Whenever a celebrity is arrested, overdoses, or dies from drugs or alcohol, there is usually renewed media interest in addiction. Most of the time, this means that experts on substance use disorders are interviewed, particularly those of us who have some experience treating high-profile addicts. Often they will interview a substance abuse counselor about what really goes on in drug counseling. The coverage usually addresses the same general principles:
Addiction is a disease, not a free choice.
Treatment, rather than incarceration, is the best choice.
Wealth and privilege tend to insulate some people from having to face the truth about their condition, but the basic principles of treatment are the same.
Treatment really works, and people do get well.
But the recent tragic overdose death of Phillip Seymour Hoffman, whom many have noted was reportedly abstinent from alcohol and drugs for over two decades, raises another set of important questions:
Do people who get sober actually stay sober?
Can’t you ever be free of addiction? Are you always at risk of relapse?
Is there some period when, like cancer, you are considered to be “cured”?
Isn’t staying sober for a long time at least somewhat protective?
In my experience treating thousands of addicts, I’ve learned that cases like these can often diminish hope and create a perception that these conditions aren’t treatable, or that addicts can never be trusted. When is an addict or alcoholic sober long enough to be considered at least relatively safe? Do most people with addiction who have been sober a long time eventually relapse? In scientific terms, what is the natural history of recovery from alcohol and drug addiction?
I’ve seen numerous experts speak up in the wake of Hoffman’s death, but few have offered hard science on what we really know about how a person’s duration of sobriety is related to their chances of being sober in the subsequent years. Fortunately, there are data to support the idea that recovery is durable, and that the vast majority of people who stay sober for a long time will continue to stay sober afterwards.
The most thorough attempt to understand what happens to addicts and alcoholics who stay sober is an eight-year study of nearly 1200 addicts. They were able to follow up on over 94% of the study participants, and they found that extended abstinence really does predict long term recovery. Some takeaways from this research are:
Only about a third of people who are abstinent less than a year will remain abstinent.
For those who achieve a year of sobriety, less than half will relapse.
If you can make it to 5 years of sobriety, your chance of relapse is less than 15 percent.
Of course, there are many people with 10, 20, 30 or even 40 years of abstinence. What happens to these people over time? Does the relapse rate stay low, or does the relapse rate bump up later? The truth is, we simply don’t know. The number of people with long-term sobriety who are subject to this type of research is very small. There isn’t much money in studying long-term abstinent addicts and alcoholics…most of the research is focused (appropriately, I might add) on helping people achieve and maintain sobriety.
When I lectured the patients at Hazelden on addiction, I would often ask for a show of hands of people who had been sober longer than 20 years and then relapsed. Of course, this is a biased sample: patients in a residential treatment center. The lectures generally had over 200 attendees, but only 1 or 2 at most ever admitted to having such long duration sobriety in the past. My experience is that people with decades of abstinence clearly can and do relapse, but the incidence is very low. Like Hoffman and many others, it’s always heartbreaking when it happens. I’ve seen it triggered by opiate prescriptions, acute pain and other life stressors. Often the people who relapse have stopped engaging in the recovery-oriented practices that served them well during their earlier sobriety. We certainly need to learn more about what factors protect such people from relapse, and what factors predispose them to returning to addictive use.
Every death from addiction is tragic. But cases like Hoffman’s are definitely the exception and not the rule.
Copyright Omar Manejwala, M.D. 2013.