Recovery from Alcohol Use Disorder | NIAAA

Currently, there is no agreed upon definition of the term "recovery" within the alcohol treatment literature. The effectiveness of treatment programs is typically evaluated based primarily on assessment of alcohol consumption, or reduction in drinking frequency and problem severity, but several treatment modalities view abstinence from drinking as a requisite criterion for recovery. The recovery process also signifies numerous lifestyle and biological changes (physical health) that are difficult to operationalize. It is critical that researchers and treatment providers develop a formal definition of recovery that has consensus among a wide group of those in recovery as well as those treating it. Thus, it is important to engage in research and clinical efforts that provide a foundation for operational definitions of recovery that reflect this process in order to improve our conceptualization of recovery. The development of more formal definitions of recovery will be of considerable interest to policymakers, who make decisions pertaining to quality of care for AUD services. 

In response, the Treatment, Health Services, and Recovery Branch (THSRB) within the Division of Treatment and Recovery (DTR) at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed a formal conceptual and operational definition of recovery for the alcohol treatment and recovery field (see below). On September 20, 2020, NIAAA hosted a virtual roundtable to present the conceptual and operational components of the NIAAA recovery definition, including presentations and discussion from senior-level NIAAA recovery-based researchers focused on critically evaluating the proposed definition. Specific emphasis was placed on conceptualizing and measuring alcohol use and quality of life, remission and the clinical practice challenges associated with defining recovery. 

NIAAA Recovery Research Definitions

What is the definition of recovery from Alcohol Use Disorder (AUD)?

Recovery from AUD

Recovery is a process through which an individual pursues both remission from alcohol use disorder (AUD) and cessation from heavy drinking1. An individual may be considered “recovered” if both remission from AUD and cessation from heavy drinking are achieved and maintained over time. For those experiencing alcohol-related functional impairment2 and other adverse consequences, recovery is often marked by the fulfillment of basic needs, enhancements in social support and spirituality, and improvements in physical and mental health, quality of life, and other dimensions of well-being3. Continued improvement in these domains may, in turn, promote sustained recovery.

Remission from DSM-5 AUD

Remission from DSM-5 AUD Remission from alcohol use disorder (AUD), as defined by DSM-5 criteria4, requires that the individual not meet any AUD criteria (excluding craving). Remission from AUD is categorized based on its duration: initial (up to 3 months), early (3 months to 1 year), sustained (1 to 5 years), and stable (greater than 5 years).

Cessation from Heavy Drinking

Cessation from heavy drinking is defined as drinking no more than 14 standard drinks5 per week or 4 drinks on a single day for men and no more than 7 drinks per week or 3 drinks on a single day for women6. Cessation from heavy drinking can be categorized based on the duration: initial (up to 3 months), early (3 months to 1 year), sustained (1 to 5 years), and stable (greater than 5 years).

Notes

1See definitions: “Remission from AUD” and “Cessation from Heavy Drinking”

2Alcohol-related functional impairment varies among individuals and may involve intimate, family, and social relations; financial status; vocational functioning; legal affairs; and residence/living arrangements.

3Self-care, personal growth, subjective experiences (e.g., happiness), engagement in community, concern for others

4DSM-5 Criteria for AUD Diagnosis

  • Consumed more alcohol or spent more time drinking than intended.
  • Want to limit or halt alcohol use but haven’t succeeded.
  • Spends an inordinate duration drinking, being ill and undergoing the after-effects of alcohol use.
  • Strong cravings for alcohol.
  • Consuming alcohol or becoming ill because of it has kept the person from properly attending to household duties and children, or resulted in difficulties performing on the job or at school.
  • Continued drinking in spite of it causing problems with family and loved ones.
  • Discontinue or are only sporadically involved with things that were once enjoyable or important to be able to drink.
  • Have repeatedly been in situations during the consumption of alcohol that have increased the chance of being injured (using machinery, driving).
  • Even though a person feels sad or distressed, or it affects an already existing health problem, the person continues to drink. Or, after episodes of forgetting or going blank about the events during drinking, the individual continues to use alcohol.
  • Have to increase drinking to get the results he/she wants. (The usual amount of alcohol provides little results.)
  • When alcohol wears off, causing symptoms like such as insomnia, difficulty staying asleep, aggravation, nervousness, sadness, stomach upset and nausea and/or perspiring. Or, the person felt items were there, but they are actually not.

5In the United States, one "standard" drink (or one alcoholic drink equivalent) contains roughly 14 grams of pure alcohol, which is found in the following: 12 ounces of beer or 5 ounces of wine or 1.5 ounces of distilled spirits/hard liquor

6The risks associated with different levels of alcohol consumption for health and functioning vary across individuals. Compared to continued heavy drinking, cessation from heavy drinking (as well as other potential significant reductions in heavy drinking) is associated with decreased risk of physical, mental, and functional impairment. Abstinence, however, is considered the safest course, especially in certain subgroups, including, individuals managing medical conditions such as liver disease, bipolar disorder, abnormal heart rhythm, and chronic pain, women who are pregnant or trying to become pregnant, individuals who are taking medications that interact with alcohol, and individuals who cannot maintain a non-heavy drinking level over time.

Virtual Roundtable Discussion of a New NIAAA Research Definition

Sponsored by the Treatment, Health Services, and Recovery Branch (THSRB) within the Division of Treatment and Recovery (DTR) at the National Institute on Alcohol Abuse and Alcoholism (NIAAA)
 
Date of Event: Wednesday, September 30th, 2020 from 12:00 pm to 3:00 pm | 3 hours | Eastern Time (US & Canada)

Agenda for Virtual Recovery Roundtable

AUD Recovery Roundtable Presentation Abstracts

John Kelly, Ph.D.
Recovery Research Institute, Massachusetts General Hospital and Harvard Medical School Departments of Psychiatry

During the past 50 years since the birth of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), much has been learned regarding the etiology, epidemiology, typologies, and prevention and treatment of alcohol use disorder and related health and social problems. Research funding from the NIAAA over these years has led to advances in our understanding of the genetic contributions and neurobiological effects of alcohol addiction and how best to safely detoxify, stabilize, and treat individuals suffering from AUD. In more recent years, given the instability and relapse risk observed in the early months and years of salutary change efforts, there has been growing recognition of the need to understand more fully how people achieve initial and sustained remission and long-term stable recovery. The notion of AUD “recovery” has provided the field with a novel guiding framework, but has proved stubborn to operational definition. It is largely recognized by stakeholders and interested and affected parties, that “recovery” is something more than just remission that is characterized by elements of improved functioning and enhanced quality of life that creates added resilience. Many have attempted to provide multidimensional definitions of the dynamic processes involved “recovery”, but explication and measurement of the component parts has proved challenging. This talk will provide context for the current Zeitgeist and focus on “recovery” within the alcohol and drug use disorder field, and discusses the question of the clinical research utility and challenges involved in arriving at an operational definition that is measurable and testable. 

Stephen A. Maisto, Ph.D.
Syracuse University, Department of Psychology

My initial reaction to NIAAA’s proposed definition of AUD recovery was that it has the potential to advance the field because of its several strengths, including that it is: an attempt to create a standardized definition of recovery that is conceptually-based and easily operationalized; includes a drinking criterion, any heavy drinking, that has been shown empirically to be an improved consumption criterion compared to abstinence per se; and takes the view that recovery is part of the dynamic process of AUD change over time. The field’s reaction likely will be mixed, dependent on stakeholders. The most positive reactions likely will be from researchers for reasons just identified, but other stakeholders, especially the 12-step community, will object to considering quality of life factors more ancillary rather than central to the definition. The definition aligns unevenly with my past research on AUD remission and relapse. It is consistent in considering recovery part of a dynamic change process. Inconsistencies are in using a narrow biomedical conceptual base and including essentially a dichotomous heavy drinking or not criterion as part of the definition. Main areas for further research based on my previous studies include developing the proposed definition toward one that is standardized, multidimensional (biopsychosocial), and easily operationalized, and that features a more nuanced heavy drinking criterion.

Constance Weisner, Ph.D.
Kaiser Permanente

Unhealthy alcohol use and alcohol use disorders are highly prevalent and critical health conditions. As such, addressing the spectrum of alcohol use, problems, disorders, and recovery is fundamental to health care; this is similar to ongoing measurement in health care of other health conditions. As a field, health services research examines how people access health care services, how they use care, and what happens to patients as a result of this care. It studies these from the perspective of patients, as well as clinicians and health policy. This is a highly useful context for studying recovery. Doing so is most efficient by measurement of alcohol use as part of the process of obtaining health care. The definition of recovery as “a process through which an individual pursues both remission from AUD and cessation from heavy drinking is highly relevant to health services.” This presentation addresses the importance of this definition for health systems – the usefulness of measurement and definitions -- how it can be used by clinicians as part of care, as well as for health policy. We discuss why measuring drinking, rather than focusing on AUD is the most important approach for clinical care, as clinicians can see the relationship of changes in drinking to other health outcomes. We discuss what non-drinking outcomes should be a focus of recovery – such as improvements in physical and mental health. For example, clinicians are concerned about changes in drinking that affect other health conditions (e.g., hypertension, diabetes, weight). As health care delivery moves to using electronic health records, we discuss how can they be used to measure remission and recovery and how can they be used to facilitate clinicians addressing alcohol. What is the most important and helpful to them?  To measure drinking and remission over time, how can EHRs be used to develop alcohol registries, and how can registries be used for health services, clinical, and policy research – as well as clinical use – to understand remission and recovery.

Katie Witkiewitz, PhD, 
University of New Mexico

Four decades ago the “controlled drinking” controversy roiled the alcohol field. Data have subsequently accumulated indicating that non-abstinent alcohol use disorder (AUD) recovery is achievable, but questions remain whether it is sustainable long-term. In the current roundtable I will present findings from two clinical trials for alcohol use disorder (AUD), Project MATCH and the COMBINE study, in which we examined whether non-abstinent recovery at three years following AUD treatment was associated with better functioning up to 10 years following treatment. In both studies, recovery was defined by latent profile analyses based on psychosocial functioning and alcohol consumption three years following treatment. Alcohol consumption, mental and physical health, and quality of life measures were assessed up 10 years following treatment. Results indicated four latent profiles at three years following treatment in both studies, characterized by low functioning frequent heavy drinking, low functioning infrequent heavy drinking, high functioning heavy drinking, and high functioning infrequent non-heavy drinking. Latent recovery profiles were significantly associated with outcomes up to ten years following treatment. The two high functioning profiles at three years had the highest level of psychological functioning at ten years post-treatment, regardless of alcohol consumption level. Abstinence at three years did not predict better psychological functioning at ten years. Based on two independent studies we conclude that non-abstinent AUD recovery is possible and is sustainable for up to 10 years following treatment. The current findings align with recent proposals to move beyond relying on alcohol consumption as a central defining feature of AUD recovery.

Jalie A. Tucker, Ph.D., M.P.H.
University of Florida – Gainesville

Historically, recovery research has been conducted from a clinical perspective emphasizing abstinence, and most AUD treatments use a program theory incorporating these assumptions. However, natural recovery is the dominant recovery pathway in the AUD population, and 40 years of natural recovery research has revealed variability in processes and outcomes that remains poorly connected to AUD services. (1) Most individuals with AUD never receive treatment; associations among AUD severity, help-seeking, and recovery are complex; and help-seeking influences are not wholly redundant with behavior change influences. (2) Improved functioning and wellbeing are not highly correlated with drinking practices, indicating that domains for defining recovery require expansion. (3) Low risk drinking is a more common outcome of natural than treatment-assisted recovery attempts, in part because most treatments are abstinence-based. (4) Longitudinal natural recovery research has found that low risk drinking outcomes are associated with distinct variability in drinking practices and monetary spending patterns that increase access to valued non-drinking rewards after initial cessation of heavy drinking. Individuals who achieved stable moderation had distinctive shifts of higher overall value compared to those who abstained or relapsed; this adds to evidence that moderation entails different behavioral regulation processes than abstinence and relapse, which were similar. Overall, natural recovery research highlights the need to consider variability in AUD problem severity, help-seeking, and recovery patterns in defining “recovery,” explicating behavior change mechanisms, and guiding services across the AUD spectrum.

Christine Timko, Ph.D.
Stanford University

This presentation will discuss NIAAA’s definition of recovery in the context of research on 12-step mutual-help organizations, such as Alcoholics Anonymous (AA), and the recovery experiences of AA members. NIAAA’s definition requires remission from alcohol use disorder and cessation from heavy drinking, with improvements in well-being. In keeping with AA’s program of “total abstinence,” AA research has focused on the primary outcome of abstinence as well as mechanisms of behavior change such as social network abstinence support. The experience of recovery described by AA members focuses on sobriety, but also on a spiritual transformation (a radical change in character, identity, and interpersonal relationships) whereby the individual comes to feel peace, joy, and freedom by engaging in constructive activity and practicing acceptance, honesty, and humility (White, 2010). There are overlaps and gaps between NIAAA’s recovery definition, researchers’ operationalization of AA outcomes, and AA members’ recovery experiences.

Her talk will present these approaches and consider how they can align and inform each other, using a framework of measuring change mechanisms and recovery components, examining their associations, and identifying factors associated with increased mechanism levels. There may be common factors associated with increases in mechanisms (e.g., provision of support, goal direction, structure, and monitoring) and change processes that facilitate recovery (e.g., increased self-efficacy, self-confidence, and effective coping skills), as described in both research and lived experience, across 12-step programs, alternative mutual-help organizations, and treatments (Moos, 2007, 2008). The framework also needs to consider that recovery’s definition and determinants vary across populations identified by demographics, alcohol use severity, time in recovery, other aspects of health, and community-environment characteristics. Researchers can use common measurement approaches across studies, while settings such as mutual-help organizations, and populations such as AA members, maintain tailored recovery definitions.