Commentary on Lopez-Quintero et al. (2011): Remission and relapse – the Yin-Yang of addictive disorders

Authors


In their analysis of data from the first wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), Lopez-Quintero and colleagues [1] contribute new information about the comparative likelihood of remission from dependence on four substances of abuse and about predictors of remission. The findings raise a host of issues about the process of remission and relapse. We focus here on two issues: an apparent epidemiologist's illusion about the prevalence and stability of remission and the need to identify psychosocial mechanisms that underlie the yin—yang of remission and relapse.

THE EPIDEMIOLOGIST'S ILLUSION

Clinicians are likely to encounter individuals with severe substance use disorders and a tendency to relapse after temporary remission. Clinicians are unlikely to continue to see individuals who achieve sustained remission. These experiences foster the ‘clinician's illusion’; that is, the belief that a substantial proportion of individuals who remit from substance use disorders eventually relapse [2]. In contrast, epidemiologists are likely to survey individuals with less severe substance use disorders and a high likelihood of remission. Epidemiologists are unlikely to survey individuals highly prone to chronic substance use disorders and relapse, who are disproportionally excluded from community surveys due to refusal to participate, homelessness, institutionalization and mortality [3,4]. Their exclusion can foster an ‘epidemiologist's illusion’; that is, the belief that almost all individuals with substance use disorders achieve ‘life-time remission’.

Several other issues may promote the epidemiologist's illusion. Estimated remission rates can be inflated by lack of information about whether individuals whose dependence ‘remitted’ continued to use the focal substance and, if so, whether they engaged in high-risk use or abuse. Lack of respondent privacy and anonymity also may bolster reported remission rates, especially among individuals who do not wish to disclose continued use of illegal substances [5]. A related issue involves the wording of survey probes. The question in the NESARC ‘about how old were you when you finally stopped having any of these experiences (dependence criteria) with (name of drug)’ may elicit a higher prevalence of remission than the question ‘did any of these experiences with (name of drug) ever stop?’.

Just as clinicians need better information about the proportion of individuals who remit, epidemiologists need to consider the likelihood of unstable remission and relapse due to high-risk use, abuse or dependence after remission [6–8]. In our study of initially untreated individuals with alcohol use disorders, 43% of those who obtained help and achieved 3-year remission were relapsed at a 16-year follow-up. Moreover, 61% of those who achieved 3-year remission without obtaining help were relapsed at the 16-year follow-up [9]. Such findings highlight the need for a longitudinal perspective and specification of a minimum time interval to identify remission that is likely to be stable.

This issue has been addressed in part by the 3-year follow-up of the NESARC cohort itself [10]. Of successfully followed individuals who were dependent on alcohol at wave 1, only 25% were in remission at the 3-year follow-up; 36% were still dependent and 39% were only in partial remission. Moreover, judging by the ns in Tables 3 and 4, the remission rates Lopez-Quintero and colleagues [1] identified at the time of interview appear to be 0.19 for nicotine, 0.42 for alcohol, 0.65 for cannabis and 0.82 for cocaine. It was not clear how the ‘standard actuarial method’ resulted in projected cumulative life-time probabilities of achieving (a period of) remission of 0.87, 0.91, 0.97 and 0.99, respectively; however, these projections probably do not preclude subsequent relapse.

As epidemiologists conduct more prospective, longitudinal studies and clinicians encounter clients with less severe substance use disorders, their illusions may fade to more accurately reflect the varied course of addictive disorders. Consistent with yin—yang, an integration of epidemiologists' and clinicians' perspectives should promote a better understanding of the intertwined processes of remission and relapse.

PSYCHOSOCIAL MECHANISMS

One way to counter illusions about the course of addictive disorders is to identify psychosocial mechanisms that underlie the complementary processes of remission and relapse. In addition to consideration of biogenetic factors, such mechanisms may help to explain the comorbidity among substance use disorders and the higher likelihood of relapse among individuals dependent on two or more substances. In this respect, several related theories specify common social processes that protect individuals from developing substance use disorders and may help to explain their ups and downs [11–13].

These social processes include support, goal direction and structure; rewards that compete with substance use, abstinence-oriented norms and models and the development of self-efficacy and coping skills [11–13]. They appear to underlie the influence of families, friends and social networks, as well as that of treatment and self-help groups, on addictive processes. Epidemiologists and clinicians need to collaborate to determine how these and other common processes affect the yin—yang of addictive disorders and heighten the likelihood of sustained remission and recovery.

Declarations of interest

None.

Acknowledgements

Preparation of this commentary was supported by National Institute on Alcohol Abuse and Alcoholism Grants AA15685 and AA08689, and by Department of Veterans Affairs Health Services Research and Development Service research funds. The authors thank Marcel O. Bonn-Miller, Penny Brennan, Evelyn Bromet and Kathleen Schutte for their helpful comments on an earlier draft of the commentary. The views expressed here are those of the authors and do not necessarily represent those of the Department of Veterans Affairs.

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