Addicts don’t recover
That’s what I was told once, admittedly a long time ago, on a visit to a service in a different locality. The reasons were twofold according to the addiction worker I was talking to. Firstly this was her observed experience over years of working in the field and secondly, she said, if you don’t accept this you will remain stressed and frustrated in the job.
I’m not sure why she held out so little hope. It could have been the timing. This was well before the first whispers of the recovery movement and before the recovery drugs policy. It could have been burnout. It could have been the result of years of working in a strictly medical, harm reduction model.
However it may have been what Gossop calls the ‘Clinical Fallacy’. This is the phenomenon whereby people moving on to abstinent recovery move out of drug treatment services. Workers don’t get to see visible recovery – instead they get to see people who have deeper problems, who relapse or fail to move on. This reinforces the belief that people don’t recover from addiction.
My gloomy colleague is not on her own in this regard. When David Best asked Welsh addiction workers how many of their clients they thought would eventually recover, they estimated 7%. That was a few years ago and things may have improved in the interim – although when I suggested this to a recovery activist last week, she rolled her eyes. While I think that things are a bit better, I have to agree that therapeutic nihilism is still around. It’s not that long ago since a prominent harm reductionist warned against abstinence and insisted that clients should be told that their chances of achieving it are very low and be warned of the dangers.
So are some right to have low expectations, to cling to the mantra that addicts don’t recover? Well the international evidence base can help to reassure us. The Scottish Government commissioned a review of the evidence base for recovery (Research for Recovery) which was published in 2010. It found that ‘recovery is the norm’.
There are two pieces of work which looked at scientific studies on addiction outcomes. The Center for Substance Abuse Treatment published a review in 2009 which found that:
58% of life-course dependent users of substances will achieve lasting recovery
William White studied this more recently and found that:
in an analysis of 276 addiction follow-up studies of adult clinical samples, the average remission/recovery rate across all studies was 47.6% and in studies published since 2000, this rose to 50.3%
In any area of health care, where outcomes are poor there are always people keen to market optimism. (There has always been a thriving market for alternative therapies in areas such as cancer and serious neurological disease where treatment options are limited.) Therefore the trap of low expectations is episodically interrupted by people who assert that there is room for optimism, that outcomes can be better even if there is not yet evidence to support this. Optimism about addiction is what patients, their families and politicians want to hear. This, by contrast, can lead to the trap of high expectations that can also be self-defeating, promoting resistance and setting patients up for failure. The ethical challenge in treating heroin (and other forms of) addiction is in finding a balance between excessively low and excessively high expectations in clinical practice and in policy.
I think we could agree that an expectation that only 7% of your caseload will eventually recover is likely to represent ‘the trap of low expectations’, but given that it is hard to predict who will do well in abstinence-oriented treatment, what are we to do?
Well, like Jason Schwartz, I wonder how rates would improve if all patients could access the standard and duration of treatment/aftercare that addicted doctors get. If evidence-based, joined-up treatment, using recovery-oriented systems of care were on offer to all then I think we could reasonably expect to see things improve. They might improve further if we all raised the bar on what we believe is achievable for the average client coming for help. Outcomes would almost certainly jump if we embedded recovery at the heart of our services with recovering people visible and volunteering at all parts of the recovery journey. And what if we built strong and wide bridges from treatment to community recovery resources like mutual aid and recovery cafes?
In any case there’s a big gap between the 7% of our clients who we might believe could recover and the 50% plus who do. How are we going to narrow it?