marginalized minority populations.

Patterns of transitions between relapse to and remission from heavy drinking over the first year after outpatient alcohol treatment and their relation to long-term outcomes

OBJECTIVES

Studying clinical course after alcohol use disorder (AUD) treatment is central to understanding longer-term recovery. This study's two main objectives were to (a) replicate a recent study that identified heterogeneity in patterns of remission from/relapse to heavy drinking during the first year after outpatient treatment in an independent data set and (b) extend these recent findings by testing associations between patterns of remission/relapse and long-term alcohol-related and functioning outcomes.

METHOD

Latent profile analyses were conducted using data from Project MATCH (N = 952; M age = 38.9; 72.3% female) and COMBINE (N = 1,383; M age = 44.4; 69.1% male). Transitions between heavy and nonheavy drinking within consecutive 2-week periods over a 1-year posttreatment period were characterized for each participant. From this, latent profiles were identified based on participants' initial 2-week heavy drinking status, the number of observed transitions between 2-week periods of relapse and remission, and the average duration of observed remission/relapse episodes.

RESULTS

In both MATCH and COMBINE, we identified six profiles: (a) "continuous remission," 25.3% of COMBINE sample/25.3% of MATCH sample; (b) "transition to remission," 19.6%/9.6%; (c) "few long transitions," 15.9%/33.7%; (d) "many short transitions," 13.2%/13.6%; (e) "transition to relapse," 7.2%/7.1%; and (f) "continuous relapse," 18.8%/10.5%. Profiles 1 and 2 had the best long-term outcomes, Profiles 5 and 6 had the worst, and Profiles 3 and 4 fell between these groups.

CONCLUSIONS

That many individuals can remit from heavy drinking following one or more relapses to heavy drinking may be of direct interest to individuals in recovery from AUD. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Spirituality in Recovery From Substance Use Disorders

Substance use disorders (SUDs) are chronic health disorders with exacerbation rates of approximately 50%. Spirituality has been identified as a factor that can improve recovery rates. Various definitions of spirituality exist that include concepts of finding meaning and connection in life and contact with the divine or something larger than ourselves. Patients generally want to include spirituality as part of their health care but barriers often exist for health care providers to address it, including lack of confidence, knowledge, and organizational support, and time constraints. Nursing programs lack content related to spirituality and should increase course content on this subject to improve comfort levels and competencies of nurses. Keeping in mind professional boundaries and respecting patients' individual differences, nurses have the potential to help patients in their recovery journey by facilitating discussion and growth in spirituality. Nurses can also advocate for their patients by including spiritual leaders in integrated health care teams. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 14-17.].

Language and stigmatization of individuals with mental health problems or substance addiction in the Netherlands: An experimental vignette study

Persons with mental health problems and/or substance addictions (MHPSA) are stigmatised more than persons with physical conditions. This includes stigmatisation by care professionals. Stigma is considered one of the most important barriers for recovery from these conditions. There is an ongoing debate that use of language can exacerbate or diminish stigmatisation. Therefore, we conducted an experiment examining how four different ways of referring to a person with (a) alcohol addiction, (b) drug addiction, (c) depression and (d) schizophrenia are related to stigmatising attitudes by care professionals in the Netherlands. We partially replicated two studies performed in the United States and used surveys with vignettes containing either 'disorder-first', 'person-first', 'victim' and 'recovery' language, which were randomly assigned to participants (n = 361). No significant differences between language conditions were found for any of the vignettes. Our findings suggest that subtle differences in language to refer to persons with mental health problems or substance addictions have no effect on stigmatising attitudes by care professionals in the Netherlands. However, more research is needed to determine the effect of language use on other groups, such as individuals with MHPSA.

Recovery processes among young adults treated for alcohol and other drug problems: A five-year follow-up

Aim

Studies on recovery from alcohol and other drugs (AOD) among young adults are scarce. In the present study, young adults, previously interviewed with a focus on their recovery process shortly after they completed treatment, were re-interviewed five years later focusing on their recovery process during the last five years in relation to their former AOD problems, other problems and processes of change.

Methods

Twenty-one young adults were interviewed: 16 women and five men aged between 25 and 33 years. After transcribing the interviews, the material was analysed thematically.

Results

Three overall themes emerged: previous problems, mental illness and the search for identity. The results were discussed in relation to recovery capital, primarily focusing on human and social capital. The results indicate that the group in focus often needs professional support for mental health issues in order to reach a stable recovery.

Conclusions

Since the problems described were heterogeneous, this client group might benefit from individual treatment and extended support after treatment. Further, the results indicate that the established period of five years for a stable recovery might need to be extended for young adults.

"Personal recovery depends on NA unity": an exploratory study on recovery-supportive elements in Narcotics Anonymous Flanders

BACKGROUND

Mutual aid organizations, such as Narcotics Anonymous (NA), can provide support in substance use disorder (SUD) recovery processes. However, research on NA and its recovery-supportive elements is scarce and perspectives of NA-members remain understudied, in particular outside the US. Therefore, this study aims to gain insight into recovery-supportive elements of NA, as experienced by its members.

METHODS

To explore the perspectives on and experiences with recovery-supportive elements in NA, 11 in-depth interviews with NA-members were conducted in Flanders (Belgium). Interviews were audio-taped, transcribed verbatim and analyzed by using CHIME-D, a personal recovery framework (Connectedness, Hope, Identity, Meaning in life, Empowerment, Difficulties) developed by Leamy and colleagues in 2011.

RESULTS

Various recovery-supportive elements of NA were highlighted, with Connectedness as a key component including opportunities for building up a social network and for providing a safety net or sounding board. Elements that enabled Connectedness were 1) a non-judgemental approach, and 2) mutual understanding through sharing in NA. Other elements of the CHIME-D framework were less frequently mentioned, although these were inextricably linked to Connectedness.

CONCLUSIONS

Connectedness appeared to be the crucial recovery-supportive element in NA, emphasizing the relational character of SUD recovery. Although other elements of the CHIME-D framework were identified, these were closely related to and intertwined with the concept of connectedness.

Perceptions of loneliness among people accessing treatment for substance use disorders

INTRODUCTION AND AIMS

Guided by cognitive theory of loneliness, this study sought to explore the experience of loneliness among people accessing treatment for substance use disorders. Specifically, contributors to, consequences and alleviators of loneliness were explored.

DESIGN AND METHODS

Individual semi-structured interviews were conducted with 20 participants. Interviews were conducted onsite at two residential treatment facilities in New South Wales, Australia. Interviews were audio recorded and transcribed and an iterative categorisation approach was used to guide data analysis and reporting.

RESULTS

Four key themes emerged as contributors to and consequences of loneliness: cognitions (mistrust, perceived support from others, low self-worth and fear of negative evaluation), quality and authenticity of relationships, unhelpful interpersonal behaviours and the role of substance use. Participants indicated that overcoming the cognitive and behavioural perpetuators helped to alleviate loneliness and also described the utility of support groups, pursuit of authentic relationships and activities that provide a sense of purpose as helpful.

DISCUSSION AND CONCLUSIONS

Cognitions related to mistrust, lack of perceived support, low self-worth, fear of negative evaluation and identification and pursuit of meaningful relationships supportive of recovery should be key treatment targets for this population.

Fighting the Battle of Recovery Together: A Content Analysis of Anonymous Posts in an Online Substance Use Forum

Background: The rates of use of substance have increased dramatically worldwide in the past several years. Approximately 10% of people who use illicit substances will develop a substance use disorder (SUD), which is a major health problem internationally. Recovery is a period of time when someone with an SUD is in remission or is not using substances. Little research has been done to examine views of patients with SUDs on recovery, particularly when that information is being shared anonymously.Objective: The purpose of the study is to gain an understanding of the experience of recovery from anonymous online postings in recovery support forums.Design: The study was conducted using a qualitative, descriptive, thematic content analysis approach to analyze 1,230 anonymous posts made to an International online recovery forum.Results: Themes identified from the online postings were that the experience of recovery included (a) the agony of withdrawal and screaming cravings, (b) a psychological roller coaster during withdrawal and recovery, and (c) use of coping skills and other strategies that help in recovery.Conclusions: These findings support current recommendations being given by healthcare providers on the use of coping skills and other recovery strategies. They also suggest that people with SUDs endure physical and psychological suffering and show a level of sophistication in managing their symptoms during recovery. Findings reveal that hope and feelings of self-satisfaction exist as a positive experience of recovery. Finally, we can interpret that there are clear benefits to online recovery communities and that healthcare providers have an important role to play as allies in the recovery experience.

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

Rehabilitation From Addiction and Chronic Illnesses: A Comparative Analysis of the Narratives of Hungarian Patients

BACKGROUND

In Hungary the psychological care provided during the rehabilitation of patients with chronic illnesses is insufficient. Patients with addiction, on the other hand, appear to make more use of psychological services. Narratives of patients recovering from addiction and patients with various chronic illnesses were examined in order to gain a better understanding of psychological phenomena during rehabilitation.

METHODS

Semi-structured interviews were carried out. Narrative and thematic analysis was used in order to determine the structure and characteristics of patients' narratives.

RESULTS

The narratives of patients recovering from addiction were found to be more structured and uniform; they identified with their illness and played an active role in their recovery. Patients with a chronic illness mainly recounted passive events and physical difficulties. Stigmatization was mentioned by both groups.

IMPLICATIONS FOR PRACTICE

The level of stigmatization experienced by patients with a chronic illness may be one of the reasons why they use healthcare services more frequently than patients with an addiction. The authors believe that teaching patients to provide good narratives about suffering from and recovering from chronic illnesses may aid them in the rehabilitation process. An adaptive mixture of different illnesses and addiction narratives might be beneficial in the recovery process of various patient groups.

Effects of 12-step mutual support and professional outpatient services on short-term substance use outcomes among adults who received inpatient treatment

BACKGROUND

Continuing care is increasingly prioritized in the treatment of substance use disorders (SUDs). Ongoing engagement in continuing care, including mutual support (e.g., 12-step groups) and/or professional outpatient services, may enhance treatment outcomes and facilitate recovery.

OBJECTIVE

This study investigates how engagement in 12-step mutual support and professional outpatient services is associated with short-term substance use outcomes in a sample of patients who completed inpatient SUDs treatment.

METHODS

As part of the Recovery Journey Project - a longitudinal cohort study - participants completed questionnaires upon admission to an inpatient SUDs treatment program, and at 1- and/or 3-months post-discharge (n = 379). Baseline data were collected by self-administered, electronic questionnaires. Follow up data were collected by phone or email. Analyses involved multivariate Generalized Estimating Equations separately modelling self-reported abstinence and percent days abstinent (PDA) over the three time periods.

RESULTS

Overall, rates of self-reported abstinence and PDA increased significantly from baseline to 1- and 3-months follow up. Engagement in 12-step activities (i.e., attended 30 meetings in 30 days, had a home group, had a sponsor, did service work) and professional outpatient substance use support were each significantly associated with abstinence and PDA. Participants who reported a higher degree of 12-step involvement (defined as engagement in more 12-step activities) were also more likely to report being abstinence and greater PDA.

CONCLUSIONS

Engagement in continuing care, including 12-step activities and professional outpatient substance use support, was highly associated with substance use. Clinical teams should encourage participation in such activities to optimize treatment outcomes.

Promoting Recovery from Substance Misuse through Engagement with Community Assets: Asset Based Community Engagement

Evidence shows that engagement with community resources can aid the process of recovery from substance misuse, yet systematic approaches to mapping resources and building bridges to these for recovery populations are limited. If done successfully, engagement with resources that are pro-social and afford access to meaningful activities not only provides a platform for personal development, but also has the ability to trigger a social contagion of positive behaviour and improve connectedness within communities. The current paper uses Asset Based Community Development (ABCD) as the basis for an enhanced version called Asset Based Community Engagement (ABCE). The work of ABCD has been pivotal in encouraging citizen-led, strengths-based approaches to community development, yet scientific support for it remains limited. While this approach has gained much traction, it has been subject to criticism for being too optimistic and unsystematic. In response to this, the new framework, ABCE, offers a more structured approach to mapping community resources. It does however advance previous work by acknowledging the need to identify current levels of community engagement and barriers to engagement, in order to support empowerment, maximise personal capital and address barriers to engagement. Identifying barriers to engagement should not draw ABCE away from its strengths-based focus but instead, provide a platform for person-centred, holistic support to be provided to those in recovery. To support the new framework, a workbook has been developed, offering a practical output that is intended to be used by the individual in recovery alongside a member of staff within a professional service supporting the individual.

At the intersection of alcohol use disorder and chronic pain

OBJECTIVE

Alcohol use disorder (AUD) and chronic pain are widespread conditions with extensive public health burden. This review seeks to describe neuroanatomical links and major mediating influences between AUD and chronic pain, in the service of identifying factors that predict the risk of chronic pain in precipitating or facilitating AUD.

METHOD

We review the neural bases of pain and the influence of AUD on processes involved in pain perception. We propose potential mechanisms involved in the development of chronic pain in AUD, and we consider implications for pain management in recovery from AUD.

RESULTS

Pain is a multidimensional and subjective experience that, in its acute form, is essential for survival, but in chronic form, pain is a disorder that negatively impacts quality of life. Neural substrates involved in initiating and maintaining chronic pain include dysfunction in descending pain pathways and reward network circuitry. AUD involves preoccupation or craving, intoxication, withdrawal, and negative affect. Neural substrates of AUD involve widespread mesocorticolimbic and cerebrocerebellar networks. Both conditions involve dysfunction of extended reward and oversight circuitry, particularly prefrontal cortex.

CONCLUSIONS

The interrelationship between chronic pain and AUD resides in the intersection of etiological influences, mental experiences, and neurobiological processes. Characterization of the connection between brain and behavioral abnormalities in AUD's precipitation of chronic pain-and vice versa-allows for early detection and treatment of patients at risk for developing either or both of these conditions and for preemptive interventional approaches to reduce the risk of consequent vulnerabilities and harm. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The recovery-oriented therapeutic community for addictions (ROTC): a response to contemporary substance use disorder treatments in the Philippines

Purpose

The Philippines’ nationwide campaign on drugs has been under the limelight due to its controversial approaches in dealing with the problem of addiction. Despite the government’s current efforts, substance use disorders continue to persist within the population. The purpose of this paper is to provide recommendations for addressing the issue of substance use disorder treatment through a modification of the therapeutic community (TC) in the Philippine context.

Design/methodology/approach

This conceptual paper reviews the existing facts about the Philippines’ campaign against drugs, the approaches implemented by the government, current state and research developments of TCs, and its resulting impact on contemporary evidence-based treatment for addiction in the country.

Findings

A treatment framework outlining a recovery-oriented therapeutic community (ROTC) is presented. The ROTC aims to address addiction as a chronic, relapsing disease. This alternative approach for addiction treatment in the Philippines is based on the concept of recovery, principles of effective substance use disorder treatment, and recent developments in TC best practices from the international community.

Originality/value

This paper discusses different recommendations for policy development, interventions and research, aimed at improving the odds of securing recovery for people suffering from addiction.

Profiles of recovery from alcohol use disorder at three years following treatment: can the definition of recovery be extended to include high functioning heavy drinkers?

BACKGROUND AND AIMS

Recovery from alcohol use disorder (AUD) is often narrowly defined by abstinence from alcohol and improvements in functioning (e.g. mental health, social functioning, employment). This study used latent profile analysis to examine variability in recovery outcomes, defined by alcohol use, alcohol-related problems and psychosocial functioning at 3 years following treatment. Secondary analysis investigated pre-treatment, post-treatment and 1- and 3-year post-treatment covariate predictors of the latent profiles.

DESIGN

Secondary analysis of data from a randomized clinical trial.

SETTING

United States.

PARTICIPANTS

We used data from the out-patient arm of Project MATCH (n = 806; 29.7% female, 22.2% non-white).

MEASUREMENTS

Recovery was defined by latent profile analyses including measures of psychosocial functioning and life satisfaction (Psychosocial Functioning Inventory), unemployment and mental health (Addiction Severity Index), alcohol and other drug use (Form 90) and alcohol-related consequences (Drinker Inventory of Consequences) 3 years following treatment. Mixture modeling was used to examine correlates of profiles.

FINDINGS

We identified four profiles at 3 years following treatment: (1) poor functioning frequent heavy drinkers, (2) poor functioning infrequent heavy drinkers, (3) high functioning occasional heavy drinkers and (4) high-functioning infrequent non-heavy drinkers. There were relatively few differences on indicators of functioning and treatment-related variables between the high functioning infrequent non-heavy drinkers and the high-functioning occasional heavy drinkers, other than high-functioning occasional heavy drinkers having lower alcohol dependence severity [odds ratio (OR) = 0.94, 95% confidence interval (CI) = 0.90, 0.98], fewer post-treatment coping skills (OR = 0.54, 95% CI = 0.32, 0.90) and lower 3-year post-treatment abstinence self-efficacy (OR = 0.37, 95% CI = 0.28, 0.49) and Alcoholics Anonymous (AA) involvement (OR = 0.87, 95% CI = 0.85, 0.99). The two high-functioning profiles showed the greatest improvements in functioning from baseline through the 3-year follow-up, whereas the low-functioning profiles showed the least amount of improvement. High-functioning occasional heavy drinkers had higher purpose in life than the poor-functioning profiles.

CONCLUSIONS

Some individuals who engage in heavy drinking following treatment for alcohol use disorder may function as well as those who are mostly abstinent with respect to psychosocial functioning, employment, life satisfaction and mental health.

ODD. Além da compulsão e da escolha: autonomia, temporalidade e recuperação pessoal

Este artigo discute a autonomia da pessoa que faz uso problemático de substâncias psicoativas (UPSP). Após o exame da ideia de autonomia de quem faz UPSP, a partir dos paradigmas médico, psicológico e moral, que oscilam entre as compreensões do uso como compulsão ou escolha, discute-se os aspectos psicopatológicos envolvidos no UPSP, em especial a experiência da temporalidade e suas implicações para o debate da autonomia dessas pessoas e para o seu processo de recuperação pessoal.

Attempting to Restore Integrity of the Self: A Grounded Theory Study of Recovery From Major Depressive Disorder

BACKGROUND: The cultural and social background of the individual would seem to be important factors that can affect recovery from major depressive disorder (MDD). Currently, there is little information on the process of recovery from MDD in Middle Eastern countries, such as Iran. AIMS: This study was conducted to explore the process of recovery from MDD in Iran. METHOD: A grounded theory approach by Corbin and Strauss was used to explore recovery from MDD. Twenty patients were recruited using purposive and theoretical sampling methods. RESULTS: Several themes emerged from the data, the primary of which was "Attempting to restore integrity of the self," which included the two subthemes of "Attempting to restore health," and "Attempting to reacquire the lost abilities." Various contextual factors also affected recovery, including poverty, inefficient health care systems, perceived support, feelings of failure, and social stigma. During the recovery process, participants adopted both "effective strategies" and "ineffective strategies." Following the attempt to restore integrity, participants experienced different levels of integrity, ranging from "complete recovery" to "no recovery/relapse." CONCLUSIONS: The results from this study contribute to the body of knowledge regarding recovery from MDD in Iran. The data suggest that recovery from depressive disorder is a very personal experience that is affected by different and variable factors and conditions. However, the attempt to restore integrity of the self can result in achieving a higher level of performance and health.

The association between perceived stigma and substance use disorder treatment outcomes: a review

Substance use disorders (SUDs) take a heavy toll on those who have them and on society more broadly. These disorders are often difficult to treat, and relapse is common. Perhaps, because of these factors, these disorders are highly stigmatized worldwide. The purpose of this study is to examine empirical work intended to determine the impact of perceived social stigma and self-stigma on the process of recovering from SUDs with the assistance of formal treatment services. Qualitative studies confirmed that stigma experiences are common among those with these disorders and that these experiences can negatively impact feelings and beliefs about treatment. One quantitative study provided good statistical support for a direct effect of stigma on outcomes, but this was contradicted by other longitudinal data. In general, quantitative articles suggested an indirect effect of stigma on treatment outcomes, via negative emotions and cognitive mechanisms such as feelings of self-efficacy. However, it was notable that there was little consistency in the literature as to definitions and measurement of the constructs of recovery, perceived social stigma, and self-stigma. Future work should focus on bringing clarity, and validated measures, to this problem in order to better determine the nature of these relationships.

Life History Theory and Recovery From Substance Use Disorder

Recovery has emerged as an important paradigm in addictions treatment but the field has yet to achieve consensus on how it should be defined and measured. The recovery construct has been extended beyond sustained reductions in use or abstinence to enhancements in global health/well-being and also prosocial community reintegration. However, few studies have included these broader domains in their measurement of recovery and few scientific theories have been advanced to explain why reductions in substance use occasion these broader life changes. This article applies life history theory to recovery for the first time to help define recovery, advance recovery measurement, and explain why broad change across multiple life domains should facilitate sustained recovery progress. We conclude with a discussion of future directions and challenges for future research informed by our life history framework for recovery.

Time to look beyond ageing as a factor? Alternative explanations for the continuing rise in drug related deaths in Scotland

Purpose

The purpose of this paper is to examine the reasons and risk factors that explain the threefold increase in drug-related deaths from 267 in 1996 to 934 in 2017 in Scotland. The authors explore the known links between deprivation and problem drug use (PDU) and discuss the impact of drug policy and service provision on PDU and drug-related deaths.

Design/methodology/approach

Using quantitative data sets from the National Records of Scotland (NRS) for drug-related deaths registered in 2017 and data sets from the Scottish Index of Multiple Deprivation (SIMD), we produce statistical data on mortality rates relating to areas of deprivation, gender and age.

Findings

The data highlight the disproportionate number of deaths in the most deprived areas in comparison to the least deprived areas and the national average. Findings indicate that one quarter of male and female DRD in 2017 were under 35. When examining the least deprived vingtile, drug-related deaths account for 2.84 per 100,000 population. Based on this mortality rate calculation, the amount of drug-related deaths are 23 times higher in the most deprived area than the least deprived area.

Research limitations/implications

The research design uses data obtained from the NRS and data from Scottish Multiple Index of Deprivation. Due to the limitations of available data, the research design focused on SIMD population vingtiles.

Practical implications

This research contributes to making unarguable links between entrenched structural inequality and increased drug-related death.

Social implications

This paper contributes to knowledge on the need for drug policy advisors to recognise the importance of deprivation that plays a major part in risks of problematic drug use and harms.

Originality/value

While several national data sets have published information by SIMD vingtile, no published research has sought to investigate the disproportionate number of deaths by population in the most deprived areas.

Quality of life and better than well: a mixed method study of long-term (post five years) recovery and recovery capital

Purpose

The purpose of this paper is to compare quality of life scores in a long-term recovery population group (post five years) with a general population group and to explore how any differences might be explained by recovering individuals themselves in a small number of follow up qualitative interviews.

Design/methodology/approach

A sequential explanatory mixed method design combining quantitative quality of life measure (WHOQOL-BREF, 1996) and six subsequent semi-structured individual interviews. The quality of life measure compared long-term recovery scores (post five years) with the general population group. The subsequent qualitative semi-structured interviews explored what the participants themselves said about their recovery.

Findings

The quantitative data provide evidence of a significant difference in quality of life (WHOQoL-BREF) in two domains. The long-term recovery group (five or more years into recovery) scored higher in both the environment and psychological domains than the general population group. Of the long-term recovery group, 17 people who still accessed mutual aid scored higher in all four domains than those 23 people who did not. The interviews provide evidence of the this difference as result of growth in psychological elements of recovery, such as developing perspective, improvement in self-esteem, spirituality, as well as contributing as part of wider social involvement.

Research limitations/implications

This study provides support for the quality of life measure as useful in recovery research. The empirical data support the concept of recovery involving improvements in many areas of life and potentially beyond the norm, termed “better than well” (Best and Lubman, 2012; Valentine, 2011; Hibbert and Best, 2011). Limitations: snowballing method of recruitment, and undertaken by public health practitioner. Some suggestions of women and those who attend mutual aid having higher quality of life but sample too small.

Practical implications

Use QoL measure more in recovery research. Public health practitioners and policy makers need to work with partners and agencies to ensure that there is much more work, not just treatment focused, addressing the wider social and environmental context to support individuals recovering from alcohol and drugs over the longer term.

Originality/value

One of small number of studies using with participants who have experienced long-term (post five years) recovery, also use of quality of life measure (WHOQOL-BREF, 1996) with this population.

Examining Barriers as Risk Factors for Relapse: A focus on the Canadian Treatment and Recovery System of Care

Objectives:

In 2016, the Canadian Centre on Substance Use and Addiction (CCSA) conducted the first survey of individuals in recovery from addiction in Canada. The findings revealed that many individuals in recovery lead meaningful lives, contributing to their families and society. However, participants also identified a number of barriers to starting and maintaining recovery. The current study examined the relationship between the barriers experienced and relapse during recovery.

Methods:

Data from the 2016 Life in Recovery (LIR) from Addiction in Canada survey were analyzed using descriptive and logistic regression analyses. Participants comprised 855 individuals (M_age = 47.3 years), all of whom self-reported being in recovery from addiction.

Results:

Logistic regressions revealed that upon starting recovery, long delays for treatment, odds ratio (OR) = 1.77, 95% confidence interval (CI) = 1.21–2.60, P < 0.01, and not having stable housing, OR = 1.83, 95% CI = 1.14–2.95, P < 0.05, were associated with increased risk of relapse. Moreover, upon examining barriers to maintaining recovery, a lack of supportive social networks, OR = 2.10, 95% CI = 1.26–3.48, p < 0.01, a lack of programs or supports, OR = 1.75, 95% CI = 1.03–2.98, P < 0.05, and the costs of recovery services OR = 1.73, 95% CI = 1.02–2.91, P < 0.05 were associated with increased risk of relapse.

Conclusions:

Targeted investments to address the treatment-related barriers that most strongly relate to relapse, could significantly improve the lives of individuals struggling with addiction and those beginning and maintaining their recovery journey.

Objectifs:

En 2016, le Centre canadien de lutte contre l’alcoolisme et les toxicomanies (CCLAT) a mené un premier sondage auprès des personnes en rétablissement à la suite d’une dépendance au Canada. Les résultats ont révélé que de nombreuses personnes en rétablissement mènent des vies significatives, contribuant ainsi à leur famille et à la société. Cependant, les participants ont également identifié un certain nombre d’obstacles au démarrage et au maintien du rétablissement. La présente étude a examiné la relation entre les obstacles rencontrés et la rechute pendant le rétablissement.

Méthodes:

Les données de l’enquête Life in Recovery (LIR) de l’Enquête sur la toxicomanie au Canada de 2016 ont été analysées à l’aide d’analyses de régression descriptives et logistiques. Les participants comprenaient 855 individus (Moyenne d’âge = 47,3 ans), qui ont tous déclaré être en rétablissement après une dépendance.

Résultats:

Les régressions logistiques ont révélé qu’au début du rétablissement, de longs délais de traitement, chance de réussite (CR) = 1,77, intervalle de confiance à 95% (IC) = 1,21-2,60, p < 0,01, et n’ayant pas de logement stable, CR = 1,83, IC 95% = 1,14-2,95, p < 0,05, étaient associés à un risque accru de rechute. De plus, en examinant les obstacles au maintien du rétablissement, un manque de réseaux sociaux de soutien, CR = 2.10, IC à 95% = 1.26-3.48, p < 0.01, manque de programmes ou de soutien, CR = 1.75, IC à 95% = 1.03–2,98, p < 0,05, et les coÛts des services de récupération CR = 1,73, IC 95% = 1,02–2,91, p < 0,05 étaient associés à un risque accru de rechute.

Conclusions:

Des investissements ciblés visant à surmonter les obstacles liés au traitement les plus étroitement liés à la rechute pourraient améliorer considérablement la vie des personnes aux prises avec une dépendance et de celles qui amorcent et poursuivent leur chemin vers le rétablissement.

Building Recovery Capital: The Role of "Hitting Bottom" in Desistance and Recovery from Substance Abuse and Crime

The aim of this article is to explore the role of "hitting bottom" as a motivation to initiate a recovery process and desistance from crime and substance use disorders (SUDs), and in building recovery capital (RC). Researchers and practitioners have long been interested in why and how offenders desist from crime. Desistance and recovery from crime and SUDs have also been linked to negative turning points, such as hitting bottom, which represents multidimensional suffering with physiological, familial, social, and criminal implications. The deleterious outcomes of SUDs cause individuals to lose their social and personal resources and hit bottom. According to the conservation of resources model, in the context of actual or potential loss of resources, individuals strive to maintain, protect, and build them. Thus, hitting bottom not only provides the initial motivation for change, but also drives individuals to build personal resources. The prospects for successful recovery are dependent upon the individual's personal and social resources, or RC. This article represents a first step in examining the role of hitting bottom in building RC in the process of long-term recovery. The conclusions may have theoretical as well as practical implications.

Negative attentional bias for positive recovery-related words as a predictor of treatment success among individuals with an alcohol use disorder

INTRODUCTION

This study assessed relationships between clients' attentional bias (AB) for different types of stimuli and their treatment outcomes. Alcohol AB during detoxification has previously been shown to predict relapse, but further research was needed to clarify this relationship. The current study determined whether AB for recovery-related words would also predict treatment outcome.

METHODS

Participants were 45 clients undergoing alcohol detoxification, and a control group of 36 staff members. They rated words for personal relevance in four categories (alcohol-related, neutral, positive change-related, and negative change-related). Participants completed an individualized Stroop task containing their chosen words. They were also assessed on readiness-to-change, difficulties with emotion regulation, drinking problems, anxiety, and depression. Clients were interviewed at a three-month follow-up to determine their treatment outcome.

RESULTS

As predicted, questionnaire measures did not predict clients' treatment outcome (p > .05). A logistic regression model indicated that the best predictor of treatment outcome was AB for positive change-related words (p = .048), with successful individuals having less AB for these words than for the other word categories. Although this finding was unexpected, it was supported by significant relationships between positive change-related interference scores and continuous measures of drinking at follow-up [i.e. number of units drunk (p = .039) and number of drinking days (p = .018)].

CONCLUSIONS

The results suggest that positive change-related words are a better predictor of treatment outcome than are either alcohol-related words or negative change-related words.

A Longitudinal Qualitative Analysis of the Lived Experience of the Recovery Process in Opioid-Dependent Patients Post-Detoxification

The aim of the study was to gain an in-depth understanding of opioid-dependent patients' lived experiences post-detoxification.

METHOD

The study employed a naturalistic, observational longitudinal design, involving baseline screening and tracking of patients post-detoxification, with follow-up interviews at three, six, and nine months to observe specific processes of interest. This in-depth investigation of patients at four points was new within an Irish context and novel throughout the literature.

FINDINGS

Recovery was seen as a process that was not always linear, and lapse and relapse were viewed as part of this process. Patients had great insight into "risk factors for relapse," information and knowledge gained over several years and many treatment episodes. Furthermore, the findings illustrate the role insight plays in any learning and growth experience and the emphasis that is placed upon it within the treatment journey; insight is a fundamental underpinning to any real growth and development. The current article argues that insight merits a more explicit role in the model of recovery capital.

"I Was Not Sick and I Didn't Need to Recover": Methadone Maintenance Treatment (MMT) as a Refuge from Criminalization

BACKGROUND

Methadone Maintenance Treatment (MMT) in the United States (U.S.) has been undergoing a shift towards conceptualizing the program as recovery-based treatment. Although recovery is seen by some as a means to restore MMT to its rightful position as a medically-based treatment for addiction, it may not represent the experiences, or meet the needs of people who use drugs (PWUD), many of whom who use the program as a pragmatic means of reducing harms associated with criminalization.

OBJECTIVES

To examine alternative constructions of MMT in order to produce a richer, more contextualized picture of the program and the reasons PWUD employ its services.

METHODS

This paper uses semi-structured interviews with 23 people on MMT (either currently or within the previous two years).

RESULTS

Most participants linked their use of MMT to the structural-legal context of prohibition/criminalization rather than through the narrative of the recovery model. Responses suggested the recovery model functions in part to obscure the role of criminalization in the harms PWUD experience in favor of a model based on individual pathology. Conclusions/Importance: In contrast to the recovery model, MMT cannot be understood outside of the structural context of criminalization and the War on Drugs which shape illegal drug use as a difficult and dangerous activity, and consequently position MMT as a way to moderate or escape from those harms.

Tulsa 1000: a naturalistic study protocol for multilevel assessment and outcome prediction in a large psychiatric sample

INTRODUCTION

Although neuroscience has made tremendous progress towards understanding the basic neural circuitry underlying important processes such as attention, memory and emotion, little progress has been made in applying these insights to psychiatric populations to make clinically meaningful treatment predictions. The overall aim of the Tulsa 1000 (T-1000) study is to use the NIMH Research Domain Criteria framework in order to establish a robust and reliable dimensional set of variables that quantifies the positive and negative valence, cognition and arousal domains, including interoception, to generate clinically useful treatment predictions.

METHODS AND ANALYSIS

The T-1000 is a naturalistic study that will recruit, assess and longitudinally follow 1000 participants, including healthy controls and treatment-seeking individuals with mood, anxiety, substance use and eating disorders. Each participant will undergo interview, behavioural, biomarker and neuroimaging assessments over the course of 1 year. The study goal is to determine how disorders of affect, substance use and eating behaviour organise across different levels of analysis (molecules, genes, cells, neural circuits, physiology, behaviour and self-report) to predict symptom severity, treatment outcome and long-term prognosis. The data will be used to generate computational models based on Bayesian statistics. The final end point of this multilevel latent variable analysis will be standardised assessments that can be developed into clinical tools to help clinicians predict outcomes and select the best intervention for each individual, thereby reducing the burden of mental disorders, and taking psychiatry a step closer towards personalised medicine.

ETHICS AND DISSEMINATION

Ethical approval was obtained from Western Institutional Review Board screening protocol #20101611. The dissemination plan includes informing health professionals of results for clinical practice, submitting results to journals for peer-reviewed publication, presenting results at national and international conferences and making the dataset available to researchers and mental health professionals.

TRIAL REGISTRATION NUMBER

NCT02450240; Pre-results.

Alcohol Dependence in Palliative Care: A Review of the Current Literature

PURPOSE

Alcohol misuse affects up to 28% of palliative care inpatients. This article aims to summarize the existing literature on the care of palliative patients with alcohol dependence.

METHODS

The author searched CINAHL, Scopus, MEDLINE, and PubMed from inception until July 2017 using search terms including "alcohol*," "dependence," and "palliative." The results were reported in a narrative manner.

RESULTS

Identification of alcohol-dependent patients can be improved through the use of validated tools such as "Cut Down, Annoyed, Guilty, Eye Opener" (CAGE) and "Alcohol Use Disorders Identification Test" (AUDIT). These patients may have specific palliative care needs such as increased susceptibility to terminal agitation, high prevalence of comorbidities, and poor social support networks. Management may involve detoxification, controlled usage of alcohol, or treatment of alcohol withdrawal.

CONCLUSIONS

Patients may derive clinical benefit when alcohol dependence is identified by health-care professionals. Routine screening should be considered. Further research is needed to directly compare treatments for alcohol dependence in palliative care.

Decreased Drinking and Alcoholics Anonymous are Associated with Different Dimensions of Spirituality

Alcoholics Anonymous (AA) is a spiritual program and involvement in it has been associated with increases in spirituality. Some who pursue recovery outside AA also use spirituality for support. Decreasing drinking without AA involvement might result in spiritual change, but this has not been explored in previous research. This study investigates drinking and AA behavior to determine their association with seven dimensions of subsequent spirituality.

METHODS

A 30-month panel study recruited 364 individuals with alcohol dependence. Multilevel models examined drinking and AA at six months as predictors of both the levels and trajectories of seven dimensions of spirituality assessed five times over 6 - 30 months.

RESULTS

Controlling for AA involvement, less drinking was associated with higher levels of purpose in life, self-forgiveness, and spiritual/religious practices. Controlling for drinking, greater AA involvement was associated with higher levels of positive religious coping, daily spiritual experiences, forgiveness of others, and spiritual/religious practices. Neither AA nor drinking predicted trajectories of spirituality. Data visualizations identified a pattern of elevated purpose in life and self-forgiveness among individuals who were abstinent and among individuals who drank less intensely.

CONCLUSIONS

Reduced drinking influenced aspects of spirituality that have been shown to respond to experience and maturation. AA was associated with aspects of spirituality embedded in the 12 steps which have been shown to be responsive to learning and modeling. This knowledge has the potential to inform decisions about recovery options, and contributes to theoretical understandings of the nature of spiritual change over the course of addiction recovery.

Community participation and mental health prior to treatment

Purpose

The purpose of this paper is to investigate Keyes’ (2007) model of mental health, the presence (flourishing) or absence (languishing) of social, emotional and psychological wellbeing, in the context of drug and alcohol misuse and the frequency and pattern of community participation (engaging in society).

Design/methodology/approach

Participants were 1,815 individuals (70 per cent male) who entered residential substance misuse treatment provided by The Salvation Army. Questionnaires were completed at intake assessments with The Salvation Army staff. The data were compared with population norms of community participation utilising t-tests, while multiple linear regression was used to examine continuous mental health.

Findings

Although participants have lower levels of community participation compared to Australian population norms, those participants who were experiencing flourishing mental health had higher rates of community participation than Australian norms. Keeping in touch with friends and family was the most common form of participation. Informal social connectedness and civic engagement were the strongest predictors of mental health over and above more traditional substance use outcomes such as cravings.

Originality/value

This is one of the first studies to describe the relationships between community participation, substance use and mental health in participants seeking treatment for substance misuse. Despite having a drug or alcohol addiction requiring treatment, those participants with flourishing mental health have higher levels of community participation than community norms. Furthermore, community participation predicts mental health. This offers promise for interventions that increase community participation but further research using longitudinal designs is needed to replicate and clarify the direction of these relationships.