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An Eight-Year Perspective on the Relationship Between the Duration of Abstinence and Other Aspects of Recovery

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  • Chestnut Health Systems, Normal, IL, United States

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Using data from 1,162 people entering treatment and followed up (> 94%) for 8 years, this article examines the relationship between the duration of abstinence (1 month to 5 or more years) and other aspects of recovery (e.g., health, mental health, coping responses, legal involvement, vocational involvement, housing, peers, social and spiritual support), including the trend and at what point changes occur. It also examines how the duration of abstinence at a given point is related to the odds of sustaining abstinence in the subsequent year. The findings demonstrate the rich patterns of change associated with the course of long-term recovery.
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Evaluation Review
DOI: 10.1177/0193841X07307771
2007; 31; 585 Eval Rev
Michael L. Dennis, Mark A. Foss and Christy K. Scott Duration of Abstinence and Other Aspects of Recovery
An Eight-Year Perspective on the Relationship Between the
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An Eight-Year Perspective
on the Relationship
Between the Duration
of Abstinence and Other
Aspects of Recovery
Michael L. Dennis
Mark A. Foss
Christy K. Scott
Chestnut Health Systems, Chicago and Bloomington, Illinois
Using data from 1,162 people entering treatment and followed up (>94%) for
8 years, this article examines the relationship between the duration of absti-
nence (1 month to 5 or more years) and other aspects of recovery (e.g., health,
mental health, coping responses, legal involvement, vocational involvement,
housing, peers, social and spiritual support), including the trend and at what
point changes occur. It also examines how the duration of abstinence at a
given point is related to the odds of sustaining abstinence in the subsequent
year. The findings demonstrate the rich patterns of change associated with the
course of long-term recovery.
Keywords: alcohol; drug; addiction; recovery; life course
1. Introduction
1.1 Problem and Research Questions
Although substance use disorders are increasingly recognized as chronic
relapsing conditions that often span decades and require multiple episodes of
treatment and/or self-help (Anglin, Hser, and Grella 1997; Anglin et al. 2001;
Dennis, Scott et al. 2003; Dennis and Scott [in press]; Hser et al. 1997; Hser
et al. 2001; McAweeney et al. 2005; McLellan et al. 2000; Moos and Moos
2005, 2006; Scott, Foss, and Dennis 2005a, 2005b; Simpson, Joe, and Broome
2002; Vaillant 1988; Weisner, Matzger, and Kaskutas 2003; White 1996),
approximately 60% of the people with lifetime substance disorders do even-
tually reach a state of sustained abstinence (Cunningham 1999a, 1999b;
Evaluation Review
Volume 31 Number 6
December 2007 585-612
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Dawson 1996; Dennis et al. 2005; Kessler 1994; Robins and Regier 1991).
This has led to multiple calls to define and better understand and study “recov-
ery” in terms of not only abstinence but improvements in health, mental
health, coping, housing, social and spiritual support, illegal activity, and voca-
tional engagement (Betty Ford Consensus Panel [in press]; Laudet, Morgen,
and White 2006; Laudet, White, and Storey [in press]; White 2005). This arti-
cle provides one of the first empirical examinations of how the “duration of
abstinence” from substance use predicts improvements in these other areas.
A life course perspective (Elder 1985) was adopted to guide these analy-
ses. This approach has proven useful in examining changes throughout time
related to HIV/AIDS risk behaviors (Corless and Nicholas 2000), crime
(Laub and Sampson 2001; Loeber and LeBlanc 1990; Piquero, Farrington,
and Blumstein 2003; Sampson and Laub 2005), mental health (Pescosolido
and Boyer 1999), and most recently for the course of substance use disorders
(Grella et al. [in press]; Hser et al. 2005; Hser, Longshore, and Anglin 2007
[this issue]; National Institute on Alcohol Abuse and Alcoholism 2006; Rush
et al. [in press] White 2005). Three key concepts embedded in the life course
perspective are turning points, timing, and capital. Turning points are when a
trajectory changes direction; for this article, the focus is on the initiation of
abstinence for at least a month. Timing is important because not everyone
sustains abstinence for the same amount of time. Timing is also relevant
to understanding how long abstinence has to be sustained to see changes in
other aspects of recovery. The term recovery capital is used to reflect resources
that can be accumulated throughout time (e.g., health, mental health, housing,
crime free, employment, strong family and social relations, and life satisfac-
tion) as abstinence is sustained. Whereas most studies organize data around
the turning point of treatment (intake or discharge) and then predict “absti-
nence” at a given time point a few months later, here the data are organized
around the onset and duration of abstinence (up to 8 years) predicting recov-
ery capital at Year 8.
Using data from 1,162 adults living in a large metropolitan area who sought
substance abuse treatment in 1998 and who were subsequently interviewed
586 Evaluation Review
Authors’Note: This article was supported by National Institute on Drug Abuse (NIDA) Grant
DA15523 and used data collected under this grant and the earlier Center for Substance Abuse
Treatment (CSAT) Grant No. TI00664 and Contract No. 270-97-7011. The authors would like
to thank Joan Unsicker and Christopher Roberts for their assistance in preparing the article.
The opinions are those of the authors and do not reflect official positions of the government.
Please address correspondence to Michael L. Dennis, Chestnut Health Systems, 720 West
Chestnut Bloomington, IL 61701; e-mail: Mdennis@chestnut.org.
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annually between Years 2 and 8 (greater than 94% follow-up rate each year),
this study addresses the following four questions:
1. How do health, mental health, and coping vary by duration of abstinence?
2. How do illegal activity, incarceration, employment, and family income vary
by duration of abstinence?
3. How do housing, clean and sober friends, recovery environment, self-effi-
cacy to resist relapse, and social and spiritual support vary by duration of
abstinence?
4. How does the likelihood of sustaining abstinence another year vary by the
duration of abstinence?
The analyses used to answer these questions compare people at Year
8 in terms of the duration of their abstinence (1 to 12 months, 1 to 3 years,
3 to 5 years, and 5 or more years). Given that this is an observational study,
comparisons are made in terms of the baseline, Year 8, and change scores
(i.e., differences within individuals). The latter helps to control for the small
amounts of individual differences at baseline that were observed.
1.2 Expected Impact of the Duration
of Abstinence on Other Aspects of Recovery
Although there are few studies that examine the duration of abstinence,
many studies have explicitly reported on the relationship between absti-
nence (or drug use) and the range of variables at which we are looking.
Below is a short summary.
1.2.1 Health, mental health, and coping. Abstinence is generally associ-
ated with better health, mental health, and coping. Among people in the com-
munity, less substance use is associated with lower rates of chronic health and
psychiatric problems, which are in turn associated with high societal costs
and death (Mokdad et al. 2004). Among people presenting to primary care,
people who are abstinent have approximately only 75% as many health and
mental health conditions as those who are currently using, including arthritis,
headache, lower back pain, depression, and anxiety (Mertens et al. 2003;
Weisner et al. 2003). In treatment settings, the severity of mental disorders is
a significant predictor of who enters treatment, is retained, and relapses (Chi,
Satre, and Weisner 2006; Chi and Weisner [in press]; Dennis et al. 2005;
Rounsaville et al. 1982; Rounsaville et al. 1986; Rush et al. [in press]; Scott
et al. 2005a; Xie, Drake, and McHugo 2006). Abstinence is also associated
Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 587
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with less “avoidance” coping styles, such as cognitive avoidance and emo-
tional discharge, as well as more “approach” coping styles, such as logical
analysis, seeking guidance, problem solving, seeking alternative rewards, and
positive reappraisal (Carpenter and Hasin 1999; Chung et al. 2001; Finney
and Moos 1995; Holahan et al. 2003; Moggi et al. 1999; Moos and Moos
2005). Thus, we expect the duration of abstinence to be associated with
improvements in health, mental health, and coping.
1.2.2 Illegal activity, incarceration, vocational activity, and poverty.
Abstinence has generally been associated with reductions in illegal activity,
incarceration, poverty, and improvements in vocational activity. Reductions
in substance use are associated with relatively rapid reductions in illegal
activity and illegal income (Dismuke et al. 2004; Scott, Foss et al. 2003).
Although this often involves some period of residential treatment or incar-
ceration, such costs are typically offset by reductions in other costs to
society, increased employment, and increased productivity (Bray et al.
2000; French, Salome, and Carney 2002; McCollister and French 2003;
Rajkumar and French 1997; Single et al. 1998). Beyond just use, substance
dependence is also associated with both lower employment rates for both
genders and fewer hours of work for men (Bray et al. 2000). Thus, we
expect the duration of abstinence to be associated with decreased crime and
increased employment and income.
1.2.3 Social and environmental supports. Abstinence is generally associ-
ated with being housed and having some friends, fewer problems in the
recovery environment, and more personal, family, social, and spiritual sup-
port. Days homeless and number of clean and sober friends were two of the
key predictors of both who transitions from using in the community to absti-
nence and who is able to remain abstinent during the course of a 1- to 2-year
period (Scott et al. 2005a). Risks (e.g., substance use among family, friends,
and victimization) and protective factors (e.g., treatment and self-help par-
ticipation, peers in recovery) in the recovery environment and self-efficacy
to resist relapse were also among the major predictors of transitions from
using to recovery and relapse (Humphreys, Moos, and Cohen 1997; Schutte
et al. 2001; Scott et al. 2005b). The general association between relapse and
stress has also been found to be moderated by the extent of support one gets
from self-perceived personal strengths, family, and social peers (Jessor,
Turbin, and Costa 1998, Laudet et al. 2004; Miller 1998; Miller et al. 1996;
Procidano and Heller 1983; Schutte et al. 2001). Thus, we expect the duration
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of abstinence to be associated with reductions in housing problems and envi-
ronmental risk as well as improvements in social and spiritual support.
1.3 Likelihood of Sustaining Abstinence
We found no studies to date using the “duration of abstinence” to predict
the likelihood of sustaining abstinence for another year. However, a recent
extensive review by Moos and Moos (2007) found one or more of four dozen
studies reporting that the odds of sustaining abstinence was positively asso-
ciated with abstinence self-efficacy, approach coping styles, vocational
engagement, income, having clean and sober friends, and having social and
spiritual support and inversely related to an avoidance approach coping style.
A problem with this literature is that most studies only looked at one or two
variables, and across studies, the results were not always consistent. For
instance, although some studies (e.g., Kushner et al. 2005; Somer 2003)
found that the severity of mental disorders was associated with sustaining
abstinence longer, others did not (e.g., Di Sclafani, Finn, and Fein 2007).
Using a multinomial logistic regression on the first 3 years of data from this
study, Scott et al. (2005a) found that the odds of “sustaining recovery another
year” were higher for females, those with more legal involvement, those hav-
ing more clean and sober friends, and weeks of treatment but lower for those
with more treatment episodes or who were homeless. Grella et al. ([in press])
used the first 5 years of data from this study to demonstrate that women were
one third less likely to relapse and that they had a different mix of the above
predictors. Similar findings of women being more likely to sustain abstinence
have also been reported in community outreach programs targeting injection
drug users (Shah et al. 2005). Thus, an evaluation of the extent to which the
likelihood of sustaining abstinence goes up with the duration of abstinence
needs to also consider a wide range of other potential variables in a multi-
variate framework.
2. Method
2.1 Data Source
A cohort of 1,326 adults (85% participation rate) were recruited between
1996 and 1998 from sequential admissions to a network of 22 substance
abuse treatment programs (10 outpatient drug-free programs, 5 intensive
outpatient drug-free programs, 3 methadone maintenance programs, 2
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short-term inpatient programs, 1 long-term inpatient program, and 1 halfway
house) operated in a large metropolitan area (Scott, Foss, and Dennis 2003,
2005a; Scott, Foss, and Sherman 2003a, 2003b; Scott, Muck, and Foss
2000). Follow-up interviews were completed with 94% to 97% of the living
participants at 6 months and 2, 3, 4, 5, 6, 7, and 8 years poststudy enrollment
(99% have one or more interviews; 80% have all eight follow-up inter-
views). Of the 1,162 participants (96% of those living from the original sam-
ple) who completed their 8-year interview, 661 (57%) were dropped because
they were currently using based on self-reported use in the past month or a
positive urine test. The analyses here focus on the remaining 501 (43%) who
were abstinent at least a month. Following recommendations to use all avail-
able information in a longitudinal study (see Kranzler et al. 1994; Kranzler
et al. 1997), data from all interviews and urine tests in all waves were used
to determine the date of last use of any substance (including alcohol,
amphetamines/methamphetamines, barbiturates, cannabis, crack/cocaine,
hallucinogens, heroin/opioids, inhalants, PCP, or other sedatives, hypnotics,
and tranquilizers) or a positive urine test (for amphetamines, cannabinoids,
cocaine, opiates, or phencyclidine). The duration of abstinence was then
calculated (based on the date of the Year 8 interview minus the date of last
use) and categorized into four groups for the second analysis: 232 (46% of
501) with 1 month to 12 months of abstinence, 127 (25%) with 1 year to
3 years of abstinence, 65 (13%) with 3 years to 5 years, and 77 (15%) with
5 or more years of abstinence.
2.2 Participants
2.2.1 Eligibility and informed consent. To be eligible, participants had to
(a) reside in the city of Chicago or declare themselves homeless, (b) report
alcohol or drug use in the past 6 months (or the 6 months before being in a
controlled environment), (c) present for treatment at one of the publicly
funded treatment programs in the study, and (d) be 18 years of age or older.
Individuals who were seeking treatment as a result of a DUI Level 2 or
higher conviction were also excluded because their treatment placement
decisions were typically made outside the treatment system being studied
(i.e., by a court officer). Informed and voluntary consent to participate was
sought under the supervision of the state’s and Chestnut’s Institutional
Review Board. Approximately 85% of all eligible participants agreed to
participate in the parent study.
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2.2.2 Participant characteristics. The first part of Table 1 gives the partic-
ipants’ baseline characteristics by duration of abstinence group. Differences
were tested using the Pearson Chi-square test for categorical variables and the
Wilcoxon-Mann-Whitney rank-order tests for continuous measures; signifi-
cance at α=.05 is based on exact pvalues for both tests. At intake to the
study, participants were mostly African American (89%), female (61%), and
between the ages of 30 to 49 (68%; M=34.1). Most were unemployed
(84%), had never been married (65%), and about half had received a high
school degree or its equivalent (53%). Most had a history of physical (28%),
emotional (39%), and/or sexual (21%) victimization. About 38% considered
themselves homeless, with 12% living on the street or in a homeless shelter
in the 6 months prior to intake. In terms of their substance use severity, they
averaged an age of first use at 16, 14 years of regular use, 16 days of use out
of 30, and 2 prior times in treatment (65% with 1 or more). There was a sig-
nificant difference (p<.05) between the duration of abstinence groups in
the years of use at baseline (14 vs. 14 vs. 13 vs. 16 years of use). The most
common substances used regularly (5 or more of 30 days) were cocaine
(36%), alcohol (27%), heroin (27%), and cannabis (7%). There were signifi-
cant differences between the duration of abstinence groups in terms of the
identification of alcohol problems (24% vs. 28% vs. 19% vs. 40%) and
cocaine problems (31% vs. 35% vs. 42% vs. 52%). Participants self-reported
symptoms suggesting a range of other problems, including major depression
(39%), generalized anxiety disorder (36%), lifetime arrests (78%), lifetime
convictions (53%), lifetime incarceration of 1 or more months (44%), and
currently being on probation or parole (31%). Again, there was a significant
difference between the duration of abstinence groups in terms of the percent-
age with lifetime convictions (57% vs. 58% vs. 46% vs. 34%), lifetime incar-
ceration (50% vs. 43% vs. 37% vs. 31%), and currently being on probation
or parole (37% vs. 29% vs. 32% vs.16%). Given that there are some baseline
differences, it was decided to do the analysis to supplement the Year 8 out-
comes with a change score (i.e., using the individual as his or her own con-
trol and at least partially controlling for baseline differences).
The second part of Table 1 shows the status of the four duration of absti-
nence groups at Year 8 with significant differences in each. Those with shorter
durations of abstinence were significantly more likely to be in substance abuse
treatment (15% vs. 6% vs. 5% vs. 1%) or incarcerated (28% vs. 21% vs. 14%
vs. 5%) and less likely to be in sustained remission (49% vs. 99% vs. 100%
vs. 100%) based on Diagnostic and Statistical Manual of Mental Disorder
(4th ed., text revision; American Psychological Association, 2000).
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592 Evaluation Review
Table 1
Participant Characteristics at Baseline and Year 8
Length of Abstinence at Year 8
30 Days to 1 to 3 to 5 or More
1 Year 3 Years 5 Years Years
Characteristic at Baselinea(n=232) (n=127) (n=65) (n=77)
Race
African American 90 83 90 92
White 4 6 5 4
Other 6 11 5 4
Female 61 58 60 68
Age
18 to 29 35 27 31 17
30 to 49 64 69 66 81
50 and older 2 5 3 3
Unemployment 82 84 85 88
Never married 70 65 71 66
High school degree/GED 54 54 43 56
Lifetime physical abuse 25 28 35 33
Lifetime emotional abuse 38 37 43 39
Lifetime sexual abuse 21 20 25 21
Homeless, self-described 37 32 42 47
Living on the street/homeless shelter 12 13 9 13
Age of first use (in years) 16 16 18 16
Years of regular substance use (in years) 14 14 13 16*
Days of substance use (of 30) (in days) 15 17 16 18
Any prior substance abuse treatment 63 58 75 59
Regular alcohol useb24 28 19 40*
Regular cocaine useb31 35 42 52*
Regular heroin useb28 29 25 23
Regular cannabis useb7738
Major depression 34 41 43 48
Generalized anxiety disorder 35 42 39 48
Arrested, lifetime 82 80 71 71
Conviction, lifetime 57 58 46 34*
Incarcerated, lifetime 50 43 37 31*
On probation/parole 37 29 32 16*
Year 8 statusa
In treatment 15 6 5 1*
Incarcerated 28 21 14 5*
Lifetime dependencec,d 88 94 89 94
Symptoms in past month 3 0 0 0*
(continued)
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2.3 Measurement
2.3.1 Instruments. The assessment package included an augmented
version (Scott et al. 1995) of the Addiction Severity Index (ASI;
McLellan et al. 1992). This instrument spells out the items and response
sets in the ASI (which is semistructured), increases the number of indi-
vidual questions in each content area of the ASI (including questions on
the age of first use, date of last use, treatment history, and current service
use), and includes several scales from the Global Appraisal of Individual
Needs (GAIN) related to substance use disorders, mental distress, and
recovery environment (see Dennis 1999; Dennis, Titus et al. 2003).
Psychometric evaluation of the A-ASI used in this sample demonstrated
good internal consistency (a=.7 or higher) and test-retest reliability (r=.7
or higher) for the ASI composite scores, GAIN, and other measures used
in this analysis (see Scott, Foss, and Dennis 2003, 2005a). Past-year absti-
nence from illicit drug use and alcohol intoxication (the endpoint for the
analyses presented here) demonstrated high test-retest reliability (n=.92)
and was largely consistent with urine test results (Kappa =.56; Dennis
et al. 2005).
To better understand the nature of long-term recovery, this battery was
supplemented further in Year 8 with additional GAIN scales measuring sub-
stance use disorders, recovery environment, spirituality, personal strengths
Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 593
Table 1 (continued)
Length of Abstinence at Year 8
30 Days to 1 to 3 to 5 or More
1 Year 3 Years 5 Years Years
Characteristic at Baselinea(n=232) (n=127) (n=65) (n=77
Symptoms 2 to 12 months, 49 1 0 0
early remission
Symptoms 1 or more years, 49 99 100 100
sustained remission
Note: Unless otherwise noted, all figures are percentages.
a. Statistical test: Pearson chi-square for percentage, Kruskal-Wallis for continuous measures;
exact pvalue.
b. Five or more days of use in the past 30 days.
c. Comparison of lifetime dependence (three or more symptoms) versus abuse/other.
d. Within lifetime dependence, comparison by current course (most recent past-month
abuse/dependence symptoms).
*p<.05.
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594
Table 2
Definitions of Scales, Indices, and Created Measures
Table in Year 8
Scale Name Source Source Items alpha Description
Psychological ASI 3 11 .87 The average of seven past-month types of psychological problems;
Composite Score whether they took prescribed medication in the past month; days
experienced these problems divided by 30 days; a 0 to 4 rating of
how bothered they were by these problems and how important
treatment was for these problems, each divided by 4.
General Mental GAIN 3 21 .94 Count of 21 past 90-day symptoms related to somatic complaints,
Distress Scale depression, anxiety, and suicide.
Logical Analysis CRI 3 6 .82 A cognitive, approach coping style that “attempts to understand and
prepare mentally for a stressor and its consequences.” All CRI
items rated 0 = not at all, 1 = one to two times, 2 = sometimes,
and 3 = often.
Seeking Guidance CRI 3 6 .79 A behavioral, approach coping style that “attempts to seek
& Support information, guidance, or support.”
Cognitive Avoidance CRI 3 6 .79 A cognitive, avoidance coping style that “attempts to avoid thinking
realistically about a problem.”
Emotional Discharge CRI 3 6 .72 A behavioral, avoidance coping style that “attempts to reduce tension
by expressing negative feelings.
Problem Solving CRI 3 6 .86 A behavioral, approach coping style that “attempts to take action to
deal directly with the problem.”
Seeking Alternative CRI 3 6 .81 A behavioral, avoidance coping style that “attempts to get involved in
Rewards substitute activities and create new sources of satisfaction.
Positive Reappraisal CRI 3 6 .87 A cognitive, approach coping style that “attempts to con strue and
restructure a problem in a positive way while still accepting the
reality of the situation.”
Acceptance or CRI 3 6 .76 A cognitive, avoidance coping style that “attempts to react
Resignation to the problem by accepting it.”
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Family Income as http://aspe.hhs.gov/ Table 4 Ratio estimate based on year of observation, family income and size
a Percentage of poverty/poverty at the time of the interview divided by the official Health and
Poverty Line .shtml Human Services guidelines for the same year and family size.
In 2006, the poverty line was $9,800 for a single person and
increased by $3,400 for each additional person in the household.
Percentage of http://aspe.hhs.gov/ Table 4 Dichotomized version of above, with less than 100% equal to 1 or
Families Below poverty/poverty higher equal to 0.
Poverty Line .shtml
Environmental Risk GAIN Table 5 21 .60 Sum of items rating (0 = none, 1 = a few, 2 = some, 3 = most, and
Scale (0 to 84) 4 = all) indicating with how many people the respondent lives,
works, goes to school or hangs out socially with, or were drinking,
using drugs, involved in illegal activities, arguing, or fighting,
as well as (reversed coded) how many were vocationallyengaged,
had been to treatment, or were in recovery.
Perceived Family Procidano and Table 5 20 .93 A measure (count of yes answers) of the extent to which an individual
Support Heller 1983 perceives that his or her needs for support, information, and
feedback are fulfilled by family.
Perceived Social Procidano and Table 5 20 .89 A measure of the extent to which an individual perceives that his or her
Support Heller 1983 needs for support, information, and feedback are fulfilled by friends.
Spiritual Social GAIN Table 5 7 .75 A count of endorsement of items related to spiritual development,
Support Index including identification with an organized religious group, strength
of spiritual beliefs, attendance, and praying.
Perceived Personal GAIN Table 5 10 .79 Count of areas the individual perceives as his or her strengths (e.g.,
Strengths doing well at home, work, with friends, art/performance, sports,
computers, and people).
Self-Efficacy to GAIN Table 5 5 .83 Self-rating 1 = strongly disagree, 2 = disagree, 3 = mixed, 4 = agree,
Resist Relapse 5 = strongly agree) of likelihood of avoiding relapse in different
kinds of situations (e.g., at home, work, with friends, with others
using in front of you).
Note: ASI =Addiction Severity Index; CRI =Coping Response Inventory; GAIN =Global Appraisal of Individual Needs.
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596 Evaluation Review
and self-efficacy to resist relapse, the Perceived Family and Social Support
Scales (Procidano and Heller 1983), and the Coping Response Inventory
(CRI; Moos 1993). Table 2 provides short definition and internal consistency
or reliability of each scale, index, or created measure used in the remaining
tables. Because of inflation and changes in family size during the 8-year time
frame, this includes two measures of the change in poverty using the U.S.
Health and Human Services (HHS) guidelines (http://aspe.hhs.gov/poverty/
poverty.shtml). The first is a percentage of the poverty line adjusting for
family size and year, which ranges in this sample from 0% to 1046%. The
second is the percentage below the poverty line (i.e., where the percentage
of the poverty is dichotomized to less than 100% [1] vs. more [0]). Both are
useful because the distribution is right skewed by a few people making a lot
of money.
2.3.2 Urine screens. Interviews were supplemented with urine
screens, and these data were used to identify who was not abstinent at
Year 8 (dropped from this article) and for the other waves as one of sev-
eral sources for estimating the recency of last use and hence the duration
of use. Of the 1,162 study participants interviewed in Year 8, 782 partic-
ipants were interviewed face to face and asked to provide a urine sample
for testing. Ninety-seven percent (n=759) agreed and 3% refused or
were unable to provide an adequate sample. Samples were checked for
color and temperature, frozen, and then shipped overnight to a Substance
Abuse and Mental Health Services Administration (SAMHSA) National
Laboratory Certification Program–certified laboratory (MedTox: http://www.
medtox.com). The laboratory conducted screenings using kinetic inter-
action of microparticles in solution (KIMS) methodology at the
SAMHSA standard cutoff levels for a panel of five drugs: amphetamines
(1,000 ng/ml), cannabinoids (marijuana/THC; 50 ng/ml), cocaine (300
ng/ml), opiates (2,000 ng/ml), and phencyclidine (PCP; 25ng/ml). The
laboratory also tested for adulteration by checking creatinine levels (less
than 20 ng/ml suggests adulteration or high levels of kidney hydration)
and if below the threshold, the specific gravity (less than 1.003 suggests
dilution). None of the samples showed signs of adulteration. Of the 776
participants tested at Year 8, 77 (10%) denied past-month use but came
up positive on the urine test. As noted earlier, this subset was excluded
from these analyses.
distribution.
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Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 597
2.4 Analytic Procedures
A number of variables were selected to assess various aspects of recovery
that were expected to change as a function of the duration of abstinence.
Given the baseline differences in the group, all variables were tested at base-
line, Year 8, and for changes between baseline and Year 8 (i.e., within par-
ticipants). The outcome variables were typically discreet, bounded (i.e.,
minimum or maximum score or both), and skewed; therefore, the Kruskal-
Wallis (Wilcoxon) rank-order test was used to compare the groups. Exact
estimates of the pvalue for the Kruskal-Wallis test were computed using SAS
9.3 (2005). Cohen’s fstatistic (Cohen 1988) was computed as an effect size
measure of group membership—where f=0.1 is interpreted as a small effect,
f=0.2 as moderate, and f=0.4 or more as large. Where the differences were
statistically significant, trends were described as “increasing,” “decreasing,”
or “having peak at [time period].” The first two terms are used when signifi-
cant trends are increasing or decreasing monotonically or if any slight shift
away from the trend was not statistically significant in pair-wise comparisons
of the adjacent groups. Conversely, the term peak was only used when there
was a change in trend and the peak was significantly different than the adja-
cent groups in pair-wise tests.
3. Results
3.1 Changes in Health, Mental Health, and Coping
Table 3 shows rows for the participants’ status at baseline, Year 8, and
changes in health, mental health, and coping between baseline and Year
8 and columns for the four duration of abstinence groups at Year 8, Cohen’s
effect size f, significance at p<.05 using a Kruskal-Wallis test, and a
symbol describing the significant trends by duration as consistently increas-
ing (Ç), decreasing (È), or a peaking (^) pattern. As noted in the “Method”
section, the first two symbols were used if the numbers were monotonically
increasing or decreasing or if an observed peak in the trend was not signif-
icantly different from its surrounding values using pair-wise testing.
Conversely, the symbol for peak is only used when there was a significant
change in the trend such that the group at the peak was significantly higher
than a preceding group and also higher than a following group in pair-wise
tests at p<.05. For a peak, the maximum period is underlined. At baseline,
there were no significant differences or effect sizes of f.1 across the four
duration groups.
distribution.
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598 Evaluation Review
Table 3
Changes in Health, Mental Health, and Coping by Abstinence
and Duration of Abstinence at Year 8
Length of Abstinence at Year 8a
1 to 12 1 to 3 3 to 5 5 or More
Months Years Years Years
Time (Range) (n=232) (n=127) (n=65) (n=77) fp t
Health
Self-rating of healthb
Baseline (1 to 4) 2.1 2.2 2.2 2.0 .04
Year 8 (1 to 4) 1.8 2.0 1.8 2.0 .15
Change score (–3 to 3) –0.3 –0.2 –0.4 –0.1 .13
Days with health
problems / past 30 days
Baseline (0 to 30) 3.4 3.5 3.6 3.2 .02
Year 8 (0 to 30) 2.1 3.2 1.7 2.2 .11
Change score (–30 to 30) –1.3 –0.3 –2.0 –1.0 .08
ER visits / past 6 months
Baseline (0 to 17) 0.3 0.5 0.6 0.4 .05
Year 8 (0 to 12) 0.3 0.2 0.1 0.1 .06
Change score (–17 to 12) –0.1 –0.4 –0.5 –0.3 .07
Mental Health
ASI Psychological
Composite Score /
past 30 days
Baseline (0 to 1) .17 .20 .22 .17 .07
Year 8 (0 to 1) .07 .13 .08 .04 .11 * Peak
Change score (–1 to 1) –.09 –.07 –.14 –.13 .10
Days of psychological
problems / past 30 days
Baseline (0 to 30) 5.7 7.1 6.0 6.9 .07
Year 8 (0 to 30) 2.5 4.8 3.6 1.5 .10 * Peak
Change score (–30 to 30) –3.1 –2.3 –2.5 –5.4 .07
General mental distress /
past 90 days
Baseline (0 to 21) 5.4 6.3 6.2 6.0 .07
Year 8 (0 to 21) 2.1 2.8 1.7 0.8 .15 * ÈDecrease
Change score (–21 to 21) –3.4 –3.5 –4.5 –5.2 .16
Coping responsec
Logical analysis 10.4 9.9 8.3 8.7 .13 * ÈDecrease
Seeking guidance
and support 10.8 11.4 9.3 8.9 .19 * ÈDecrease
Cognitive avoidance 9.5 8.6 7.4 6.3 .17 * ÈDecrease
Emotional discharge 7.3 7.3 6.3 5.0 .14 * ÈDecrease
distribution.
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Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 599
At Year 8, there were no significant differences in the trends for physi-
cal health by duration of abstinence. Mental health problems, however,
peaked between 1 and 3 years of abstinence, followed by decreases, sug-
gesting improvements in ASI psychological composite scores and days of
psychological problems. Although the GAIN General Mental Distress scale
had a significant downward trend, the slight peak in Years 1 through 3 was
not statistically significant. Use of the first four coping mechanisms (logi-
cal analysis, seeking guidance and support, cognitive avoidance, and emo-
tional discharge) was more common during early abstinence and generally
decreased with time. Thus, it appears that 1 to 3 years of abstinence was
characterized by a slight increase in mental distress and reliance on several
classic coping mechanisms but that as the duration of abstinence increased
(and the number of mental health problems eventually decreased), use of
these coping mechanisms also decreased.
3.2 Changes in Legal and Vocational Activity
Table 4 is organized like Table 3 but shows the baseline, Year 8, and
changes in legal and vocational activity. At baseline, there were no significant
differences across these eight legal and vocational measures. As the duration
of abstinence increased, the days of illegal activity for money and illegal
income decreased significantly. Illegal income actually dropped to 0 after
Table 3 (continued)
Length of Abstinence at Year 8a
1 to 12 1 to 3 3 to 5 5 or More
Months Years Years Years
Time (Range) (n=232) (n=127) (n=65) (n=77) fp t
Problem solving 12.4 12.5 11.3 11.2 .15
Seeking alternative rewards 9.6 10.0 9.2 8.6 .14
Positive reappraisal 12.3 12.1 11.2 10.3 .14
Acceptance and resignation 8.2 8.1 7.4 6.5 .09
Note: ASI =Addiction Severity Index.
a. Summarized with Cohen’s f; * exact p value for α<.05 using Kruskal-Wallis Test, and trend
as described as increasing (Ç), decreasing (È), or has a peak () based on pair-wise testing
(p <.05)—with the maximum period underlined.
b. Self-reported health: 1 =excellent, 2 =good, 3 =fair, and 4 =poor.
c. Measured only at Year 8, each scale goes from 0 to 18.
distribution.
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600 Evaluation Review
a year of abstinence. The small number of days of incarceration in the past 6
months (182 days) decreased significantly from 9.3 days for those abstinent
1 to 12 months to 1.6 days for those abstinent 5 or more years. The increas-
ing duration of abstinence was associated with significantly more days of
work, individual income from employment, and fewer days of financial prob-
lems. To control for inflation and family size during the 8-year period, the last
two sets of rows were determined by dividing the participant’s family income
by the HHS poverty line for the year and their family size (see “Method” sec-
tion for more details). The first row shows the change in the raw ratio (fam-
ily income to year-family-size-based poverty line), and the second shows the
percentage of families below the poverty line (i.e., ratio less than 100%). As
the duration of abstinence increased, family income as the percentage of the
HHS poverty line also increased (f=0.17, p<.05) and a smaller percentage
of families were living below the poverty line (f=0.14, p<.05).
3.3 Changes in Recovery Environment
Table 5 is organized like Tables 3 and 4 but shows the baseline, Year 8, and
changes in housing, friends, and other aspects of the recovery environment.
At baseline, there were no significant differences by duration of abstinence
for days housed or the number of clean and sober friends. At Year 8, the
number of days housed in the community was the lowest in the first 12
months of abstinence and then consistently rose with the duration of absti-
nence. The change in the number of clean and sober friends rose consistently
with the duration of abstinence. At Year 8, the duration of abstinence was
associated with decreased environmental risks and increased social support,
spiritual support, and self-efficacy to resist relapse.
3.4 Sustaining Abstinence
To address the fourth research question (How does the likelihood of sus-
taining abstinence another year vary by the duration of abstinence?), the
data were subsetted to the 482 people abstinent at least a month at the Year
7 interview and categorized into the same four duration of abstinence
groups based on all data available before then. A 0/1 variable was then cre-
ated to indicate if they were able to maintain continuous abstinence from
Year 7 to Year 8 (based on self-reported recency of use, days of use, and
urine test results). No one died in the period and all were re-interviewed
at Year 8, however, 32 people (6.6%) spent more than 11 of the next
12 months incarcerated and were dropped from this analysis. Figure 1
shows how well the duration of abstinence at Year 7 predicted who sustained
distribution.
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Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 601
Table 4
Changes in Legal and Vocational Activity by Abstinence
and Duration of Abstinence at Year 8
Length of Abstinence at Year 8a
1 to 12 1 to 3 3 to 5 5 or More
Months Years Years Years
Time (Range) (n=232) (n=127) (n=65) (n=77) ƒ pt
Legal
Days of illegal activity for
money / past 6 months
Baseline (0 to 180) 11.7 12.6 6.5 6.0 .05
Year 8 (0 to 180) 5.4 0.0 0.0 0.0 .10 * ÈDecrease
Change score (–180 to 180) –6.3 –12.6 –6.5 –6.0 .05
Illegal income / past 6 months
Baseline ($0 to $30,000) $779 $1,174 $450 $434 .04
Year 8 ($0 to $60,000) $555 $0 $0 $0 .07 * ÈDecrease
Change score (–$30,000 to
$60,000) –$224 –$1,174 –$540 –$434 .05 * ÈDecrease
Days of incarceration /
past 6 months
Baseline (0 to 182) 1.0 0.7 0.4 0.3 .07
Year 8 (0 to 182) 9.3 6.7 4.2 1.6 .43 * ÈDecrease
Change score (–182 to 182) 8.3 5.9 3.8 1.3 .41 * ÈDecrease
Vocational
Days worked for pay /
past 30 days
Baseline (0 to 30) 2.7 1.8 2.5 3.4 .05
Year 8 (0 to 30) 6.5 8.8 13.3 13.7 .20 * Increase
Change score (–30 to 30) 3.8 6.9 10.7 10.3 .17 * Increase
Individual employment
income / past 6 months
Baseline ($0 to $30,000) $1,211 $948 $1,068 $1,339 .04
Year 8 ($0 to $72,000) $2,919 $3,128 $5,154 $8,311 .24 * ÇIncrease
Change score (–$18,000 to
$72,000) $1,708 $2,180 $4,087 $6,972 .23 * ÇIncrease
Days without financial
probation / past 30 days
Baseline (0 to 30) 19.7 19.2 21.9 21.1 .06
Year 8 (0 to 30) 9.2 7.4 4.1 4.8 .15 * ÈDecrease
Change score (–30 to 30) –10.6 –11.8 –17.8 –16.4 .15 * ÈDecrease
Family income as a
percentage of poverty lineb
Baseline (0% to 590%) 97.4 89.8 100.3 86.0 .09
Year 8 (0% to 1046%) 75.8 73.2 110.2 134.3 .17 * ÇIncrease
(continued)
distribution.
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602 Evaluation Review
abstinence during the subsequent year. Only 36% of the people with 1 to 12
months of abstinence sustained it, whereas 64% relapsed. Of the individu-
als with 1 to 3 years of abstinence, more than 66% sustained it (Odds Ratio
[OR] =3.4, p<.05). Of those with 3 or more years of abstinence, 86% sus-
tained it (OR =11.2, p<.05). Thus, the odds of sustaining abstinence
improved through the first 3 years and then stabilized.
Next, a logistic regression was used to evaluate how the duration of
abstinence would do with other variables in the model. The years of absti-
nence in Year 7 were entered (OR =1.54 per year of abstinence; 95% con-
fidence interval [CI] =1.37 to 1.74), followed by all baseline variables from
Table 1, and the Year 7 version of the variables from Tables 3 to 5 were then
entered using a step-wise selection (p<.10 in, p>.15 out). With duration
in the model, only “gender” predicted additional variance in who was able
to sustain abstinence (OR =1.76 for being female; 95% CI =1.15 to 2.69).
Females were significantly more likely than males to sustain abstinence fol-
lowing 1 to 12 months of abstinence (40% vs. 31%), 1 to 3 years (75% vs.
54%), and 3 to 5 years (93% vs. 71%) and were similar at 5 or more years
(85% vs. 88%).
Table 4 (continued)
Length of Abstinence at Year 8a
1 to 12 1 to 3 3 to5 5 or More
Months Years Years Years
Time (Range) (n=232) (n=127) (n=65) (n=77) ƒ pt
Change score (–246%
to 892%) –21.6 –16.6 9.9 48.3 .18 * Ç
Increase
Percentage of families below
poverty linec
Baseline (0% to 100%) 65.0 67.7 59.7 68.5 .04
Year 8 (0% to 100%) 74.0 73.4 53.2 50.7 .14 *ÈDecrease
Change score (–100% to 100%) 9.0 5.7 –6.5 –17.8 .10
a. Summarized with Cohen’s f; * exact p value below criterion α<.05 using a Kruskal-Wallis
Test and trend described as increasing (Ç), decreasing (È), or has a peak () based on a pair-
wise testing (p <.05)—with the maximum period underlined.
b. Based on year of interview, family income and size at the time of the interview per the offi-
cial Health and Human Services guidelines (http://aspe.hhs.gov/poverty/poverty.shtml). In
2006, the poverty line was $9,800 for a single person and increased by $3,400 for each addi-
tional person in the household.
c. Dichotomized as less than 100% (1) or higher (0).
distribution.
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Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 603
4. Discussion
4.1 Reprise of Findings
This study demonstrates that duration of abstinence is related to changes
in other aspects of recovery but at different rates and times. With regard to
physical health, it was slightly counterintuitive that health did not improve
with longer periods of abstinence. It may be that a more comprehensive
Table 5
Changes in Housing, Friends, and Recovery Environment by
Abstinence and Duration of Abstinence at Year 8
Length at Abstinence at Year 8a
1 to 12 1 to 3 3 to 5 5 or More
Months Years Years Years
Time (Range) (n=232) (n=127) (n=65) (n=77) fp t
Days housed / past 30 daysb
Baseline (0 to 30) 18.6 19.8 21.5 20.2 .09
Year 8 (0 to 30) 16.9 20.7 25.6 27.1 .45 * ÇIncrease
Change score (–30 to 30) –1.7 1.0 4.0 7.0 .24 * ÇIncrease
Friends who are clean and soberc–126% –85% –38% 7%
Baseline (1 to 4) 2.6 2.5 2.4 2.2 .08
Year 8 (1 to 4) 3.3 3.5 3.5 3.5 .32
Change score (–3 to 3) 0.7 1.0 1.1 1.4 .23 * ÇIncrease
Other (Year 8 only)
Environmental risk (0 to 84) 33.3 30.1 29.5 27.7 .26 *ÈDecrease
Perceived family support
(0 to 20) 15.7 16.2 14.6 16.5 .10
Perceived social support
(0 to 20) 13.6 14.6 14.6 16.2 .18 * ÇIncrease
Spiritual Social Support
Index (1 to 7) 5.4 5.7 6.1 5.9 .19 * ÇIncrease
Perceived personal
strength (1 to 10) 6.2 6.3 6.4 7.1 .12
Self-efficacy to resist
relapse (1 to 5) 3.9 4.0 4.0 4.3 .18 * ÇIncrease
a. Summarized with Cohen’s f; * exact pvalue below criterion α<.05 using a Kruskal-Wallis
Test, and trend described as increasing (Ç), decreasing (È), and peak () based on pair-wise
testing (p <.05)—with the maximum period underlined.
b. Days living in own house, apartment, with friend; that is, not on the street, incarcerated, or
in treatment.
c. Response rate: 0 =none, 1 =a few, 2 =some, 3 =most, and 4 =all.
distribution.
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604 Evaluation Review
measure of health is needed to identify differences. Use of coping mecha-
nisms started out high and decreased as the number of years of abstinence
increased, suggesting that the high rates of these coping strategies previ-
ously reported by others (see Moos and Moos 2007) may actually be a char-
acteristic of early abstinence. Mental health problems peaked during 1 to
3 years of abstinence and decreased thereafter, suggesting the potential
need for both early and ongoing mental health treatment. This also shows
the potential value of changing the perspective of the analysis from treat-
ment outcomes (e.g., Chi and Weisner [in press]) to the duration of absti-
nence (this article). Because people go through multiple episodes of care
“when” they start abstinence, this peak is averaged out and not evident from
the “treatment outcome perspective.” It is not that either is wrong but rather
that they represent different perspectives of a complex problem.
The rapid decrease in illegal activity and illegal income sustained across
varying lengths of abstinence was consistent with the literature given that
many of the crimes were drug related. Following 1 year of abstinence, the
number of days worked and legal income generated significantly increased
and days with financial problems decreased. After 3 years of abstinence,
there were also significant reductions in the percentage of families living
below the poverty line, which indicates continued gains in financial status.
Figure 1
Percent Sustaining Abstinence Through Year 8
by Duration of Abstinence at Year 7
36%
66%
86% 86%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 to 12 months
(n=157; OR=1.0)
1 to 3 years
(n=138; OR=3.4)
3 to 5 years
(n=59; OR=11.2)
5+ years
(n=96; OR=11.2)
Duration of Abstinence at Year 7
% Sustaining Abstinence through Year 8
distribution.
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These findings are consistent with the life course theories about desistence
from crime (Laub and Sampson 2001) that suggest people need to both stop
deviant behaviors and engage in vocational activities. They are also consis-
tent with Laub and Sampson’s warning both to clients and funders about
unrealistic expectations regarding the speed with which people who have
become abstinent will be able to be vocationally engaged and improve their
financial position. Although many expect this to happen almost immedi-
ately, in practice, it is more likely to take several years.
Consistent with the literature, the duration of abstinence was associated
with reduced environmental risks and increased number of clean and sober
friends, level of social support, spiritual support, and self-efficacy to resist
relapse. This is again consistent with both life course work on other socio-
logical changes associated with desistance from crime (e.g., Laub and
Sampson 2001) as well as on the development of “recovery capital” with
time (Laudet et al. [in press]; White 2005).
The odds of sustaining abstinence increased dramatically (OR =11.2)
during the first 3 years and then leveled off. Among people with 5 or more
years of abstinence, there was still some risk of relapse (14%). There was
also evidence of gender differences, with women improving their odds of
staying abstinent faster than men. This is consistent with earlier findings by
Grella et al. (Grella, Scott, and Foss 2005; Grella et al. 2003; Grella et al.
[in press]) that women were more likely to enter and stay in recovery.
4.2 Strengths and Limitations
This study had several strengths, including a large sample size, long-
term follow-up, high follow-up rates, and a wide range of standardized
measures. It is also one of the first to look at how the duration of abstinence
predicts other aspects of recovery. It is, however, important to acknowledge
some of the article’s limitations. The analyses are fundamentally observa-
tional, comparing a retrospective classification of the duration of abstinence
at Year 8 with other aspects of recovery at Year 8. It is possible that 2 years
of abstinence at the beginning of the study has a different kind of effect than
2 years of abstinence at the end of 8 years. It would be useful to see if the
findings can be replicated by allowing the start date of abstinences to vary
and/or when the duration of recovery is experimentally increased, such as
has been done in the Early Re-Intervention (ERI) experiments (Dennis,
Scott et al. 2003; Scott et al. 2005b). Using a change score only partially
controls for the observed differences at baseline. In the future, it would be
useful to reorganize the data based on the initial year of abstinence and
examine change within individuals (as their own control) over time. The
Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 605
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606 Evaluation Review
data here primarily rely on multiple types of self-reports (recency, 6-month
frequency, and 30-day frequency) and annual urine screening. Ideally, it
would be useful to replicate the analyses with more frequent urine moni-
toring and/or other sources of data (e.g., criminal justice system or employ-
ment records). Finally, the sample is from one location (the west side of
Chicago), and all were adults and disproportionately female and African
American relative to the U.S. treatment system. Ideally, it should be repli-
cated in other locations with a more diverse sample.
It is also worth noting that in our previous work, we often broke out
people who were in substance abuse treatment or incarcerated when pre-
dicting 3- to 12-month transition patterns (e.g., Grella et al. [in press]; Scott
et al. 2005a, 2005b). We did not do so here because these groups are usu-
ally small (5% to 10% at any given time) and much more transitory (typi-
cally less than 90 days), they are interventions primarily associated with
attempts to “initiate” abstinence, and they did not predict who “sustained”
abstinence. We did rerun the analysis, dropping from all groups anyone
who had been incarcerated in the past 6 months (about 13% of the sample;
21% of abstinent subsample). This tended to increase the size of the differ-
ence (in the same direction with some additional variables now reaching
significance) in the using versus abstinent analysis but did not change the
substantive finding that those in abstinence were functioning at a higher
level than those still using. For the duration of abstinence variable, it had
little or no impact on anything except the days of incarceration (where the
contrast was reduced). Although it may not affect the findings from this
article, this is probably still an area worthy of further investigation.
4.3 Implications for Practice, Policy, and Research
Consistent with earlier findings that the average person requires three to
four treatment admissions for 8 to 9 years to achieve a year of abstinence
(Dennis et al. 2005), these findings suggest the need for a shift from focus-
ing on acute episodes of treatment to the management of recovery during
longer periods of time. This includes evaluating the impact of improving
our approaches to continuing care, monitoring and ERI, and linkage to
mental health and wraparound services and other sober activities (Dennis
and Scott [in press]).
Although they are only observational, these findings are consistent with
federal policies to increase the integration of mental health services
(SAMHSA 2002) and divert people from the criminal justice system to sub-
stance abuse treatment to reduce long-term crime (National Institute on
distribution.
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Dennis et al. / Duration of Abstinence and Other Aspects of Recovery 607
Drug Abuse 2006). These findings also suggest caution in welfare reforms
designed to get people back into the workforce. Although this evidence
supports the goal, it suggests that the process may face an initial lag and
take several years. This is also consistent with vocational experiments with
clients in long-term methadone maintenance where some people may be
employed, others work ready, others in training or training ready, and some
people who first need help with motivation to prepare them for work
(Dennis et al. 1993; Karuntzos 2002).
Most of the drug abuse treatment research to date has focused on reduc-
ing days of use or abstinence in the first 6 to 12 months after treatment
(Dennis and Scott [in press]; Prendergast et al. 2002). More health services
research is needed on managing long-term recovery, both in terms of how
to deliver it in ways that are both effective and cost effective for multiple
years. This includes research on ways to integrate these other kinds of
services, minimize some of the negative trends (e.g., the early peak in
mental health problems), and accelerate the positive trends (e.g., more pos-
itive recovery environment and vocational activity).
4.4 Conclusion
Although much of the research on substance abuse treatment outcomes
has focused on abstinence in the first 6 to 12 months after treatment, this
article suggests that initial abstinence and the initial time period do not fully
represent the changes associated with long-term recovery. This research
shows that risk of relapse is particularly problematic in the first 3 years of
abstinence and never completely goes away, suggesting the need for pro-
moting strategies and programs that support the long-term management of
recovery.
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Behaviors 11 (4): 308–23.
Anglin, M. D., Y. I. Hser, C. E. Grella, D. Longshore, and M. L. Prendergast. 2001. Drug treat-
ment careers: Conceptual overview and clinical, research, and policy applications. In Relapse
and recovery in addictions, ed. F. Tims, C. Leukefeld, and J. Platt, 18–39. New Haven, CT:
Yale University Press.
distribution.
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Michael L. Dennis, PhD, is a senior research psychologist and the GAIN coordinating center
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Mark A. Foss, PhD, is the senior research analyst in Chestnut Health Systems’ Chicago Office
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and the principal investigator of the Pathways to Recovery Study.
612 Evaluation Review
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... Problematic drug use imposes a significant burden on individuals and societies alike by exacting substantial and lasting physical, psychological, economic, and social costs (2). Successful treatments are elusive and relapse remains prevalent (3,4). Relapse rates vary as a function of substance type (5) but are particularly problematic in the case of stimulant use disorder (SUD) (6) (including [meth]amphetamine and [crack] cocaine). ...
... Predicting drug relapse represents an important first step toward developing better interventions for prevention, but very few measures reliably predict relapse to stimulant use (9). While many physiological, psychological, social, and clinical factors have been associated with the risk of relapse across a broad range of substances (3,5), the role of these factors in relapse to stimulant use is less clear. Since addiction has been associated with alterations in neural circuits (10,11), new neuroimaging methods offer the hope that neural markers related to addiction can be noninvasively measured in humans (12). ...
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Diffusion tractography allows identification and measurement of structural tracts in the human brain previously associated with motivated behavior in animal models. Recent findings indicate that the structural properties of a tract connecting the midbrain to nucleus accumbens (NAcc) are associated with a diagnosis of stimulant use disorder (SUD), but not relapse. In this preregistered study, we used diffusion tractography in a sample of patients treated for SUD ( n = 60) to determine whether qualities of tracts projecting from medial prefrontal, anterior insular, and amygdalar cortices to NAcc might instead foreshadow relapse. As predicted, reduced diffusion metrics of a tract projecting from the right anterior insula to the NAcc were associated with subsequent relapse to stimulant use, but not with previous diagnosis. These findings highlight a structural target for predicting relapse to stimulant use and further suggest that distinct connections to the NAcc may confer risk for relapse versus diagnosis.
... Traditionally, recovery from OUD has been understood as abstinence [12], but likely also involves something beyond mere abstinence, such as improvements in health and wellness [13]. Achieving long-term abstinence from opioids can require both time and multiple efforts [14][15][16], highlighting the complex nature of opioid dependence and the importance of effective treatments. Medication for opioid use disorder (MOUD), with the opioid agonists buprenorphine or methadone, has long been the recommended treatment for opioid use disorders by the World Health Organization [17], and has been shown to reduce illicit opioid use, prevent relapse and reduce mortality [18][19][20][21]. ...
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Background The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time. Methods Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder (15 men, four women, 22–55 years of age) participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used. Findings Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension. Conclusions XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach. Trial registration : Clinicaltrials.gov # NCT03647774, first Registered: Aug 28, 2018.
... 57 However, clinical observations from other studies also showed that treatment outcomes including abstinence, quality of life, health, coping, happiness, and social and family relationships often do not progress smoothly in clients during recovery. 58,59 Manifestations of such symptomatic changes tend to be uneven and dynamic, varying from one person to another and over the course of time. Enhanced coping has been proposed as a core component to a conceptualization of RC 60 to be made a process goal in treatment and recovery. ...
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Purpose Employment and family/social relationships are 2 of the highest priorities among those in substance use recovery. This study examined the relationship of work status with couple adjustment and other recovery capital treatment outcomes among symptomatic alcohol, substance use, and gambling participants ( N = 38) using data collected in a randomized trial comparing a systemic Congruence Couple Therapy (CCT) and individual-based Treatment-as-Usual (TAU). Method Change scores and associations between work status and couple adjustment together with 8 other recovery outcome variables at post-treatment (5 months from baseline) and follow-up (8 months from baseline) in TAU ( n = 17) and CCT ( n = 21) were analyzed. Results Number of those working increased with both CCT and TAU but without reaching significance in either CCT (Cochran’s Q = 5.429, P = .066) or TAU (Cochran’s Q = 2.800, P = .247). Relative to those not working in the combined sample, those working showed significantly improved scores in post-treatment and follow-up in addictive symptoms, couple adjustment, psychiatric symptoms, depression, and life stress. Separating the CCT and TAU groups, similar trend was found in the CCT group but was inconsistent in the TAU group. Conclusion Significantly greater improvement in addictive symptoms and recovery capital of couple adjustment, mental health, and life stress was found in the working vs not-working group. Compared to individual-based TAU, exploratory findings indicate that the systemic treatment of CCT showed a clearer and more consistent difference in improved working days, addictive symptoms and recovery capital. Replication with larger samples is needed to generalize these results.
... The current results also indicated a significant positive association between length of abstinence and recovery capital, which is generally consistent with several prior studies noting the importance of different types of recovery capital (e.g., human, physical, social, cultural) at different points in recovery (Best, Gow, et al., 2012;Best, Honor, et al., 2012;Best et al., 2015;Hillios, 2013;Mawson et al., 2015;van Melick et al., 2013). Of note, while some data exist to suggest that it takes 5 years for recovery to become selfsustaining (Dennis et al., 2007(Dennis et al., , 2005, defining recovery stage by length of abstinence may be problematic as it no longer aligns with our understanding of recovery. Thus, the current study examined a continuous measure of abstinence rather than categorizing individuals into time-dependent recovery stages. ...
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Introduction Research defines recovery capital as the amount of tangible and intangible resources (e.g., human/personal, physical, social, and cultural) available to initiate and sustain recovery from substance use disorders (SUDs). An individual's amount of recovery capital is dynamic over time and influenced by a number of factors such as baseline amount at initiation of recovery/treatment, length of abstinence, access/availability of resources, and individual factors such as the decision to utilize available resources. Research has been proposed delay discounting (DD), which reflects an individual's relative preference for immediate versus delayed rewards, as a candidate behavioral marker for SUDs but has not yet examined it in the context of recovery capital, and DD may be an important aspect of human capital. Thus, the aim of the current study was to examine associations among recovery capital, DD, and length of abstinence. Methods The study included in its analysis data from 111 individuals in recovery from SUDs from the International Quit and Recovery Registry, an ongoing data collection program used to further scientific understanding of recovery. The study assessed recovery capital using the Assessment of Recovery Capital (ARC) and assessed discounting rates using an adjusting-delay task. The study team performed univariate linear regression to examine the relationship between total ARC score and demographic variables, length of abstinence, and DD. The research team performed a mediation analysis to understand the role of length of abstinence in mediating the relationship between DD and ARC score. Results Total ARC score was significantly negatively associated with DD and positively associated with length of abstinence, even after adjusting for covariates. Mediation analysis indicated that length of abstinence significantly partially mediated the relationship between DD and ARC score. Conclusion These findings support the characterization of DD as an important aspect of human capital and a candidate behavioral marker for SUDs. Future research may wish to investigate whether interventions designed to increase the value of future rewards also increase recovery capital.
... The GAP demonstrated early promise in supporting participants in the process of recovery. Addiction recovery is not linear, but rather involves cycles of harm reduction, abstinence, and relapse [37][38][39]. This evaluation identified important incremental measures of PG intervention success for people experiencing poverty and/or homelessness, including engaging with the program, increasing awareness of the harms of gambling, recognizing oneself as a "gambler," moving toward recovery, developing therapeutic relationships, establishing support networks, managing finances, and stabilizing housing. ...
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The burden of harm from problem gambling weighs heavily on those experiencing poverty and homelessness, yet most problem gambling prevention and treatment services are not designed to address the complex needs and challenges of this population. To redress this service gap, a multi-service agency within a shelter setting in a large urban centre developed and implemented a population-tailored, person-centred, evidence-informed gambling addiction program for its clients. The purpose of this article is to report on qualitative findings from an early evaluation of the program, the first designed to address problem gambling for people experiencing poverty and/or homelessness and delivered within a shelter service agency. Three themes emerged which were related to three program outcome categories. These included increasing awareness of gambling harms and reducing gambling behaviour; reorienting relationships with money; and, seeking, securing, and stabilizing shelter. The data suggest that problem gambling treatment within the context of poverty and homelessness benefits from an approach and setting that meets the unique needs of this community. The introduction of gambling treatment into this multi-service delivery model addressed the complex needs of the service users through integrated and person-centered approaches to care that responded to client needs, fostered therapeutic relationships, reduced experiences of discrimination and stigma, and enhanced recovery. In developing the Gambling Addiction Program, the agency drew on evidence-based approaches to problem gambling treatment and extensive experience working with the target population. Within a short timeframe, the program supported participants in the process of recovery, enhancing their understanding and control of their gambling selves, behaviours, and harms. This project demonstrates that gambling within the context of poverty requires a unique treatment space and approach.
Article
Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.
Article
Although the research base around 12-step effectiveness has been grown markedly in recent years, there has also been growth in the broader evidence base around recovery models, and this article reviews three key components: the transition to a social model of recovery; the emergence of a metric of recovery progress, recovery capital focused on building strengths; and multiple pathways to recovery, involving mutual aid groups, recovery community organizations, and access to jobs, friends, and housing. We conclude with an overview of the practical implications for addiction treatment and sustaining the gains made in specialist treatment services.
Article
Mutual-help organizations (MHOs) such as alcoholics anonymous (AA) are the most commonly sought source of help for alcohol and other drug (AOD) problems in the United States. Popularity, however, is not commensurate with efficacy; hence, following a call for more rigorous research on AA and 12-step treatments from the Institute of Medicine in 1990 a flurry of clinical trials, cost-effectiveness analyses, and mechanisms studies, have been published during the past 30 years. This body of work has now revealed the true clinical and public health utility attributable to these freely available resources in aiding addiction remission and recovery. AA, and possibly similar organizations, may be the closest thing public health has to a "free lunch" in terms of their ability to facilitate higher rates and longer durations of sustained remission while substantially reducing health care costs.
Article
While substance experimentation typically begins in adolescence, substance use disorders (SUDs) usually develop in late teens or early adulthood, often in individuals who are vulnerable because of biological and socioeconomic risk factors. Severe SUDs-synonymous with addiction-involve changes in limbic and prefrontal brain areas after chronic drug exposure. These changes involve learned associations between drug reward and cues that trigger the anticipation of that reward (known as incentive salience), as well as heightened dysphoria during withdrawal and weakened prefrontal circuits needed for inhibiting habitual responses.
Article
Purpose The aim of this study was to investigate how the drug use behaviors of addicted individuals have been affected by the regulations imposed due to the coronavirus disease 2019 (COVID-19) pandemic, such as quarantine, social isolation, and social distancing, by examining the factors of individuals with alcohol/substance use disorder, such as their levels and frequency of use, withdrawal process, and cravings before and during the COVID-19 pandemic. Method The sample of the study consisted of 416 individuals who applied to the Green Crescent Consultancy Center (YEDAM), which provides out-patient psychosocial support to alcohol/substance users, such as those using alcohol, substances, and both alcohol and substances. Individuals who applied to the center in the 3 months prior to the COVID-19 pandemic, whose initial examination was conducted, and who had been assessed at least 3 times, were included in the study. A questionnaire was prepared by the authors to examine the addictive behaviors of the individuals during the COVID-19 pandemic. In addition to the survey, the Addiction Profile Index (API) was used. The survey was administered by clinical psychologists. The interviews were conducted by telephone. The individuals who were surveyed consisted of those who had seen and were continuing to see clinical psychologists. Data was collected between May 3rd and 8th, 2020. The data obtained from the questionnaire and from the API forms filled out during the initial application by the individuals were combined. The follow-up phases were categorized and evaluated in 3 different periods. A similar categorization was made for the number of interviews. Comparisons of the addiction characteristics and mental states of those continuing to use alcohol/substances before and during the COVID-19 pandemic and those who did not continue to use, were conducted by evaluating the API sub-scales using the t test. Results The rate of those who said that they did not buy any substances during the COVID-19 pandemic, was 64.4%, while for those who said that they bought it from different sellers during the pandemic was 28.7%. Of those who did not use or infrequently used alcohol/substances before the pandemic, 91% continued to not use alcohol/substances during the pandemic. The rate of those who regularly used alcohol/substances before the pandemic, but discontinued using alcohol/substances or used it less frequently during the pandemic, was 49.1% (N = 52), and those who did not use or infrequently used alcohol/substances before the pandemic, but started to use alcohol/substance regularly, was 9% (N = 28). Conclusion Negative circumstances and a lack of social support were the main factors appeared to have increased substance use during the COVID-19 pandemic. Key health responses, such as following hygiene and social distancing rules and family factors, appear to be protective.
Chapter
Monitoring participants' satisfaction with service components is an important aspect of managing any treatment system, but it is of particular importance when implementing systemic changes of the magnitude proposed in the Chicago Target Cities project. As with any demonstration program, prior to implementation, the extent to which the project's desired goals would be achieved or whether the interventions would have unintended negative effects was unknown. Consequently, during the development phase of the Chicago Target Cities project, several staff members representing treatment programs across the city debated the potential advantages and disadvantages of centralizing intake and controlling access to treatment, as well as the other proposed components of the model.
Chapter
The Chicago Target Cities Project was designed as a system-level change and was implemented primarily with the intent of altering the method by which individuals access publicly funded substance abuse treatment. Although it was not intended to specifically change the treatment services participants received, there were reasons to believe that centralized intake could impact treatment outcomes. It was difficult, however, to predict the direction and intensity of these outcomes, because the existing research had produced contradictory findings (cf. Rohrer et al., 1996; Wickizer et al., 1994).
Chapter
The association between opiate addiction and psychopathology has a long history which is now partially supported by empirical data. For example, opiate addicts have been shown to have high rates of depression (Dorus, 1980; Lehman, 1972; Robins, 1974; Rounsaville, 1979; Steer, 1980; Wieland, 1970; Weisman, 1976), antisocial personality characteristics (Craig, 1979), schizophrenia or schizotypal features (Sheppard, 1969; Hekimian, 1968; Zimmering, 1952), manic symptomatology (Craig, 1979; Flemmenbaum, 1974), and alcoholism (Belenko, 1979). The major problem to date, in the studies of psychopathology in opiate addicts, is the measure of psychopathology which has usually been dimensional symptom or personality scales. Diagnostic techniques, particularly the more recently improved measures, have rarely been applied to the opiate addict (Ling, 1973). The result is that there has been a gap between general psychiatric practice and the treatment of opiate abusers. This gap is reflected in the fact that opiate addicts are usually treated in separate specialty clinics. The isolation of the addict in separate treatment programs and from recent developments in psychiatric diagnostic practice could lead to missed opportunities for useful treatment. For example, the opiate addict who is also bipolar might benefit from lithium, or the addict who is also depressed, might benefit from treatment with a tricyclic antidepressant.
Article
This study examined drinking to cope with distress and drinking behavior in a baseline sample of 412 unipolar depressed patients assessed 4 times over a 10-year period. Baseline drinking to cope operated prospectively as a risk factor for more alcohol consumption at 1-, 4, and 10-year follow-ups and for more drinking problems at 1- and 4-year follow-ups. Findings elucidate a key mechanism in this process by showing that drinking to cope strengthened the link between depressive symptoms and drinking behavior. Individuals who had a stronger propensity to drink to cope at baseline showed a stronger connection between depressive symptoms and both alcohol consumption and drinking problems. (PsycINFO Database Record (c) 2012 APA, all rights reserved)