DEFINING RECOVERY:

removing stigma FROM “ABSTINENCE”

For a few years now, abstinence and harm-reduction workers have been willing to understand each other’s work, and begin to inter-refer to each other’s services along a true continuum of care, and recent Scottish and US definitions of “recovery” acknowledge this – so why settle for a UK version which does not encompass both? Let’s work together for a definition to unite the field, urges Deirdre Boyd

For well over half a century, people recovering from addiction/dependency on alcohol and drugs have used that term “recovering” or “in recovery” in the same sense that they were used and written as guidelines by the founders of Alcoholics Anonymous in the 1930s and onward. But how about “medication-assisted recovery”, as encompassed by a Betty Ford consensus definition? After all, the founders of AA worked were so forward thinking that they advocated psychotherapeutic interventions when they were in their infancy – and they sought pharmaceutical help. In the latter they were unsuccessful (LSD was not an effective solution!) but science has moved on, if slowly. Should a definition of “recovery” encompass medication-assisted recovery – or should we differentiate with two definitions: “abstinent recovery” and “medication-assisted recovery”?

What would work not only for you and your organisation but also the partners you deal with such as statutory services, doctors and psychiatrists? What would be an acceptable definition to reassure employers wondering whether to recruit or retain an employee “in recovery”? What would be an acceptable definition for the company insuring the health of someone “in recovery”?

And, if today’s search for outcome statistics is to lead to clinical effectiveness and clinical cost-effectiveness, what definition will help us to measure outcomes, for both comparative purposes and to feedback into programme improvements?

A one-line statement cannot hope to encompass all that is involved in “recovering” from substance abuse or dependence. But, as starting points, let’s look at the definitions in play.

“Recovery from substance dependence is a voluntarily maintained lifestyle characterised by sobriety, personal health, and citizenship,” stated the Betty Ford Institute Consensus Panel, in the Journal of Substance Abuse Treatment last year. However, we must search through seven pages of explanations including, under the heading Sobriety sustained by medications, that “those who are abstinent from alcohol, all illicit drugs, and all nonprescribed or misprescribed medications would qualify for this component of the definition regardless of whether those behaviours were maintained by a medication, a form of unforced outpatient treatment, support from a recovering peer group, or some alternative lifestyle”.

“Recovery is a process through which an individual is enabled to move-on from their problem drug use towards a drug-free life and become an active and contributing member of society,” declares this year’s scottish drug policy document, The Road To Recovery. Although accompanied by 95 pages of policy, the definition can, in my view, stand alone. “This commitment to recovery, to responding to the desire of people who use drugs to become drug free, lies at the heart of this strategy... Aiming for recovery means coupling common sense with aspiration, pragmatism with idealism... public money invested in drug treatment services should have clear outcomes attached,” Fergus Ewing SMP writes in the Ministerial Foreword.

The UKDPC definition omits mention of “sobriety” or “drug-free life”, and readers must scour nine pages to find it: “The process of recovery from problematic substance use is characterised by voluntarily-sustained control over substance use which maximises health and wellbeing and participation in the rights, roles and responsibilities of society”. This is slightly altered from its earlier version, which also centred round “control over substance use.” As the first redefinition to publicise itself in the UK, Addiction Today sought the views of CEOs/directors in the treatment field. Well over 20 replied: only 30% thought the UKDPC definition covered substance abuse, only 25% thought it covered substance dependence, and only 15% thought it covered co-occurring disorders; 70% thought a definition should cover all three.

Among those publicising detailed concerns over the summer were DrugLink July, Mike Ashton of Findings at an All-Party Parliamentary Drugs Misuse Group, Wired/Daily Dose blogs, Centre for Policy Studies blogs and DDN contributors. And, after attending the £3million charitably-funded UKDPC’s second meeting, Addiction Today urged that its name not be attached to the project. Where does that leave us?  Well... awaiting your definitions. Watch this space as we seek true consensus.

ERRATA, issue 113 | UKDPC

Addiction Today agreed to publicise a statement from the UK Drug Policy Commission in the last issue. Its use of the names of the Addiction Recovery Foundation and its CEO should not be perceived as an endorsement: we wrote to the UKDPC in early June asking it not to link the names in support of its definition of “recovery”.

Also, the “small” survey cited was, in fact, of almost 30 CEO/directors representing organisations, rather than “individuals” – more than those individuals in the UKDPC project.

The charity has also objected to the use of its UKESAD name in UKDPC’s Vision document, as it could create a misleading interpretation.

Comments

[Peter O'Loughlin]

Addiction is an irreversible condition, which both experience and more latterly science has shown us increases in severity with the ongoing use of addictive psycho active substances. In the absence of any evidence to the contrary, it follows that for recovery to commence abstinence from substances which are known to trigger addiction, is fundamental to putting addiction into remission. Suggestions to the contrary appear to be based on psychosocial learning hypotheses, and, or individuals and organisations who appear to have more than one agenda, but with the common and constant theme, of ongoing substance use.

It appears to this writer that rather than challenge the facts relating to addiction with empirical evidence, those seeking to redefine recovery, simply dispense with the use of the terms ‘addiction’ or ‘dependency’ and coin euphemisms such as ‘problematic substance use’, ‘entrenched patterns of drug misuse’ and various other innocuous sounding and vacuous descriptions, all of which lack universal definition. Add to that their documented aversion to definine what those conditions are, and one begins to realise that there is little or no substance to their declared desire to heal any perceived rifts between those who advocate harm reduction, which in itself is also a term lacking in universal definition, and those who through experience, research and scientific evidence, know that abstinence, in the case of those who meet the diagnostic criteria in either DSM-1V or ICD-10 for that condition, wherein it is described as ‘dependency’, and not withstanding current pharmacotherapy advances, is a pre-requisite if lasting recovery is to be achieved.

The writer would like to make it clear that he acknowledges there are cases of addiction, where for a number of reasons abstinence focused recovery may not be possible, and that those who are unfortunate enough to meet that criteria in accordance with the Addiction Severity Index, (ASI) are in need of ongoing medical and psychiatric care, which sadly may also include substances, which not only have numerous unpleasant side effects, but also addictive properties. It seems almost unnecessary to point out that such cases, in common with other intractable diseases are unable to achieve remission and therefore, are neither physically, or mentally capable of entering into recovery. Fortunately such cases are very much in the minority and are not to be confused with the judgemental ‘not ready’. A term which is frequently used by some treatment services, where in fact the truth is that the service itself is either not ready, or willing, to deal with the challenging demands of abstinence focused recovery.

Insofar as defining successful outcome in terms of recovery, this writer suggests that anything less than five years of unbroken abstinence cannot be regarded as being ‘staple’. That view which is which is widely held, should not be regarded as being patronising or scornful of those in substance free recovery who have yet to achieve that, but rather as a pragmatic view of the fact that addiction is a three dimensional condition, and for lasting remission to be achieved, the addicted need to learn how to bring about changes in their attitude and outlook on life, together with recreating their own fundamental personal values and priorities. The authority for that view can be found in the highly acclaimed and peer reviewed Transtheoretical model, together with the opinions of not only other leading addictions specialists, but that of Carl Jung who in an exchange of correspondence with the co founder of Alcoholics Anonymous, made the following comments:

“Science has no answer to this problem, psychotherapy alone is useless, what is required is a spiritual experience”

That holistic and realistic view of what constitutes recovery holds good today, the evidence is to be found in the millions who have achieved a staple drug free recovery, and who notwithstanding the unfortunate circumstances they found themselves in, have managed to bring about 180 degree turn around in their lives. Sadly no such views are voiced or endorsed by those who seek for their own reasons, to redefine recovery, and in doing deliberately avoid mentioning either addiction or dependency, because to do so would expose the fact that their views are not in the best interests of those who are addicted, and are mentally and physically capable of achieving sobriety, rather than the necessary purgatory of abstinence.

If, as it appears the NTA have used tax payers money to publish and endorse the views of those who want to redefine recovery, this writer is of the opinion that it is not merely a case of misuse of taxpayers money, but a gross abuse, and whoever authorised the use of taxpayers money to advance the causes of a privately funded organisation is, to coin a phrase, ‘unfit for purpose’.

[domlingus]

If the UKDPC definition of recovery is intended to include recovery from addiction, it has fallen at the first hurdle, since a defining characteristic of that condition, is an inability to control use. It would therefore be helpful if they would confirm that their definition of recovery does not extend to those who are addicted, or as it is more commonly referred to 'dependent., in accordance with the criteria stipulated in ICD-10