NCAD West | As Views on Addiction Evolve, Emphasis Shifts to Achieving Stable Recovery Sooner

Since the Nixon administration declared a war on drugs in 1970, there has been a significant shift in the way addiction is understood, John F. Kelly, PhD, ABPP, professor of psychiatry in addiction medicine at Harvard Medical School, told attendees in the opening plenary of the National Conference on Addiction Disorders West in Denver on Friday.

What was once public enemy No. 1—and treated as such with a punitive approach and minimum sentencing requirements—is now viewed more as public health problem No. 1, as evidenced by the passage of parity laws and the implementation of drug courts. Still, Kelly said, there is opportunity for growth, especially when it comes to helping individuals achieve remission and stable recovery sooner.

“We have treated addiction like a burning building,” he said. “We have learned how to detox, stabilize and provide acute treatment up to 12 weeks. That has been important because we need to put the fire out. Where we’ve done a less good job is how do we prevent the fire from restarting?”

Kelly, who is also founder and director of the Recovery Research Institute at Massachusetts General Hospital and associate director of the hospital’s Center for Addiction Medicine, said that about 9.1% of the U.S. population (22.35 million Americans) has resolved a significant alcohol or drug problem. Notably, however, only about half of these individuals self-identify as being in recovery. Those with more severe addiction issues are more likely to self-identify as being in recovery, he said.

Progress in recovery rarely is linear, Kelly said. The median number of serious attempts to resolve an addiction is 2, but requiring 4 or 5 attempts is not uncommon, particularly for individuals with opioid use disorder.

On average, it takes patients 5 years in stable recovery before their risk for relapse drops to a rate in line with the general population. Over their first 5-6 years in recovery, SUD patients experience significant improvement in several areas—quality of life, happiness, self-esteem and recovery capital, along with lower levels of psychological distress. Improvement of these metrics continues at a gradually slower pace over the course of 40 years, with SUD patients generally reporting scores on par with the general population after 15 years, Kelly said.

Pathways to recovery

Individuals with substance use disorders can recover by following 3 pathways:

• Clinical. Treatment provided by a clinician or medical professional; encompasses both medication and psychosocial interventions
• Nonclinical. Services not involving clinicians, such as Alcoholics Anonymous
• Self-management. Recovery change processes that involve no formal services

Kelly said that research has shown about 54% of individuals in recovery engage with some form of assistance. While mutual help groups remain the most popular option (43% of patients in recovery), recovery support services—a “new kid on the block,” Kelly said—are emerging. This includes the launch of recovery community centers or “recovery cafes.” In Massachusetts, for example, 40 such programs now exist, which is 8 times as many as 5 years ago.

The use of such tools and a continued shift from addressing solely the clinical pathology of addiction to understanding the social determinants of recovery, are critical for continued progress, Kelly said.

“We’ve learned a lot over last 50 years,” Kelly said, “But we’re not out of woods yet, of course.”