What is recovery and how do you measure it? It’s contentious; that’s for sure. Recovery aggro is a reality. We could take off our coats and go outside to settle it or we can try to get some sort of consensus.
Abstinence or maintenance
If you align recovery solely with abstinence, you risk losing out on the gains people make earlier on in the journey. Recovery can’t be that exclusive. On the other hand, I once heard a leading light in the addictions field say, ‘if someone reduces crack use to six days a week from using seven days a week, then as far as I’m concerned, that’s recovery.’ Low aspirations aside, that produces another set of difficulties for folk who’ve worked hard to achieve something with more tangible benefits.
There are other unresolved topics in the field including whether there is true opiate-maintained recovery and whether recovery imperatives ‘push’ people into abstinence too soon risking failure. Those concerned about lack of movement in long term opioid-maintained patients would argue that a decade on methadone is hardly ‘too soon’, yet those doing well on ORT may well evidence plenty of recovery landmarks.
We also have the issue that the 12-step mutual aid groups, around since the 1940s in the UK, have historically some degree of ownership of the word recovery and their take on it doesn’t really encompass one day less of crack use a week.
Joanne Neil & colleagues acknowledge these difficulties at the start of a paper which sets out to explore ways of measuring recovery and tries to get a handle on how much professionals in the field agree or disagree with suggested recovery indicators.
The researchers recruited diverse service providers and used online groups to seek their views. Although they came at it with an open mind, it’s clear the authors didn’t expect to get too much agreement on some issues. They were right.
Who made up the groups? Addiction psychiatrists (10); senior residential rehab staff (9) and senior inpatient detoxification staff (6). They were recruited from all over the UK. The authors grilled them by email with questions using the same structured format over three rounds. After the first round they got to hear a bit about others’ views allowing them to reconsider their own, though in the end people pretty much stuck to their original guns, suggesting fairly fixed views.
The groups identified a broad range of parameters of change. What were they?
(1) substance use; (2) treatment/support; (3) psychological health; (4) physical health; (5) use of time; (6) education/training/employment; (7) income; (8) housing; (9) relationships; (10) social functioning; (11) offending/anti-social behaviour; (12) well-being; (13) identity/self-awareness; (14) goals/aspirations; and (15) spirituality.
There were differences between the groups, which weren’t too far from what I might have guessed:
“the addiction psychiatrists did not include changes relating to ‘goals/aspirations’ or to ‘spirituality’; when talking about engaging with treatment and support, the addiction psychiatrists focused on formal/medicalised treatments, the residential rehabilitation staff focused on peer support groups and private therapy, and the detoxification unit staff referred to both formal/medicalised treatment and mutual aid/peer support groups; and when discussing substance use, the detoxification unit staff only included changes relating to abstinence (not harm reduction or reduced drug use as identified by the two other groups).”
There was variation on how the different groups rated, in terms of importance, the different indicators of recovery. Even within groups there was variation. However there was also consensus.
“the only domains not recognised by all three groups were ‘treatment/support’ and ‘spirituality’ (both only identified by residential rehabilitation staff) and ‘goals/aspirations’ (not highlighted by the addiction psychiatrists).”
The authors indicate that recovery is more than just reducing or stopping substance use, but that measuring it remains hard because it’s hard to get agreement on what to measure. What do they think it means?
“Ultimately, this must raise the question of whether producing a comprehensive single measure of recovery is possible or even desirable.”
They go on:
“It will be necessary to find innovative ways of measuring recovery that are psychometrically robust but also flexible enough to allow individuals experiencing addiction to identify their own needs, make choices about the support they receive, and pursue personally meaningful recovery outcomes.”
Recovery aggro – abstinence
There are challenges in my mind that I have yet to resolve and it brings me full circle. How do we value gains in treatment that don’t tick too many recovery indicators while at the same time avoiding the diminishment of harder gains like enduring abstinence? If one day less crack a week is really recovery, the bar feels very low. We also still have authorities who feel that moving on from opioid replacement is too dangerous and methadone should really be for life in most cases.
I agree that recovery needs to be more than abstinence. I quite like the phrase (was it Phil Valentine’s?), ‘You are in recovery if you say you are.’ However we have evidence that abstinence plays an important part in the minds of clients coming to treatment for help. We cannot really avoid talking about abstinence when we talk about recovery, because it’s what a significant number of people want and choice is important.
This means services offering a recovery orientation (i.e. all Scottish services) really do need to take this on board, for in Scotland we have a clear goal for treatment to be recovery-focused and aimed at achieving a drug-free status. As I say, some (maybe many) clients want abstinence, some achieve it and almost all who achieve it value it. If we are to know if services are delivering what the policy calls for, then we can’t get away from the need to measure abstinent recovery. Most of us would want the best outcomes possible for our partners, our parents and our children if they were to become addicted. Do our clients deserve any less?
Neale, J., Finch, E., Marsden, J., Mitcheson, L., Rose, D., Strang, J., Tompkins, C., Wheeler, C., & Wykes, T. (2014). How should we measure addiction recovery? Analysis of service provider perspectives using online Delphi groups Drugs: Education, Prevention, and Policy, 1-14 DOI: 10.3109/09687637.2014.918089