Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition

Maisto S.A., Hallgren K.A., Roos C.R., Swan J.E., Witkiewitz K.

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 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) 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).

Witkiewitz K., Wilson A.D., Roos C.R., Swan J.E., Votaw V.R., Stein E.R., Pearson M.R., Edwards K.A., Tonigan J.S., Hallgren K.A., Montes K.S., Maisto S.A., Tucker J.A.

Objective Four decades ago, the controlled controversy roiled the alcohol field. Data have subsequently accumulated indicating that nonabstinent alcohol use disorder (AUD) recovery is achievable, but questions remain whether it is sustainable long-term. This study examined whether nonabstinent recovery at 3 years after AUD treatment is associated with better functioning at 10 years after treatment. Methods Data were from the 10-year follow-up of Project MATCH (New Mexico site only, n = 146; 30.1% female, 58.6% non-White). Recovery was defined by latent profile analyses based on psychosocial functioning and alcohol consumption 3 years after treatment. Drinking practices and consequences, depression, purpose in life, and anger were assessed 10 years after treatment. Distal outcome analyses examined differences in drinking and functional outcomes at 10 years as a function of the 3-year latent profiles. Analyses were preregistered at https://osf.io/3hbxr. Results Four latent profiles identified at 3 years after treatment (ie, low functioning frequent heavy drinkers, low functioning infrequent heavy drinkers, high functioning heavy drinkers, and high functioning infrequent nonheavy drinkers) were significantly associated with outcomes 10 years after treatment. The 2 high functioning profiles at 3 years had the highest level of psychological functioning at 10 years posttreatment, regardless of alcohol consumption level. Abstinence at 3 years did not predict better psychological functioning at 10 years. Conclusions Nonabstinent AUD recovery is possible and is sustainable for up to 10 years after treatment. The current findings align with recent proposals to move beyond relying on alcohol consumption as a central defining feature of AUD recovery.

Witkiewitz K.

Witkiewitz K., Pearson M.R., Wilson A.D., Stein E.R., Votaw V.R., Hallgren K.A., Maisto S.A., Swan J.E., Schwebel F.J., Aldridge A., Zarkin G.A., Tucker J.A.

Background Recent research indicates some individuals who engage in heavy drinking following treatment for alcohol use disorder fare as well as those who abstain with respect to psychosocial functioning, employment, life satisfaction, and mental health. The current study evaluated whether these findings replicated in an independent sample and examined associations between recovery profiles and functioning up to 6 years later. Methods Data were from the 3-year and 7- to 9-year follow-ups of subsamples initially recruited for the COMBINE study (3-year follow-up: n = 694; 30.1% female, 21.0% non-White; 7- to 9-year follow-up: n = 127; 38.9% female, 27.8% non-White). Recovery at 3 years was defined by latent profile analyses including measures of health functioning, quality of life, employment, alcohol consumption, and cannabis and other drug use. Functioning at the 7- to 9-year follow-up was assessed using single items of self-rated general health, hospitalizations, and alcohol consumption. Results We identified 4 profiles at the 3-year follow-up: (i) low-functioning frequent heavy drinkers (13.9%), (ii) low-functioning infrequent heavy drinkers (15.8%), (iii) high-functioning heavy drinkers (19.4%), and (iv) high-functioning infrequent drinkers (50.9%). At the 7- to 9-year follow-up, the 2 high-functioning profiles had the best self-rated health, and the high-functioning heavy drinking profile had significantly fewer hospitalizations than the low-functioning frequent heavy drinking profile. Conclusions Previous findings showing heterogeneity in recovery outcomes were replicated. Most treatment recipients functioned well for years after treatment, and a subset who achieved stable recovery engaged in heavy drinking and reported good health outcomes up to 9 years after treatment. Results question the long-standing emphasis on drinking practices as a primary outcome, as well as abstinence as a recovery criterion in epidemiologic and treatment outcome research and among stakeholder groups and funding/regulatory agencies. Findings support an expanded recovery research agenda that considers drinking patterns, health, life satisfaction, and functioning.

Witkiewitz K., Heather N., Falk D.E., Litten R.Z., Hasin D.S., Kranzler H.R., Mann K.F., O'Malley S.S., Anton R.F.

Aims To examine whether World Health Organization (WHO) risk-level reductions in drinking were achievable, associated with improved functioning and maintained over time among patients at varying initial alcohol dependence severity levels. Design and setting Secondary data analysis of multi-site randomized clinical trials: the US Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study and the UK Alcohol Treatment Trial (UKATT). Participants Individuals with alcohol dependence enrolled in COMBINE (n = 1383; 68.8% male) and seeking treatment for alcohol problems in UKATT (n = 742; 74.1% male). Interventions Naltrexone, acamprosate or placebo, and combined behavioral intervention or medication management in COMBINE. Social behavior network therapy or motivational enhancement therapy in UKATT. Measurements WHO risk-level reductions were assessed via the calendar method. Alcohol dependence was measured by the Alcohol Dependence Scale, the Leeds Dependence Questionnaire and the Diagnostic and Statistical Manual of Mental Disorders. Measures of functioning included alcohol-related consequences (Drinker Inventory of Consequences and Alcohol Problems Questionnaire), mental health (Short Form Health Survey) and liver enzyme tests. Findings One- and two-level reductions in WHO risk levels in the last month of treatment were maintained at the 1-year follow-up [adjusted odds ratio (OR), 95% confidence interval (CI) = one-level reduction in COMBINE: 3.51 (2.73, 4.29) and UKATT: 2.65 (2.32, 2.98)] and associated with fewer alcohol-related consequences [e.g. B, 95% CI = one-level reduction COMBINE: -26.22 (-30.62, -21.82)], better mental health [e.g. B, 95% CI = one-level reduction UKATT: 9.53 (7.36, 11.73)] and improvements in γ-glutamyltransferase [e.g. B, 95% CI = one-level reduction UKATT: -89.77 (-122.50, -57.04)] at the end of treatment, even among patients with severe alcohol dependence. Results were similar when abstainers were excluded. Conclusions Reductions in World Health Organization risk levels for alcohol consumption appear to be achievable, associated with better functioning and maintained over time in both the United States and the United Kingdom.

Witkiewitz K., Tucker J.A.

Kelly J.F., Greene M.C., Bergman B.G., White W.L., Hoeppner B.B.

Alcohol and other drug (AOD) problems are commonly depicted as chronically relapsing, implying multiple recovery attempts are needed prior to remission. Yet, although a robust literature exists on quit attempts in the tobacco field, little is known regarding patterns of cessation attempts related to alcohol, opioid, stimulant, or cannabis problems. Greater knowledge of such estimates and the factors associated with needing fewer or greater attempts may have utility for health policy and clinical communication efforts and approaches.Cross-sectional, nationally representative survey of U.S. adults (N = 39,809) who reported resolving a significant AOD problem (n = 2,002) and assessed on number of prior serious recovery attempts, demographic variables, primary substance, clinical histories, and indices of psychological distress and well-being.The statistical distribution of serious recovery attempts was highly skewed with a mean of 5.35 (SD = 13.41) and median of 2 (interquartile range [IQR] = 1 to 4). Black race, prior use of treatment and mutual-help groups, and history of psychiatric comorbidity were associated with higher number of attempts, and more attempts were associated independently with greater current distress. Number of recovery attempts did not differ by primary substance (e.g., opioids vs. alcohol).Estimates of recovery attempts differed substantially depending on whether the mean (5.35 recovery attempts) or median (2 recovery attempts) was used as the estimator. Implications of this are that the average may be substantially lower than anticipated because cultural expectations are often based on AOD problems being "chronically relapsing" disorders implicating seemingly endless tries. Depending on which one of these estimates is reported in policy documents or communicated in public health announcements or clinical settings, each may elicit varying degrees of help-seeking, hope, motivation, and the use of more assertive clinical approaches. The more fitting, median estimate of attempts should be used in clinical and policy communications given the distribution.

Ashford R.D., Brown A., Brown T., Callis J., Cleveland H.H., Eisenhart E., Groover H., Hayes N., Johnston T., Kimball T., Manteuffel B., McDaniel J., Montgomery L., Phillips S., Polacek M., et. al.

A number of definitions exist for the concept of “recovery” in both the substance use disorder (SUD) and mental health (MH) fields. Previous attempts to define recovery have not reached consensus a...

Witkiewitz K., Wilson A.D., Pearson M.R., Montes K.S., Kirouac M., Roos C.R., Hallgren K.A., Maisto S.A.

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.Secondary analysis of data from a randomized clinical trial.United States.We used data from the out-patient arm of Project MATCH (n = 806; 29.7% female, 22.2% non-white).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.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.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.

Kelly J.F., Abry A.W., Milligan C.M., Bergman B.G., Hoeppner B.B.

The concept of recovery has become an organizing paradigm in the addiction field globally. Although a convenient label to describe the broad phenomena of change when individuals resolve significant alcohol or other drug (AOD) problems, little is known regarding the prevalence and correlates of adopting such an identity. Greater knowledge would inform clinical, public health, and policy communication efforts. We conducted a cross-sectional nationally representative survey (N = 39,809) of individuals resolving a significant AOD problem (n = 1,995). Weighted analyses estimated prevalence and tested correlates of label adoption. Qualitative analyses summarized reasons for prior recovery identity adoption/nonadoption. The proportion of individuals currently identifying as being in recovery was 45.1%, never in recovery 39.5%, and no longer in recovery 15.4%. Predictors of identifying as being in recovery included formal treatment and mutual-help participation, and history of being diagnosed with AOD or other psychiatric disorders. Qualitative analyses regarding reasons for no/prior recovery identity found themes related to low AOD problem severity, viewing the problem as resolved, or having little difficulty of stopping. Despite increasing use of the recovery label and concept, many resolving AOD problems do not identify in this manner. These appear to be individuals who have not engaged with the formal or informal treatment systems. To attract, engage, and accommodate this large number of individuals who add considerably to the AOD-related global burden of disease, AOD public health communication efforts may need to consider additional concepts and terminology beyond recovery (e.g., "problem resolution") to meet a broader range of preferences, perspectives and experiences. (PsycINFO Database Record

Kelly J.F., Greene M.C., Bergman B.G.

Alcohol and other drug (AOD) treatment and recovery research typically have focused narrowly on changes in alcohol/drug use (e.g., "percent days abstinent") with little attention on changes in functioning or well-being. Furthermore, little is known about whether and when such changes may occur, and for whom, as people progress in recovery. Greater knowledge would improve understanding of recovery milestones and points of vulnerability and growth.National, probability-based, cross-sectional sample of U.S. adults who screened positive to the question, "Did you used to have a problem with alcohol or drugs but no longer do?" (Response = 63.4% from 39,809; final weighted sample n = 2,002). Linear, spline, and quadratic regressions tested relationships between time in recovery and 5 measures of well-being: quality of life, happiness, self-esteem, recovery capital, and psychological distress, over 2 temporal horizons: the first 40 years and the first 5 years, after resolving an AOD problem and tested moderators (sex, race, primary substance) of effects. Locally Weighted Scatterplot Smoothing regression was used to explore turning points.In general, in the 40-year horizon there were initially steep increases in indices of well-being (and steep drops in distress), during the first 6 years, followed by shallower increases. In the 5-year horizon, significant drops in self-esteem and happiness were observed initially during the first year followed by increases. Moderator analyses examining primary substance found that compared to alcohol and cannabis, those with opioid or other drugs (e.g., stimulants) had substantially lower recovery capital in the early years; mixed race/native Americans tended to exhibit poorer well-being compared to White people; and women consistently reported lower indices of well-being over time than men.Recovery from AOD problems is associated with dynamic monotonic improvements in indices of well-being with the exception of the first year where self-esteem and happiness initially decrease, before improving. In early recovery, women, certain racial/ethnic groups, and those suffering from opioid and stimulant-related problems appear to face ongoing challenges that suggest a need for greater assistance.

Kelly J.F., Bergman B., Hoeppner B.B., Vilsaint C., White W.L.

Alcohol and other drug (AOD) problems confer a global, prodigious burden of disease, disability, and premature mortality. Even so, little is known regarding how, and by what means, individuals successfully resolve AOD problems. Greater knowledge would inform policy and guide service provision.Probability-based survey of US adult population estimating: 1) AOD problem resolution prevalence; 2) lifetime use of "assisted" (i.e., treatment/medication, recovery services/mutual help) vs. "unassisted" resolution pathways; 3) correlates of assisted pathway use. Participants (response=63.4% of 39,809) responding "yes" to, "Did you use to have a problem with alcohol or drugs but no longer do?" assessed on substance use, clinical histories, problem resolution.Weighted prevalence of problem resolution was 9.1%, with 46% self-identifying as "in recovery"; 53.9% reported "assisted" pathway use. Most utilized support was mutual-help (45.1%,SE=1.6), followed by treatment (27.6%,SE=1.4), and emerging recovery support services (21.8%,SE=1.4), including recovery community centers (6.2%,SE=0.9). Strongest correlates of "assisted" pathway use were lifetime AOD diagnosis (AOR=10.8[7.42-15.74], model R2=0.13), drug court involvement (AOR=8.1[5.2-12.6], model R2=0.10), and, inversely, absence of lifetime psychiatric diagnosis (AOR=0.3[0.2-0.3], model R2=0.10). Compared to those with primary alcohol problems, those with primary cannabis problems were less likely (AOR=0.7[0.5-0.9]) and those with opioid problems were more likely (AOR=2.2[1.4-3.4]) to use assisted pathways. Indices related to severity were related to assisted pathways (R2

Hasin D.S., Wall M., Witkiewitz K., Kranzler H.R., Falk D., Litten R., Mann K., O'Malley S.S., Scodes J., Robinson R.L., Anton R., Fertig J., Isenberg K., McCann D., Meulien D., et. al.

Alcohol dependence is often untreated. Although abstinence is often the aim of treatment, many drinkers prefer drinking reduction goals. Therefore, if supported by evidence of benefit, drinking reduction goals could broaden the appeal of treatment. Regulatory agencies are considering non-abstinent outcomes as efficacy indicators in clinical trials, including reduction in WHO drinking risk levels-very high, high, moderate, and low-defined in terms of mean ethanol consumption (in grams) per day. We aimed to study the relationship between reductions in WHO drinking risk levels and subsequent reduction in the risk of alcohol dependence.In this population-based cohort study, we included data from 22 005 drinkers who were interviewed in 2001-02 (Wave 1) and re-interviewed 3 years later (2004-05; Wave 2) in the US National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol consumption (WHO drinking risk levels) and alcohol dependence (at least three of seven DSM-IV criteria in the previous 12 months) were assessed at both waves. We used logistic regression to test the relationship between change in WHO drinking risk levels between Waves 1 and 2, and alcohol dependence at Wave 2.At Wave 1, 2·5% (weighted proportion) of the respondents were very-high-risk drinkers, 2·5% were high-risk drinkers, 4·8% were moderate-risk drinkers, and most (90·2%) were low-risk drinkers. Reduction in WHO drinking risk level predicted significantly lower odds of alcohol dependence at Wave 2, particularly among very-high-risk drinkers (adjusted odds ratios 0·27 [95% CI 0·18-0·41] for reduction by one level, 0·17 [0·10-0·27] for two levels, and 0·07 [0·05-0·10] for three levels) and high-risk drinkers (0·64 [0·54-0·75] for one level and 0·12 [0·09-0·15] for two levels), and among those with alcohol dependence at Wave 1 (0·29 [0·15-0·57] for one level, 0·06 [0·04-0·10] for two levels, and 0·04 [0·03-0·06] for three levels in very-high-risk drinkers).Our results support the use of reductions in WHO drinking risk levels as an efficacy outcome in clinical trials. Because these risk levels can be readily translated into standard drink equivalents per day of different countries, the WHO risk levels could also be used internationally to guide treatment goals and clinical recommendations on drinking reduction.US National Institute on Alcohol Abuse and Alcoholism, New York State Psychiatric Institute, the Alcohol Clinical Trials Initiative.

Kline-Simon A.H., Litten R.Z., Weisner C.M., Falk D.E.

Treatment for alcohol use disorders (AUDs) has traditionally been abstinence oriented, but new research and regulatory guidelines suggest that low-risk drinking may also be an acceptable treatment outcome. However, little is known about long-term outcomes for patients who become low-risk drinkers posttreatment. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and psychosocial outcomes over 9 years.Study participants were adults with AUDs at treatment entry who received follow-up interviews 6 months posttreatment intake (N = 1,061) in 2 large randomized studies conducted at Kaiser Permanente Northern California, a large private, nonprofit, integrated health system. Six-month drinking status was defined as abstinent, low-risk (nonabstinent, no 5+ drinking days), or heavy drinking (1 or more days of 5+ drinks). Using logistic regression models, we explored the relationship between past 30-day drinking status at 6 months and odds of being abstinent or a low-risk drinker (compared to heavy drinking), and positive Addiction Severity Index psychosocial outcomes over 9 years (9-year follow-up rate of 73%).Abstainers and low-risk drinkers at 6 months had higher odds of recent abstinence/low-risk drinking over 9 years than heavy drinkers; abstainers had better drinking outcomes than low-risk drinkers. Additionally, among those with interview data, 95% of abstainers and 94% of low-risk drinkers at 6 months were abstinent/low-risk drinkers at 9 years; surprisingly, 89% of heavy drinkers at 6 months were also abstinent/low-risk drinkers although still significantly fewer than the other groups. Abstainers and low-risk drinkers at 6 months had better psychiatric outcomes, and abstainers had better family/social outcomes than heavy drinkers; medical outcomes did not differ. Low-risk drinkers and abstainers showed no reliable differences across psychosocial measures.The findings suggest that a low-risk drinking outcome may be reasonable over the long-term for some alcohol-dependent individuals receiving addiction treatment.

Witkiewitz K., Hallgren K.A., Kranzler H.R., Mann K.F., Hasin D.S., Falk D.E., Litten R.Z., O'Malley S.S., Anton R.F.

Alcohol use disorder (AUD) is a highly prevalent public health problem associated with considerable individual and societal costs. Abstinence from alcohol is the most widely accepted target of treatment for AUD, but it severely limits treatment options and could deter individuals who prefer to reduce their drinking from seeking treatment. Clinical validation of reduced alcohol consumption as the primary outcome of alcohol clinical trials is critical for expanding treatment options. One potentially useful measure of alcohol treatment outcome is a reduction in the World Health Organization (WHO, International Guide for Monitoring Alcohol Consumption and Related Harm. Geneva, Switzerland, 2000) risk levels of alcohol use (very high risk, high risk, moderate risk, and low risk). For example, a 2-shift reduction in WHO risk levels (e.g., high risk to low risk) has been used by the European Medicines Agency (2010, Guideline on the Development of Medicinal Products for the Treatment of Alcohol Dependence. UK) to evaluate nalmefene as a treatment for alcohol dependence (AD; Mann et al. 2013, Biol Psychiatry 73, 706-13).The current study was a secondary data analysis of the COMBINE study (n = 1,383; Anton et al., ) to examine the association between reductions in WHO risk levels and reductions in alcohol-related consequences and mental health symptoms during and following treatment in patients with AD.Any reduction in WHO risk drinking level during treatment was associated with significantly fewer alcohol-related consequences and improved mental health at the end of treatment and for up to 1 year posttreatment. A greater reduction in WHO risk drinking level predicted a greater reduction in consequences and greater improvements in mental health.Changes in WHO risk levels appear to be a valid end point for alcohol clinical trials. Based on the current findings, reductions in WHO risk drinking levels during treatment reflect meaningful reductions in alcohol-related consequences and improved functioning.

Minozzi S., La Rosa G.R., Salis F., Camposeragna A., Saulle R., Leggio L., Agabio R.

Gavriel-Fried B., Vana N., Xu T., Kraus S.W.

Abstract Purpose of Review Gambling disorder (GD) presents significant psychiatric challenges, particularly for vulnerable populations like military veterans, who often also face mental health comorbidities. Recovery is a crucial issue in the gambling field, representing a transition from illness to health. Currently, there is no consensus regarding its definition. This scoping review aimed to map the characteristics of studies on recovery in veterans with GD, explore how it is defined and measured, identify the dominate recovery approach, and the main research topics. Recent Findings This review identified 13 scientific articles. Findings showed minimal explicit use of the term “recovery” by researchers. The main recovery approach is the deficit based. Most studies focused on treatment programs and their effectiveness, neglecting the unique characteristics of veterans and alternative recovery pathways.  Summary Future studies should explore and conceptualize recovery in veterans, and inquire into the specific recovery needs of veterans living with GD. 

Fontes R.M., Tegge A.N., Freitas-Lemos R., Cabral D., Bickel W.K.

Moniz-Lewis D.I., Witkiewitz K.

Substance use disorder (SUD) recovery is heterogeneous. Yet, over the last 50 years, substance use treatment providers and researchers have often defined success as sustained abstinence from substance use. An often overlooked but equally valid pathway to recovery for persons with SUD is non-abstinent recovery. However, most of the literature on non-abstinent recovery exists for individuals with alcohol use disorder (AUD) with few studies of non-abstinent recovery for other types of SUD. Literature exploring the mechanisms that lead to non-abstinent recovery is also lacking. As such, the current study aimed to examine recovery profiles for individuals (N = 454) recruited in two randomized clinical trials comparing mindfulness-based relapse prevention with cognitive-behavioral relapse prevention and/or treatment as usual.

Salonen D., O’Donnell A., Jackson K., Hulse S., Crosbie J., Swiers R., Tasker F., Muldowney G., Pickford A., Christie-de Jong F., Kaner E., Holland E.

To address the holistic and continuity of care needs of people who attend North East hospitals frequently for alcohol-related reasons, Recovery Navigator (Navigator) roles were introduced into Alcohol Care Teams in six hospitals in the North East of England, UK, in 2022. The Navigators aimed to provide dedicated holistic support to patients experiencing alcohol harms, starting whilst in the hospital with the potential to continue this beyond discharge. This qualitative study explores the contributions that the Navigators make towards integrated alcohol care. Twenty-five semi-structured interviews were undertaken with 7 patients, 1 carer, and 17 staff. We used reflexive thematic analysis and applied the concept of continuity of care and Self-Determination Theory. The findings suggest that all of the participants value Navigators having dedicated time to work with patients to address their social needs, that patients benefit from having someone who provides relational support and is ‘gently persistent’, and that most of the Navigators have good relationships with community providers and have supported the transition of patients to these services. Staff recognise the challenges of holistic alcohol care in hospitals, and the support of the Alcohol Care Teams and Navigators is seen as invaluable. Navigators help to address gaps in the provision of holistic support for patients who experience significant health inequalities.

Apsley H.B., Lancaster J., Ren W., Brick T., Cleveland H.H.

IntroductionRecovery community centers (RCCs) offer various support services to people in addiction recovery, such as hosting mutual help meetings and sober social activities and providing employment support and recovery coaching. To date, very little is known about RCCs and their relationship with recovery outcomes, as well as how RCCs may vary in helpfulness from visit to visit. This study used a daily diary approach to assess the intraindividual variation of daily RCC helpfulness, and whether RCC helpfulness predicted the holistic recovery indices of daily meaningfulness and recovery identity.Methods and materialsRCC attendees (analytical N = 88) from RCCs in Pennsylvania completed daily diary assessments using a smartphone application, for 10 consecutive days. If participants reported that they had spent time at the RCC that day, they then reported the perceived helpfulness of the RCC visit using 7 items. Participants also reported their daily meaningfulness and recovery identity. Ultimately, participants visited their RCC on 247/799 (30.9%) of all reported study days. Multilevel models were used to assess the hypotheses.ResultsParticipants generally reported that their RCC visits were very helpful (M = 87.13 [scale of 0–100], SD = 13.26). Nearly half of the variation in RCC helpfulness was attributable to intraindividual variation (ICC = 0.51). Multilevel models revealed that both interindividual and intraindividual RCC experiences predicted increased holistic recovery outcomes, over the prior day. Individuals’ mean levels of perceived RCC helpfulness, as well as person-mean-centered RCC daily helpfulness, positively predicted daily meaningfulness and recovery identity.ConclusionRCCs predict the holistic recovery outcomes of meaningfulness and recovery identity outcomes on the particular days that the RCCs are visited, and for the individuals who find RCCs more helpful overall. This study offers preliminary evidence to suggest that RCCs are appropriate recipients of public funding intended to support recovery in US communities.

Luk J.W.

Luk J.W., Ha N.B., Shui A.M., Snyder H.R., Batki S.L., Ostacher M.J., Monto A., Wong R.J., Cheung R., Parekh P., Hua W., Tompkins D.A., Fakadej T., Haight C.G., Liao M., et. al.

AbstractBackgroundAlcohol use disorder (AUD) treatment can help improve clinical outcomes among patients with alcohol‐associated cirrhosis but is underutilized. Among socioeconomically disadvantaged patients with alcohol‐associated cirrhosis, we examined rates of lifetime and past 12‐month AUD treatment utilization and associated demographic and clinical characteristics.MethodsRacial/ethnically diverse patients with alcohol‐associated cirrhosis who had at least one hepatology clinic visit in the prior 6 months were recruited from three Northern California medical centers serving veterans and safety‐net populations. Participants self‐reported their AUD treatment utilization, liver disease quality of life (LDQoL), history and current symptoms of anxiety and depression, and problematic drinking as measured by the Alcohol Use Disorders Identification Test (AUDIT). Clinical measures including liver disease severity were captured from medical records.ResultsAmong 196 participants, the majority were male (88%) with a mean age of 62 years. Two‐thirds of participants (67%) reported ever utilizing AUD treatment and 32% reported utilizing AUD treatment in the past 12 months. Compared with those who did not utilize AUD treatment, participants who utilized lifetime or past 12‐month AUD treatment were younger, had lower LDQoL scores, and had higher scores on current symptoms of anxiety, depression, and problematic drinking. In multivariable analyses, the odds of ever utilizing pharmacological treatment alone or both behavioral and pharmacological treatment (vs. none) were lower with older age or higher LDQoL, and higher among those with a history of anxiety/depressive disorder. For past 12‐month treatment utilization, odds were lower with older age, and higher among those with current clinically significant anxiety/depression or problematic drinking.ConclusionsPatients with alcohol‐associated cirrhosis who were younger or had anxiety/depression and problematic drinking were more likely to utilize AUD treatment. To improve AUD treatment utilization, targeted outreach to patients less likely to receive care and the provision of integrated ALD and AUD treatment is warranted.

Srivastava A.B., Wai J.M.

Currently, available FDA-approved pharmacotherapeutic options for alcohol use disorder (AUD) remain limited. In the case of acamprosate and naltrexone, the proposed therapeutic mechanisms are neurotransmitter-based, and in the case of disulfiram, the putative therapeutic mechanism occurs outside of the central nervous system. As psychiatry moves from neurotransmitter to neurocircuit-based treatments, the treatment of AUD should follow accordingly. This chapter focuses on novel pharmacotherapeutics and their proposed effects on brain circuits involved in AUD and brain stimulation methods, which are also proposed to work through targeting neural systems. The extant literature will be summarized, and future directions in terms of research and treatment will be proposed.

Cabrera M.A., Han B.H.

As it does throughout an individual’s personal history of alcohol use, stigma plays a significant role in one’s experience of recovery. Exploring aspects of stigma can help identify the role and meaning that alcohol has taken in an individual’s life and, thus, what is at stake to be both gained and lost for that person in moving toward recovery. In addition to the practical criteria of symptom remission and heavy drinking cessation, we view recovery as a holistic process of behavioral change and psychological growth toward greater health, wellness, and meaning. This understanding can help guide an effective aftercare plan and the employment of relapse prevention strategies that address the affective, cognitive, behavioral, and physiologic/psychiatric dimensions of recovery over time.

Peng Q., Yang K., Hou Q., Zheng H., Zheng X., Xie G.

Nieder A., Schachter J., Ajayi A.A.

Krentzman A.R., Bowen E.A., Zemore S.E.

Garber M.L., Belisario K., Levitt E.E., McCabe R.E., Kelly J., MacKillop J.

Abstract Aims Structured clinical interviewing is considered the gold standard in psychiatric diagnosis. The Diagnostic Assessment Research Tool (DART) is a novel modularized, non-copywritten, semi-structured interview; however, no studies have examined the psychometric properties of its alcohol use disorder (AUD) module. The primary aims of this study were to: (i) validate the factor structure of the DART AUD module and (ii) examine measurement invariance across several key demographic and subgroup factors. Methods Participants were community members in Hamilton, Canada and Boston, USA who self-identified as making a significant AUD recovery attempt (N = 499). Internal reliability was examined via the Kuder–Richardson 20 statistic, and correlations between symptom count and drinking quantity/frequency were examined. Then, symptom-level data were included in a confirmatory factor analysis to examine model fit of a single hypothesized factor structure. Finally, measurement invariance analyses were conducted for sex, age, ethnicity (White vs. racialized), and study site. Results This study found evidence for adequate internal reliability (rKR20 = 0.75), and symptom scores correlated with drinking quantity and frequency (r = 0.16–0.43). Confirmatory factor analysis results suggested excellent fit for the unidimensional one-factor AUD model (χ2 = 0.09, confirmatory factor index = 0.99, Tucker Lewis index = 0.99, standardized root mean square residual = 0.06, root mean square error of approximation = 0.02). Measurement invariance analyses revealed that the factor structure was equivalent between sex, age, ethnicity, and study site. Conclusions Findings provide strong evidence for the psychometric validity of the DART AUD module and support its use in research and clinical practice. The DART represents a credible alternative to other diagnostic interviewing tools for AUD.

Pasman E., Evans-Polce R.J., Schepis T.S., Engstrom C.W., McCabe V.V., Drazdowski T.K., McCabe S.E.

Objectives Most US treatment and recovery services are abstinence-based. However, many people in recovery from an alcohol or other drug (AOD) use problem do not abstain completely. This study estimated the prevalence of and characteristics associated with nonabstinence among US adults in recovery. Methods Nonabstinence—operationalized as past-month use of alcohol, illicit drugs, or nonmedical use of prescription drugs—was estimated among a sample of 3763 US adults in self-identified recovery from the 2022 National Survey on Drug Use and Health, weighted to be nationally representative. Multivariable logistic regression identified factors associated with nonabstinence. Results An estimated 65.2% (95% confidence interval [CI] = 62.6–67.8) of adults in self-identified recovery reported past-month AOD use. Half (50.8%) reported alcohol use, and one-third (33.2%) reported cannabis use. Females had lower odds of use than males (adjusted odds ratio [AOR] = 0.73, 95% CI = 0.54–0.99), and lesbian/gay-identified individuals had greater odds of use than heterosexual/straight-identified individuals (AOR = 2.39, 95% CI = 1.13–5.07). Greater religiosity (AOR = 0.90, 0.84–0.96) and mutual aid attendance (AOR = 0.16, 95% CI = 0.06–0.27) were associated with lower odds of use. Significant differences were not detected for self-reported health, psychological distress, and other measures of functioning. However, relative to those without a past-year substance use disorder (SUD), odds of nonabstinence were greater among those with one mild (AOR = 14.60, 9.05–23.55), one moderate or severe (AOR = 13.05, 7.06–24.14), and multiple (AOR = 23.33, 10.59–51.37) past-year SUDs. Conclusions Most US adults who self-identified as in recovery from an AOD use problem were nonabstinent. Treatment and recovery services may improve engagement and outcomes by supporting nonabstinent goals.