Changing How We Measure "Addiction"
Dr. Adi Jaffe
We've been measuring recovery the same way for over a century.
It’s no secret that people who tend to drink a lot or use drugs excessively may find themselves strugglinging with substance dependency. So, it’s not an illogical jump to presume that, in order for people to no longer “have an addiction”, they must completely abstain from drugs and alcohol. Right?
Have you ever wondered why is this such a common belief informing traditional treatment approaches? According to the 2015 National Survey on Drug Use and Health (NSDUH), 56 percent of people age 18 or older reported that they drank alcohol in the past month, while 9.4 percent of the population age 12 or older have used an illicit drug in the past month. Interestingly, less than 15 percent of the adult population report that they have not had any alcohol in their lifetime. This tells us that absolute non-drinkers are actually in the minority.
What does this mean for people struggling with substance use? It’s at least possible that lifelong abstinence is a ridiculous expectation. We’re asking people with an alcohol use or substance use disorder (who rely on alcohol for a slew of reasons) to quit when we know that between 56 to 85 percent of the population continues to drink. It could be said that we’re setting people with a substance use disorder up for failure.
Measuring success in recovery only by how many consecutive days someone is sober is like measuring diabetes treatment outcomes by the last time someone had a doughnut—it’s not an adequate method. In fact, it’s outdated and unrealistic.
How common is addiction?
According to the NSDUH, more than 20 million people have a substance use disorder, and within that group, more than 15 million have an alcohol use disorder (AUD). Almost 10 million men account for an AUD, compared to 5.3 million women. Only 6.7 percent of all adults with an AUD received treatment in the past year.
It’s clear from these statistics there are a lot of people struggling with AUD and other substance use disorders and only a small percentage are receiving any form of help. In a previous article, I talked about shame and stigma as a major barrier to treatment, and I believe abstinence (the requirement to quit alcohol and drugs) before entering traditional treatment programs is just as much of a deterrent.
How do we currently measure addiction recovery success?
At present, essentially the only factor that matters in measuring recovery success is abstinence. “How many days do you have?” is the recovery battle cry de jour.
This is the core of programs like AA (Alcoholics Anonymous), which measure months sober and participants are encouraged to submit to a higher power to address “defects of character” and make amends for past problems. Twelve-step treatment programs nearly unanimously reject reduced drinking as a potential outcome for participants. The expected outcome is complete abstinence.
The Betty Ford Consensus Panel (2007)1 put forth a contentious definition of "recovery" as consisting of three parts: sobriety, personal health, and citizenship. Sobriety, in this context, refers to complete abstinence from alcohol and substances while personal health refers to improved physical well-being and citizenship refers to living with others respectfully. This definition, however, has been widely criticized as no other illness is measured for recovery status on the construct of citizenship.
Nevertheless, academics have been arguing for more nuance and better measurement for over a decade. For instance, McLellan, Chalk, & Bartlett (2007)2 define "recovery" as consisting of three domains: substance use, employment/self-support, and criminal activity and Sanghani and colleagues (2015)3 assert that “Addiction treatment and recovery are multifaceted processes, and treatment success cannot be determined by a single metric.”
It’s time for the whole field to catch up.
Why is measuring sobriety an outdated measure of recovery success?
Measuring recovery success by months sober is an outdated and narrow way to measure the success of recovery. Here are some reasons why:
It prevents people from seeking help. To begin with, some people don't want to give up alcohol completely. I’ve worked with many clients who wanted to get a better handle on their drinking but didn’t want to quit altogether. Discounting every other area of improvement because alcohol was not completely missing from their life can devalue their motivation for change.
It can also prevent people from seeking help following “failed” attempts because they feel guilt, shame, or defeat, thus prompting them to keep their distance from traditional treatment facilities. These people can be difficult to reach for follow-up treatment. The number of times I’ve heard of people who feared being re-labeled “newcomers” is staggering, and the concept makes no sense—suggesting that the recovery of someone with years of sobriety who has had a drink is equivalent to that of someone who has just begun their process makes no sense without deeper examination.
When we measure recovery success as an absence of relapse, we are setting people up for failure. Estimates suggest that as many as 80 percent of people struggling with a substance use disorder who seek help and complete an addiction program will relapse after treatment (many within 30 days). And those are the people who actually complete the program. What does this say about current treatment programs and what does it say about the trajectory of addiction? As Sanghani and colleagues write in their paper, "Relapse rate cannot serve as the sole indicator of recovery success, lest the industry as a whole be interpreted as widely ineffectual." We need to move away from outdated measurements of recovery success.
Finally, we should not view substance use disorder as solely a problem with alcohol or drugs. It isn’t and never was. There are many more variables that should be accounted for like quality of life, daily functioning, criminal involvement, social integration, and more. What if an unemployed man who drinks seven nights a week and is cut off from his family and arrested regularly is able to cut down his drinking a bit, maintain a job, earn an income and keep a roof over his head while staying out of jail? Shouldn’t that be measured as success compared to the alternative—a man who is in jail, has no job, money or home? The answer is a resounding yes.
The point of recovery is to allow people to achieve a way of life in which they are happier, more satisfied, and operating as functional members of society. As helpers, if we are only measuring their success by consecutive days sober, we aren't giving them a lot to be hopeful for.
What modern approach should we take to measure recovery?
Instead of only measuring one’s consecutive days abstinent, here are additional ways we could measure recovery:
Percentages of abstinence over a period of time. For instance, a person who has been abstinent for a year (365 days) and then drank for a weekend (3 days) would be said to be 99 percent sober over the last year along with currently having 0 consecutive days sober. This would immediately acknowledge BOTH the victories and the struggles instead of the current system that only focuses on the “failure.”
Overall quality of life. There are many areas of life that deserve attention when a person is entering recovery and they include relationships (family and romantic), employment, mental well-being, criminal involvement, fun and recreation (yes, life is lived to be enjoyed AND be purposeful), personal growth and more. As it currently stands, it is assumed that working on abstinence will automatically confer benefits in all of these areas. But this is a false belief as I point out in my book. We know individuals in recovery who are abstinent and yet miserable. It takes work to address each of these areas of life.
Criminal justice involvement. Many people who are new to recovery have found themselves tangled in criminal behavior. While they’ve typically been judged as being deviant for these reasons, it is often heavily influenced by the fact that the drugs they are using are illegal and so is the act of procuring them. Being able to pull yourself away, even if imperfectly, from this way of life should be celebrated. This is also where maintenance drugs (like methadone, suboxone, etc.) should be celebrated because they allow many people to kick the “drug-free” can down the road while getting their life in order. That effort should not be denigrated.
To be sure, I’m not advocating for people to binge drink and pass out every night as long as they can hold down a job. For some reason, this is one of the retorts I typically get to articles like this. But if people can get to a point where their drinking or drug use is no longer a problem, or is at least less of an obstacle in their life, shouldn’t we celebrate that success?
A major false assumption is that these approaches—what is believed by traditional recovery advocates to be the “easier softer way"—set people who are addicted up for failure. The problem with this thinking is that the underlying belief is that people will choose these alternative approaches instead of the more traditional abstinence-only ways. But that isn’t true in the least. And we know that because 85 percent of people who struggle with addiction don’t seek help and among those who do, more than 90 percent “fail” by current measures within a single year. Giving options is the ethical, appropriate, and right thing to do.
A personal treatment plan that includes personalized goals and more nuanced measures of success can make the client feel more connected to the treatment provider and less resistant to treatment. This, in turn, will open the communication channel between staff, clients, alumni and treatment centers to follow-up or receive additional help.
In Summary
Everyone always marks their recovery by saying how many days in a row they've been sober, but there is so much more to recovery and more nuanced ways to measure. As I discuss in the IGNTD Recovery Podcast, beating addiction is not solely about quitting. This holistic approach is the foundation on which my IGNTD Hero Program has been built, to promote individualized treatment for people with an addiction in a shame-free, abstinent-free package that is accessible to all.
References
1. The Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute (2007). Journal of Substance Abuse Treatment, 33, 221–228. doi: 10.1016/j.jsat.2007.06.001. Sourced: https://www.ncbi.nlm.nih.gov/pubmed/17889294
2. McLellan A.T., Chalk, M., & Bartlett, J. (2007) Outcomes, performance, and quality - What's the difference? Journal of Substance Abuse Treatment, 32, 331–340. doi: 10.1016/j.jsat.2006.09.004. Sourced: https://www.ncbi.nlm.nih.gov/pubmed/17481456
3. Sanghani, R. M., Carlin, A. L., & Moler, A. K. (2015). Assessing success--a commentary on the necessity of outcomes measures. Substance abuse treatment, prevention, and policy, 10, 20-20. doi:10.1186/s13011-015-0017-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4432513/