Physical Health in Long-term Addiction Recovery

The threats to health that accrue during active addiction have been widely communicated in the popular media and in the scientific literature. But how does the health of people in recovery from addiction compare to the health of those who have not experienced such challenges? The answer to that question has remained something of a mystery, but results of a health survey recently published in the Journal of Psychoactive Drugs outlines findings of import to every addiction professional (White, Weingartner, Levine, Evans, & Lamb, 2013). While one might assume that physical and emotional health rapidly improves following recovery initiation and stabilization, the results of this latest survey reveal a much more complex and ominous picture. In this article, we will outline the major findings of this study and discuss its clinical and policy implications.

The Philadelphia Recovery and Health Survey  

In 2010, the Philadelphia Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) contracted with the Public Health Management Corporation (PHMC) to incorporate recovery-focused items into PHMC’s 2010 Southeastern Pennsylvania (SEPA) Household Health Survey of Philadelphia and four surrounding counties. The survey results revealed a recovery prevalence rate in the adult population of 9.45 percent (11.4 percent for Philadelphia and 7.5 percent in the four surrounding counties)—recovery defined in the survey as once having but no longer having an alcohol or drug (AOD) problem. This recovery prevalence rate is comparable to national surveys that have reported rates of remission from substance use disorders, meaning the percentage of adults who meet lifetime criteria for a substance use disorder but did not meet such criteria in the past year (Compton, Thomas, Stinson, & Grant, 2007; Dawson 1996; Dawson et al., 2005; Dawson, Stinson, Chou, & Grant, 2008; Hasin & Grant 1995; Hasin, Stinson, Ogburn, & Grant, 2007; Hasin, Van Rossem, McCloud, & Endicott, 1997; Kessler et al., 1994; Robins, Locke, & Regier 1991; see White, 2012 for review). The Philadelphia and national studies confirm the presence of a large population of people—more than twenty million in the US—who have resolved a significant AOD problem. This large population of people quietly and invisibly living out their lives in long-term recovery defies the pessimism about addiction recovery fueled by the media obsession with celebrities recycling through rehab or dying of drug overdoses.  

More troubling within the survey findings was the health profile of people in recovery. In the Philadelphia survey, people in recovery, compared to citizens not in recovery, were twice as likely to describe their health as poor, and they reported higher rates of asthma, diabetes, high blood pressure, obesity, and past-year emergency room visits. They were also more likely to report lifetime smoking (82 percent vs. 44 percent), current smoking (50 percent vs. 17 percent), exposure to smoke in their residence, no daily exercise, and eating fast food three or more times per week. In terms of resources to address health concerns, people in recovery compared to the general population reported greater family/social isolation, lower income, less insurance coverage, and less likelihood of past year health screenings, primary health care, and dental care.  

Health Management in Addiction Recovery  

The DBHIDS/PHMC survey was one of the first community population surveys to measure the comparative physical health of people in addiction recovery. Its findings confirm the burdensome legacies that can be brought into the recovery process—legacies that when unattended, can undermine personal health and quality of personal and/or family life for years to come. The findings also reveal the roles, past and present, that nicotine addiction plays in the health problems of people in recovery, and they reveal the limited natural resources available to many people in recovery to address these problems. So what do these findings reveal about the state of professional care for AOD problems in the United States?

At a systems level, they expose a model of care that functions as an emergency room to provide acute biopsychosocial stabilization, but that is not designed to provide long-term health management for people in recovery. The management of other chronic health disorders, such as asthma, diabetes, hypertension, and cancer, is viewed as requiring the management of global health over a prolonged period, if not for life. This would include management of co-occurring medical conditions, diet, exercise, and psychosocial stressors. It is time—no, past time—the treatment of the most severe and complex AOD problems was reconceived in this same way. Such approaches would move beyond brief episodes of symptom amelioration like recovery initiation and diagnostic remission to the promotion of global health and quality of personal, family, and community life in long-term recovery. Of course, that process has already begun in the United States via the shift from models of acute care to models of sustained recovery management. Addiction professionals are playing important leadership roles in these systems transformation processes.

There is a long history of conceptualizing addiction as a medical disorder warranting medical treatment, but individuals and families in addiction treatment in the United States spend very little time with physicians and other medical personnel. The DBHIDS/PHMC survey findings suggest that every person entering recovery should have an ongoing relationship with a primary care physician who is knowledgeable about addiction recovery and who can serve as an ongoing consultant on the achievement and maintenance of health and wellness. It also suggests the need for addiction professionals and recovery support specialists to serve as a source of collateral encouragement and guidance in this long-term health management process. It is time we broadened our vision beyond what we can subtract from people’s lives in the short run to encompass what can be added to enrich those lives in the long term. We envision a day in the not-too-distant future when primary care physicians and other primary healthcare personnel, addiction professionals, and other recovery support specialists will form integrated teams to support individuals and families through the course of long-term addiction recovery. 

At a clinical level, it is also time we defined recovery to encompass smoking cessation. People in self-proclaimed addiction recovery are dying in great numbers not from the addictions that brought them to treatment or to the meeting rooms of mutual aid groups but from their addiction to nicotine. They are dying of the conceptual blindness that sees no contradiction between present nicotine addiction and claimed recovery status. Through our silence, addiction professionals and peers in recovery participate in these deaths—a form of collective enabling for which we will be judged harshly in historical retrospect.  

Measuring Recovery Prevalence and Health  

The DBHIDS/PHMC survey demonstrates how communities can imbed recovery-related questions within local health surveys to measure recovery prevalence by discrete catchment areas like zip codes or census tracts, and to evaluate the health and service needs of individuals and families in addiction recovery. Such survey data can be incorporated into larger processes of recovery resource mapping. In Philadelphia, for example, the vision is to achieve a more strategic allocation of community resources by comparing alcohol and other drug problem indicator data and recovery resource data by city zip code. The goal is to mobilize and sustain needed recovery support resources as close as possible to where such resources are most needed.   Does your local community conduct periodic health surveys? Could you suggest the inclusion of recovery prevalence and health questions within the survey? We would be happy to talk with you about how this was achieved in Philadelphia. 

Closing Reflections   

At a personal level, the Philadelphia recovery survey is a call for each person in recovery to take command of his or her own health. Such ownership includes a physical inventory of the legacies of addiction and making amends for the injuries and neglect inflicted on one’s own body. At a professional level, the Philadelphia survey reinforces the need for assertive health management in long-term recovery and our need as addiction professionals to explore the roles we can best play in this aspect of long-term recovery management. At a systems level, this latest recovery survey underscores the potential for the tri-directional integration of addiction treatment, mental health, and primary health care services aimed at a singular vision: the long-term recovery and wellness of affected individuals and families. Requests for a copy of the full survey results may be sent to bwhite@chestnut.org.

References  

Compton, W. M., Thomas, Y. F., Stinson, F. S., & Grant, B. F. (2007). Prevalence, correlates, disability, and comorbidity of DSM-IV drug abuse and dependence in the United States:  Results from the National Epidemiologic Survey on Alcohol and related conditions. Archives of General Psychiatry, 64(5), 566-576. doi:10.1001/archpsyc.64.5.566

Dawson, D. A. (1996). Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, 20(4), 771-779. doi:10.1111/j.1530-0277.1996.tb01685.x

Dawson, D. A., Grant, B. F., Stinson, F. S., Chou, P. S., Huang, B., & Ruan, W. J. (2005). Recovery from DSM-IV alcohol dependence: United States, 2001-2002. Addiction, 100(3), 281-292. doi:10.1111/j.1360-0443.2004.00964.x

Dawson, D. A., Stinson, F. S., Chou, S. P., & Grant, B. F. (2008). Three-year changes in adult risk drinking behavior in relation to the course of alcohol-use disorders. Journal of Studies on Alcohol and Drugs, 69(6), 866-877.

Hasin, D. S., & Grant, B. F. (1995). AA and other helpseeking for alcohol problems: Former drinkers in the US general population. Journal of Substance Abuse, 7(3), 281-292. doi:10.1016/0899-3289(95)90022-5 

Hasin, D. S., Stinson, F. S., Ogburn, E., & Grant, B. F. (2007). Prevalence, correlates, disability and comorbidity of DSM-IV alcohol abuse and dependence in the United States:  Results from the National Epidemiologic Survey on Alcohol and related conditions. Archives of General Psychiatry, 64(7), 830-842. doi:10.1001/archpsyc.64.7.830

Hasin, D. S., Van Rossem, R., McCloud, S., & Endicott, J. (1997). Differentiating DSM-IV alcohol dependence and abuse by course: Community heavy drinkers. Journal of Substance Abuse, 9, 127-135. doi:10.1016/S0899-3289(97)90011-0

Kessler, R., McGonagle, K, Zhao, S., Nelson, C., Hughes, M., Eshelman, S. & Kendler, K. (1994). Lifetime and 12-month prevalence of DSM-II-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19.

Robins, L. N., Locke, B. Z., & Regier, D. (1991). An overview of psychiatric disorders in America. In L. N. Robins & D. A. Regier (Eds.), Psychiatric disorders in America: The epidemiologic catchment area study. New York: The Free Press.

White, W. L. (2012). Recovery/remission from substance use disorders: An analysis of reported outcomes in 415 scientific studies, 1868-2011. Great Lakes Addiction Technology Transfer Center, Philadelphia Department of Behavioral Health and Intellectual disAbility Services Mental Retardation Services and Northeast Addiction Technology Transfer Center.

White, W. L., Weingartner, R. M., Levine, M., Evans, A. C., & Lamb, R. (2013). Recovery prevalence and health profile of people in recovery: Results of a Southeastern Pennsylvania survey on the resolution of alcohol and other drug problems. Journal of Psychoactive Drugs, 45(4), 287-296. doi:10.1080/02791072.2013.825031