ReviewRemission from substance use disorders: A systematic review and meta-analysis
Introduction
Substance use disorders (SUDs), including drug and alcohol abuse and dependence, constitute a major public health issue, and cause substantial harm to individuals, families and society (Calabria et al., 2010). According to the World Health Organization, nearly 5% of the total burden of disease involves SUDs; alcohol accounts for 4% and illicit drug use 0.8% (WHO, 2004). Alcohol use is responsible for 3.6% of deaths worldwide, and illicit drug use 0.4% (Whiteford et al., 2015). SUDs are associated with health problems including cardiovascular diseases, cancers, infectious diseases, mental disorders, and with social problems such as domestic violence, criminal negligence, road accidents and suicide (Beck and Richard, 2012, Cullen et al., 2009, Von Laue et al., 2003). In the context of high SUD morbidity and mortality, efforts to improve treatments have proliferated in past decades. Numerous studies have measured outcomes, and confirmed the effectiveness of various treatments, and have demonstrated the value of self-help groups (Gerstein et al., 1997, UKATT Research Team, 2005). A recent review of 415 clinical and population studies published between 1868 and 2011 found that about half of participants had achieved remission from SUDs by final study follow-up periods (White, 2012). However, most studies measured short-term treatment outcomes (12 months), in line with the usual duration of SUD treatment (Arria and McLellan, 2012).
Whether SUDs should be understood and treated as acute or chronic diseases is the critical question that has faced the SUD community as far back as the early 19th century, but particularly in the climate of healthcare reforms since 2000. Unlike acute diseases that are usually severe and relatively short term conditions, chronic diseases are defined as diseases lasting a significant number of years, even the entire lifespan, or as diseases that include multiple episodes of relapse and remission differing in duration and clinical severity. There is no consensus around the number of years of consumption, minimum number of relapses or treatment episodes that an individual must experience in order to be labelled as a chronic SUD patient (Kelly and White, 2011, White, 2012). If SUDs are chronic diseases, then treatment needs to shift from acute to long-term care; and research should focus on longitudinal outcome studies. Many analysts have referred to SUD remission as a “natural process”, occurring after several years of addiction and often without treatment (Biernacki, 1986, Toneatto et al., 1999, Waldorf et al., 1991). This perspective supports the development of acute-care services and short-term outcome studies. Yet SUD duration is shorter and less severe among individuals who achieve remission without treatment; there is also less comorbidity, and fewer risk factors associated with these cases (Sobell et al., 1996, White, 2012). By contrast, other research has described SUDs as chronic relapsing disorders characterized by alternating cycles of remission and relapse of varying duration, but lasting several years (Brecher, 1972, Gossop et al., 2003, Hser et al., 1993, Vaillant, 1973, White et al., 2002). Under these conditions, care would need to be continuous, long-term and of variable intensity. Furthermore, similarities related to symptom recurrence and relapse rates have been identified between SUDs and chronic medical disorders such as type two diabetes, hypertension, and asthma (McLellan et al., 2000). Treatment adherence is also comparable for these populations: fewer than 30% of individuals with chronic medical conditions adhere to health-enhancing behavioral changes, for example, much like individuals with SUDs (McLellan et al., 2000).
Yet SUDs do not evolve inevitably into chronic disorders, nor does research predict with certainty under which conditions chronicity will occur (White and McLellan, 2008). The course of SUDs is highly individual, and is influenced by factors such as age of onset, intensity and duration of the disorder, cycles of remission and relapse, as well as medical and psychiatric status (El-Guebaly, 2012, White and McLellan, 2008). Family help and availability of community or health system resources also influence long-term remission (Bischof et al., 2004, Granfield and Cloud, 1999). A recent study based on syntheses of national epidemiological surveys including representative samples of substance users found that remission rates varied widely according to the primary substance used and whether substance were legal or illegal (Heyman, 2013). Numerous studies have also identified factors that positively affect the courses of SUDs, including gender (female) (Fillmore, 1987, Gomberg, 1995, Hyman et al., 2006, Liu and Kaplan, 1996, O'Brien et al., 2005, Walton et al., 2003, Weisner et al., 2003), age (older) (Chi and Weisner, 2008, Kalaydjian et al., 2009, Tuithof et al., 2013, Weisner et al., 2003), and greater participation in treatment (Best and Lubman, 2012, Dawson et al., 2012, El-Guebaly, 2012, Hser et al., 2015, Hser et al., 2003, Laudet et al., 2002, Nosyk et al., 2013, Xie et al., 2009). Research indicates that the probability of SUD remission also varies according to diagnosis, and is generally better for abuse than dependence (Hasin et al., 1997, Schuckit and Smith, 2011). Furthermore, total abstinence as opposed to controlled substance use is usually reported as more effective in achieving remission (Chi et al., 2011). Even though treatment outcome studies indicate that half or more of individuals achieved remission from SUDs in the short to medium term (Armor et al., 1978, Edwards et al., 1977, Sellman and Joyce, 1996), other research has determined that about a quarter of people with SUDs achieve continuous abstinence over the long term (Vaillant, 1988). How remission is defined, whether in terms of total abstinence or controlled substance use, how the concept is measured (e.g., no SUDs for 6 months, 12 months, or longer), and duration of follow-up (e.g., from 1 to 15 years) have a great influence on SUD outcomes (Dennis et al., 2007). Longer follow-up studies are particularly sensitive to sample retention issues, tending to inflate or under-report SUD remission rates (Simpson et al., 1997).
More accurate and updated information on remission rates and duration of consumption would allow decision-makers to develop services that are more responsive to the diverse needs of SUD populations (Arria and McLellan, 2012). While recent literature on the long-term course of SUDs, including remission rates, provides useful information, the available evidence on SUD trajectories is limited. For example, Hser et al. (2015) dealt specifically with opioid remission rates, whereas Calabria et al. (2010) studied remission rates in illicit drug use, but did not assess duration of consumption or remission in alcohol use disorder (AUD). A narrative review (Finney et al., 2013) reported SUD remission rates and duration of consumption by comparing treated and untreated individuals. The broad objective of our review was to provide a complete portrait of the long-term course of SUDs over the past 15 years. To this end, we undertook the first known systematic review and meta-analysis of studies reporting remission rates from SUDs (including both alcohol and illicit drugs) based on studies published from 2000 to 2015 that examined long-term SUD outcomes in terms of remission rates. The duration of consumption was also examined for studies that provided this information. Finally, potential sources of heterogeneity in remission rates that may explain variation across studies were explored.
Section snippets
Search strategy and study inclusion criteria
This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). We searched Medline, PubMed, EMBASE, and PsycINFO for relevant studies using keywords such as SUDs (abuse, dependence), cohort-specific substance type (e.g., heroin, alcohol), remission, recovery, abstinence, predictors, and long-term follow-up. Manual searches were also conducted in 19 specialized addiction journals selected by experts in the field. Further
General information on retained studies
Fig. 1 presents a flowchart illustrating each stage of the study selection process. Of 8885 potentially relevant studies retained for screening, 119 were selected for full-text assessment, and 21 met the eligibility criteria for the review. The main reason for exclusion was that studies did not provide data on remission rates at the final follow-up. Among the 21 studies included for review, eight also reported duration of consumption before remission. One of the 21 studies used lifetime
Discussion
The present review demonstrated that relatively few studies have documented the course and duration of SUD remission despite awareness that SUDs are, for a significant proportion of patients, “chronic” or long term disorders (American Society of Addiction Medicine (ASAM), 2016, Kelly and White, 2011, McLellan et al., 2000). Only 21 studies published since 2000 met the inclusion criteria, particularly the requirement of a minimum three-year follow-up period. More than half of these studies
Conflict of interest
The authors report no conflicts of interest, including financial interests or affiliations relevant to this manuscript.
Role of funding sources
This study was partly funded by a grant from the National Institute of Excellence in Health and Social Services, Quebec, Canada (Institut National d'Excellence en Santé et en Services Sociaux – INESSS). This funding agency had no role in study design or data collection for this review.
Author contributions
MF and AD were responsible for the development of the research questions, interpretation of data, organization of results, and manuscript writing. AD and MF were also responsible for screening studies and data extraction for the review. CH and GB conducted the meta-analysis, and reported this data in the manuscript. All authors critically reviewed and approved the final manuscript.
Acknowledgments
We would like to thank the funding agency (INESSS). We also wish to acknowledge the work of our advisory committee, as well as the assistance provided by Ms. Maria Chauvet, Dr. Judith Sabetti and Dr. Jean-Marie Bamvita.
References (111)
- et al.
Drop-out from addiction treatment: a systematic review of risk factors
Clin. Psychol. Rev.
(2013) - et al.
Systematic review of prospective studies investigating remission from amphetamine, cannabis, cocaine or opioid dependence
Addict. Behav.
(2010) - et al.
Trajectories of alcohol use over time among adults with alcohol dependence
Addict. Behav.
(2014) - et al.
Patterns of sustained heroin abstinence amongst long-term, dependent heroin users: 36 months findings from the Australian Treatment Outcome Study (ATOS)
Addict. Behav.
(2007) - et al.
Dependent and problem drinking over 5 years: a latent class growth analysis
Drug Alcohol Depend.
(2004) - et al.
The duration and correlates of addiction and treatment careers
J. Subst. Abuse Treat.
(2005) - et al.
Participation rates in epidemiologic studies
Ann. Epidemiol.
(2007) - et al.
Differentiating DSM-IV alcohol dependence and abuse by course: community heavy drinkers
J. Subst. Abuse
(1997) - et al.
Tobacco addiction
Lancet
(2008) - et al.
Gender comparisons of drug abuse treatment outcomes and predictors
Drug Alcohol Depend.
(2003)
Comparing the dynamic course of heroin, cocaine, and methamphetamine use over 10 years
Addict. Behav.
Sociodemographic predictors of transitions across stages of alcohol use, disorders, and remission in the National Comorbidity Survey Replication
Compr. Psychiatry
Long-term outcomes of adolescents treated for substance misuse
Drug Alcohol Depend.
Effect of co-occurring disorders and intimate partner violence on substance abuse treatment outcomes
J. Subst. Abuse Treat.
Modelling disease frequency measures in schizophrenia epidemiology
Schizophr. Res.
Onset and course of alcoholism over 25 years in middle class men
Drug Alcohol Depend.
Utilizing recovery management checkups to shorten the cycle of relapse, treatment reentry, and recovery
Drug Alcohol Depend.
Prospective study of alcoholism treatment eight-year follow-up
Am. J. Med
The natural course of cannabis use, abuse and dependence over four years: a longitudinal community study of adolescents and young adults
Drug Alcohol Depend.
Public Policy Statement: Definition of Addiction
Recovery from mental illness: the guiding vision of the mental health service system in the 1990
Psychosoc. Rehabil. J.
Alcoholism And Treatment
Evolution of concept, but not action, in addiction treatment
Subst. Use Misuse
Épidémiologie de l’alcoolisation
Endocrinol. Nutr.
The recovery paradigm: a model of hope and change for alcohol and drug addiction
Aust. Fam. Physician
Pathways from Heroin Addiction: Recovery Without Treatment
What triggers remission without formal help from alcohol dependence? Findings from the TACOS-Study
Introduction to Meta-Analysis
Licit and Illicit Drugs; The Consumers Union Report on Narcotics, Stimulants, Depressants, Inhalants, Hallucinogens, and Marijuana—Including Caffeine, Nicotine, and Alcohol
Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment
Psychiatr. Serv. (Washington D.C.)
Trajectories of alcohol and drug use and dependence from adolescence to adulthood: the effects of familial alcoholism and personality
J. Abnorm. Psychol.
Nine-year psychiatric trajectories and substance use outcomes: an application of the group-based modeling approach
Eval. Rev.
Continuing care and long-term substance use outcomes in managed care: early evidence for a primary care–based model
Psychiatr. Serv. (Washington, D.C.)
British opiate addicts: an 11-year follow-up
Br. J. Psychiatry
Critical Appraisal Skills Programme, Learning Resources: Cohort Studies
Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care
BMC Fam. Pract.
Correlates of recovery from alcohol dependence: a prospective study over a 3-year follow-up interval
Alcohol. Clin. Exp. Res.
An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery
Eval. Rev.
A nonparametric trim and fill method of accounting for publication bias in meta-analysis
J. Am. Stat. Assoc.
Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis
Biometrics
Alcoholism: a controlled trial of treatment and advice
J. Stud. Alcohol
As the years go rolling by: drinking problems in the time dimension
Br. J. Psychiatry
The meanings of recovery from addiction: evolution and promises
J. Addict. Med.
A review of psychologically oriented treatment of alcoholism: the use and interrelationship of coutcome criteria and drinking behaviour following treatment
Q. J. Stud. Alcohol
Langzeitverläufe bei Alkoholikern [Longterm course in alcoholics]
Women's drinking across the adult life course as compared to men's
Br. J. Addict.
The course of treated and untreated substance use disorders: remission and resolution, relapse and mortality
Longitudinal patterns of drug injection behavior in the ALIVE Study cohort, 1988–2000: description and determinants
Am. J. Epidemiol.
National Treatment Improvement Evaluation Study, Final Report. Submitted to Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration
Older women and alcohol. Use and abuse
Rec. Dev. Alcohol.
Cited by (111)
Evolutionary perspectives on substance and behavioural addictions: Distinct and shared pathways to understanding, prediction and prevention
2024, Neuroscience and Biobehavioral ReviewsLateral hypothalamic GABAergic neurons encode alcohol memories
2024, Current BiologyLong-term patterns of treatment use for opioid use disorder (OUD): Findings from the 18-20-year Australian Treatment Outcome Study
2023, International Journal of Drug PolicyPromoting research engagement among women with addiction: Impact of recovery peer support in a pilot randomized mixed-methods study
2023, Contemporary Clinical Trials