Embed Size (px)
Citation preview
This article was downloaded by: [Adams State University]On: 21 November 2014, At: 07:49Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Groups in Addiction &RecoveryPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wgar20
Comparing the Addiction Careers ofHeroin and Alcohol Users and TheirSelf-Reported Reasons for AchievingAbstinenceDavid Best a , Teodora Groshkova b , Jessica Loaring c , SafeenaGhufran c , Ed Day c & Avril Taylor da Center for Criminal Justice and Police Studies , University of theWest of Scotland , Hamilton, Lanarkshire, Scotlandb Institute of Psychiatry , King's College London , London, Englandc School of Psychology , University of Birmingham , Birmingham,United Kingdomd Institute for Applied Social and Health Research , University of theWest of Scotland , Paisley, ScotlandPublished online: 15 Nov 2010.
To cite this article: David Best , Teodora Groshkova , Jessica Loaring , Safeena Ghufran , Ed Day& Avril Taylor (2010) Comparing the Addiction Careers of Heroin and Alcohol Users and Their Self-Reported Reasons for Achieving Abstinence, Journal of Groups in Addiction & Recovery, 5:3-4,289-305, DOI: 10.1080/1556035X.2010.523364
To link to this article: http://dx.doi.org/10.1080/1556035X.2010.523364
PLEASE SCROLL DOWN FOR ARTICLE
Taylor & Francis makes every effort to ensure the accuracy of all the information (the“Content”) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.
This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Journal of Groups in Addiction & Recovery, 5:289–305, 2010Copyright © Taylor & Francis Group, LLCISSN: 1556-035X print / 1556-0368 onlineDOI: 10.1080/1556035X.2010.523364
Comparing the Addiction Careers of Heroinand Alcohol Users and Their Self-Reported
Reasons for Achieving Abstinence
DAVID BESTCenter for Criminal Justice and Police Studies, University of the West of Scotland, Hamilton,
Lanarkshire, Scotland
TEODORA GROSHKOVAInstitute of Psychiatry, King’s College London, London, England
JESSICA LOARING, SAFEENA GHUFRAN, and ED DAYSchool of Psychology, University of Birmingham, Birmingham, United Kingdom
AVRIL TAYLORInstitute for Applied Social and Health Research, University of the West of Scotland,
Paisley, Scotland
This study employs a developmental model (Hser, Longshore, &Anglin, 2007) for mapping alcohol- and drug-using careers, fol-lowing in the tradition of work done by Blomqvist (1999). Basedon a rolling sample of 269 former alcohol and heroin addicts,initially reported by Best, Ghufran, Day, Ray, & Loaring (2007),this article examines differences in trajectories of careers amongproblem substance users and examines reasons for achieving andmaintaining desistance, based on three groups: primary drinkers(n = 98), primary heroin users (n = 104), and those who reportedproblems with both alcohol and drugs (n = 67).Former heroinusers reported more rapid escalation to problematic use but muchshorter careers involving daily use than was the case in the alcoholcohort. Alcohol and heroin users also differed in their self-reportedreasons for stopping use, with drinkers more likely to report workand social reasons and drug users more likely to report criminaljustice factors. In sustaining abstinence, alcohol users were slightlymore likely to report partner support, while drug users were more
Address correspondence to David Best, Center for Criminal Justice and Police Studies,University of the West of Scotland, Hamilton Campus, Room 822A, Almada Street, Hamilton,ML3 0JB, United Kingdom. E-mail: [email protected]
289
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
290 D. Best et al.
likely to report peer support and were also more likely to emphasizethe need to move away from substance-using friends than was thecase for former alcohol users. Users of both alcohol and heroinwere least likely to cite partner factors in sustaining recovery butwere more likely to need to move away from using friends and to citestable accommodation as crucial in sustaining abstinence. Careerfactors would appear to vary across substance types, with multiple-substance users having trajectories that share characteristics withthe primary users of each substance. Poly-drug use patterns havesignificant implications for our understanding of addiction careersand desistance patterns.
KEYWORDS life course, addiction careers, desistance factors,recovery, heroin career, alcohol career
INTRODUCTION
In spite of addiction being characterized as a chronic, relapsing condition(O’Brien & McLellan, 1996), there is a rich history of achieving long-termabstinence among problematic users of drugs and alcohol. From formal re-search outcome studies, Simpson and Sells (1990) reported a typical activeheroin-using career of 9.9 years in the follow-up sample from the Drug AbuseReduction Program. In English drug services, Gossop, Marsden, Stewart, andTreacy (2002) reported that around one-third of the intake sample from theNational Treatment Outcome Research Study (NTORS) had achieved someform of abstinence 2 years after study intake, with the figure for the sampleattending residential services at treatment intake at nearly 50%. Also, encour-agingly in the NTORS data, the majority of those abstinent at 2 years werealso those who had been abstinent at the earlier follow-up points, indicatinga stability of this effect.
However, this is not to suggest that there is a cut-off beyond whichclients are “safe” from relapse risk. In 2007, Dennis, Foss, and Scott reportedon 8-year outcomes among a cohort of 1,326 substance users accessing treat-ment services. At the 8-year follow-up point, 501 were abstinent from alcoholand illicit drugs (37.8%), and of those, only 77 (15.4%) had been abstinentfor 5 years or more. A total of 142 individuals (10.7% of the total sample)had been abstinent for at least 3 years. Increasing duration of abstinence wasassociated with more days in employment, fewer debts, and fewer days ofincarceration.
This model of change contingent on life events is consistent with the“life-course perspective model” of substance use, a model discussed by Hser,Longshore, and Anglin (2007), who used longitudinal data to examine pre-dictors of desistance in heroin users followed up during a 33-year window
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 291
and found that self-efficacy and psychological well-being were predictors ofstable recovery. Hser and colleagues emphasize key developmental conceptssuch as trajectories and turning points, although they concede that there isa dearth of information about cessation factors. One of their observations isthat career pathways appear to differ based on substances, with cocaine useincreasing through the 20s to early 30s and then declining, but heroin usecontinuing to increase. In terms of the typology of heroin users developedby Hser and colleagues, the authors differentiate between stable high-levelusers, decelerating users, and early quitters. The last group (who constitutedjust under half of their longitudinal sample) had heroin careers of typicallyless than 10 years. This early quitting population of heroin users had higherfrequencies of use in the first 2 to 3 years of use but then showed markedreductions and was abstinent by Year 11.
In the alcohol field, Vaillant (1988) reported on an 18-year follow-upof a sample of 106 drinkers and found that 39% were abstinent at the fi-nal follow-up point. However, Vaillant pointed out, as Laub and Sampson(2004) have done in relation to crime careers, that changes are not alwayspredictable and that it is the dynamics of life-course transitions and turn-ing points that determine long-term outcomes to a much greater degreethan risk or protective factors in childhood or adolescence. In a study oflong-term remission among treated and untreated drinkers, Moos and Moos(2006) reported a 62% remission rate in treated drinkers compared with 43%in the drinkers who did not seek help from treatment services. In the un-treated group, those who improved had more personal resources and feweralcohol-related deficits, leading the authors to conclude that “the likelihoodof relapse rises in the absence of personal and social resources that reflectmaintenance factors for stable remission” (Moos & Moos, p. 219).
The notion of protective factors has also arisen in the literature on“natural recovery” (Granfield & Cloud, 2001), based on interviews with 46individuals who overcame addiction to alcohol and drugs and who achievedsustained remission without assistance from treatment services or from mu-tual aid groups. In this study, the recovery process was often triggered bypersonal problems such as adverse health effects or relationship problems. Aswith the offenders in the Laub and Sampson (2004) study, many respondentsexperienced key life events that acted as turning points that motivated cessa-tion in use patterns. However, Granfield and Cloud differentiated the turningpoint that led to stopping use from the need for ongoing strategies to sus-tain abstinence, with the latter often involving alternative activities, changingsocial networks, and increased reliance on family and nonusing friends. AsGranfield and Cloud have found, “those who possess larger amounts of so-cial capital, perhaps even independently of the intensity of use, will be likelycandidates for less intrusive forms of treatment” (p. 58). Blomqvist (1999) hasargued that the allocation of resources and opportunities in life will shapethe likelihood of recovery journeys and the options available to people. In
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
292 D. Best et al.
an equivalent UK study, McIntosh and McKeganey (2000) discussed the needfor a change in self-perception and identity and talked of the need to “repair”the user’s identity, based on interviews with 70 individuals in recovery.
An alternative approach to mapping natural recovery involves the use ofpopulation survey methods. Sobell, Cunningham, and Sobell (1996) reportedrates of 75% and 77% recovery without formal help in former problematicdrinkers. In a further Canadian study based on population survey data, Cun-ningham (2000) assessed recovery from a range of substances and reportedthat the use of any formal treatment ranged from 43.1% for cannabis to 90.7%for heroin, with 59.7% of cocaine users seeking formal treatment at somepoint in their recovery journeys. Bischof, Rumpf, and Hapke (2001) analyzedgeneral population surveys in Northern Germany to compare current alcohol-dependent drinkers with remitters who had sought no formal help and foundthat the remitters had a later onset of dependence and had fewer years of de-pendent drinking but higher average daily alcohol consumption. The authorsalso found that the remitters were more likely to live in a stable relationshipand be more satisfied with work and with their financial situation.
Price, Risk, and Spitznagel (2001) examined patterns of substance useand remission during a 25-year period, based on epidemiological datacollected from three subsamples of Vietnam War-enlisted men and civiliancontrols. The typical substance use careers reported were between 9.1and 14.1 years, with remission generally reported as a gradual processinvolving only one quit attempt and only a minority of subjects seekingformal treatment as part of the remission process. The authors concludedthat, with nontreatment samples of this kind, there is little evidence of the“remission to relapse” cycle.
Blomqvist (1999) reported data on a comparison of recovery in drug andalcohol users, finding that drug users typically had more preresolution nega-tive events than alcohol misusers (particularly around legal and psychologicalfactors) and that these strains persisted during the course of the recovery jour-ney. Nonetheless, Blomqvist also reported that three-quarters of the samplecited at least some positive factors in their reasons to stop, such as findinga new partner. Blomqvist concluded that natural recovery was more likelyto be associated with a combination of positive and negative motives, whiletreated recovery was more typically associated with hitting “rock bottom.”Although there are variations between studies in what constitutes recov-ery without treatment (this debate is often about engagement in mutual aidgroups), the literature review above has focused primarily on nontreatmentpopulations recruited by a variety of methods, shows high rates of remissionover time across a range of substances, and where possible, has consideredthese in terms of developmental or long-term trajectories of change.
The current study explores further this comparison of reasons givenby drug and alcohol users and examines this using the framework adopted byBlomqvist (1999) of assessing reasons for giving up substance use separately
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 293
from the factors associated with maintaining abstinence. This builds on workby Klingemann (1991), who found that among the “autoremitting” popula-tion studied, heroin users stopped their substance use at a markedly earlierage (86% of the heroin users stopped before age 30). The current articlefollows from earlier work using a sample of former heroin addicts work-ing in the addictions field and uses a broader definition of recovery thatincludes recovery journeys involving formal treatment (Best, Ghufran, Day,Ray, & Loaring, 2007). This study examined factors associated with imme-diate desistance—which often involved being “tired of the lifestyle” andpsychological problems resulting from use—and long-term maintenance fac-tors, which included changes in the social networks of former users andincreased stability around families, accommodation, and training or employ-ment. The current article builds on this work by including those whoseproblems involve alcohol and both alcohol and heroin to examine the po-tential “additive” effect of combined problem use and to assess whetherthe differences in immediate and prolonged recovery explanations could beapplied across this wider population.
METHOD
Questionnaires were distributed in two waves. The first wave was reportedin Best et al. (2007) from three sites. Data were obtained opportunisticallyduring a 12-month period, involving the piloting of the questionnaire at aconference (United Kingdom/European Symposium on Addictive Disorders[UKESAD], London, 2006), distribution at the reunion meeting for a residentialrehabilitation center, and then through a national magazine about addictionissues (Addiction Today). Individuals were invited to complete a form if theyfelt they had been dependent on alcohol or heroin at some point in theirlives but had not used for at least 1 year.
The questionnaire was a brief semistructured questionnaire, developedfollowing a discussion group with individuals in recovery, and gatheredinformation on:
• Demographic characteristics• History of ages of onset, peak use, first quit attempt, first treatment, and
final cessation of substance use• Checklists of options for achieving abstinence and separately for sustaining
it• History of use of structured treatment and mutual aid services (this asked
about lifetime use of a checklist of types of treatment including “communitydrug or alcohol teams,” “residential rehabilitation,” “residential detoxifica-tion,” and so on)
• Previously unsuccessful quit attempts
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
294 D. Best et al.
Additionally, the fourth and final page of the questionnaire asked partic-ipants to respond to open-ended questions: “Why were previous quit at-tempts unsuccessful?” “What was different on this occasion?” “What werethe key things that finally helped you become completely abstinent?” and,“what are the key things that enable you to stay completely abstinent?”Thus, for the key issues of reasons for stopping using and for being ableto stay abstinent, checklist responses were supplemented by open-endedquestions.
A second wave was an amended version of the initial questionnairelooking for more detailed information on transitions in patterns of substanceuse throughout the substance use career. Because of the interest generatedby the questionnaire and the responses elicited, a second wave was launchedat the same conference the following year, and questionnaires were againdistributed though the Addiction Today magazine. Many of the items werecommon to both questionnaires, but additional items were added to addressperceived omissions in the initial questionnaire. In both waves, individu-als were asked to complete the form if they felt they had had a lifetimesubstance problem that they managed to overcome. The inclusion criteriawere that the individual reported lifetime dependence on either alcohol orheroin but that they had not used their primary substance (irrespective ofother forms of substance use, such as substitute prescriptions) for the lastyear.
Although respondents were given the option of providing contact de-tails to take part in an in-depth qualitative interview, the questionnaire wasotherwise anonymous and was returned by post to the university depart-ment. As a consequence, the research team had no control over sampling,and it is not possible to draw inferences about the representativeness or thereliability of the information returned to us.
STATISTICAL ANALYSIS
The primary methods of between-group analysis conducted are chi-squaresfor categorical variables and a one-way analysis of variance for continuousvariables to compare the three groups of substance users. No adjustment hasbeen made for multiple testing.
RESULTS
One of the key aims of the article is to examine age of desistance (measuredas the age of last use) and to see how this relates to other aspects of addictioncareers and to reasons for achieving and sustaining abstinence.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 295
Sample
A total of 256 individuals participated in either the initial phase (n = 179,69.9%) or the second phase (n = 77, 30.1%) of data collection (referred to asWave 1 and Wave 2 data). In the questionnaire, these participants reportedhaving used alcohol or illicit drugs on a daily basis at some point and alsoreported that they are now completely abstinent. The overall populationhad a mean age of 44.6 years (±10.3 years) and consisted of 190 males(71.4%) and 76 females (28.6%)—3 individuals did not report their gender.The majority of the sample (n = 236, 90.8%) described their ethnicity asWhite; 2.3% described their ethnicity as Asian, 3.1% as Black, 3.1% as MixedHeritage, and 0.8% were from Other ethnic groups. Nine individuals did notreport on their ethnicity.
Data were collected on working status in the first wave but not in thesecond. One hundred and thirty-three individuals (74.3%) reported that theyworked in the addictions field; this included 97.0% of those recruited atUKESAD, 59.4% of those attending the reunion at the rehabilitation unit,and 71.9% of those replying to the first wave of inclusion in AddictionToday.1 Working status was not associated with age at time of questionnairecompletion, age of onset of drinking or heroin use, length of career, orage of desistance, and as a consequence is not included as a covariate insubsequent analysis.
The breakdown of patterns of self-reported substance use in each phaseof data collection is reported in Table 1.
There was a significantly higher proportion of alcohol only and alco-hol/heroin users at the second wave of data collection (χ2 = 27.73, p <
.001). However, multiple-drug use was the normal pattern, with 165 (61.3%)reporting daily use of alcohol at some point, 142 (52.8%) reporting dailyuse2 of heroin, and 102 (37.9%) reporting daily use of cocaine (powder orcrack) at some point in addition to their use of alcohol and/or heroin. Forthe former drinkers, the time since last drink was an average of 7.9 years(±8.2 years), and for the heroin users, the research form was completed 9.8years (±7.7 years) since their last use of heroin.
TABLE 1 Patterns of Daily Substance Use in Each Phase of Data Collection and History ofTreatment
Alcohol Alcohol Drugusers only and heroin users only
Wave 1 data collection 71 (37.4%) 27 (14.2%) 81 (42.6%)Wave 2 data collection 43 (54.4%) 24 (30.4%) 10 (12.7%)No formal treatment 20 (22.0%) 3 (4.8%) 8 (7.7%)At least one period of formal treatment 71 (78.0%) 60 (95.2%) 96 (92.3%)Ethnicity (% White) 92.7% 86.4% 94.0%Gender (% male) 62.5% 74.4% 84.3%Age 48.3 years 41.5 years 43.2 years
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
296 D. Best et al.
1. TREATMENT HISTORIES
This population is not a “treatment population” exclusively, as shown inTable 1. There are a total of 31 individuals (12.0%) who reported no historyof contact with formal treatment services in their recovery journeys, repre-senting a “natural recovery” subsample. Lifetime users of alcohol only weresignificantly more likely never to have accessed formal treatment than thosewho had used illicit drugs (χ2 = 13.52, p < .01). A much higher proportionof the females in the sample (n = 15, 20.8%) had never accessed formaltreatment compared with the male participants in the study (n = 16, 8.7%;χ2 = 7.07, p < .01).
2. ALCOHOL CAREERS
There were 114 individuals who were primary alcohol users with a meanage of 48.3 years at the time of interview (SD = 10.2 years). Seventy weremale and 42 were female (data missing for 2). The characteristics of theirdrinking careers are shown in Figure 1.
From an onset age of around 14.6 years, there was an average gapof around 9 years to the onset of daily drinking and a further 4.5 yearsbefore drinking was regarded as problematic. The mean length of drinkingcareer—defined here as the time from first daily drinking age to age of lastalcoholic drink—was 16.8 years (SD = 8.9 years). However, the median was15.0 years.
FIGURE 1 Drinking Career Variables of Daily Drinkers.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 297
3. HEROIN-USING CAREERS
a. Overall sample. A total of 142 participants reported ever havingused heroin on a daily basis and reported a mean age of initiation of heroinuse of 19.9 years (±4.6 years), consistent with the data reported in Bestet al. (2007). The mean age of first daily heroin use was reported as 21.7years (±5.1 years), and the age of heaviest use was at a mean of 22.4 years(±5.7 years). On average, heroin careers in the overall sample averaged 10.5years (±7.0 years), and the mean age of last heroin use was 32.7 years (±7.1years). This is consistent with the “early quitters” group described by Hseret al. (2007), who reported heroin-using careers of typically just under 10years. During the heroin-using career, the sample reported a mean of 2.5periods of abstinence (range = 0–18) and an average number of treatmentepisodes of 3.0 (range = 0–20). Participants were asked about quantity andfrequency of heroin use in the 3 months prior to the final quit attempt. Inthis period, participants reported using heroin on an average of 75.5 days(out of 90), and the average daily amount used was 1.05 grams, suggestingintensive and consistent use.
b. Analysis of additional items in second wave of heroin users. Asmaller subsample of 34 daily heroin users, drawn from the second wave ofinterviews, were asked what age they felt they had first been dependent onheroin. This occurred at a mean age of 21.2 years, and the first quit attemptwithout treatment occurred on average at the age of 24.7 years. Twenty-sixindividuals in this group reported an initial age of formal treatment of 29.7years. In other words, although there was a gap of around 3.5 years betweenperceiving heroin use to be dependent and self-initiated quit attempts, a fur-ther 5 years passed on average before formal treatment was accessed. Theoverall career pathways for this group are shown in Figure 2.
FIGURE 2 Heroin Use Career Factors Among Lifetime Heroin Users.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
298 D. Best et al.
TABLE 2 Reasons for Achieving Abstinence by Substance-Using Group
Reasons for Heroin Alcohol Both heroinachieving abstinence only only and alcohol χ , sig
Physical health 74.4% 73.5% 82.1% 1.10Psychological health 75.3% 81.8% 76.2% 0.61Criminal justice factors 64.0% 42.1% 67.6% 8.54∗
Work opportunities 21.1% 44.6% 21.1% 10.19∗∗
Tired of the lifestyle 95.3% 90.8% 100.0% 4.81Family and friends 55.7% 69.6% 56.4% 0.18
∗p < 0.05; ∗∗p < 0.01.
4. COMPARING ALCOHOL AND HEROIN CAREERS
The final analysis is based on 256 participants across the two waves of datacollecting and consists of:
1. Individuals who had only ever used heroin on a daily basis (n = 91)2. Individuals who had only ever used alcohol on a daily basis (n = 114)3. Individuals who reported daily lifetime use of both heroin and alcohol
(n = 51)
An analysis was conducted looking at the reasons for quitting across eachof these groups, with the proportions of each group “agreeing” or “stronglyagreeing” with reasons for their final (and successful) attempt to becomeabstinent from problematic substance use reported for each of the threegroups in Table 2.
Alcohol users only were significantly less likely to cite criminal justicefactors as reasons for their final quit attempt but were more likely to citework reasons. Participants who had used both heroin and alcohol in theirsubstance-using careers were more similar to the heroin-only users than tothe drinkers in their reasons for quitting. Table 3 compares the same groupson the factors reported as enabling the participants to sustain abstinence.
TABLE 3 Reasons for Sustaining Abstinence by Substance-Using Group
Reasons for sustaining Heroin Alcohol Both heroinabstinence only only and alcohol χ , sig
Support from partner 31.0% 47.1% 22.7% 5.83Support from friends 66.7% 55.4% 63.6% 2.37Moving away from substance-using friends 84.4% 60.4% 91.7% 14.63∗∗
Having a job 41.9% 48.1% 50.0% 2.25Having reasonable accommodation 72.4% 60.3% 90.5% 8.59∗
Religious or spiritual factors 55.8% 66.7% 69.6% 3.22
∗p < 0.05; ∗∗p < 0.01.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 299
Multiple-substance users were significantly more likely to attribute suc-cess to moving away from substance-using friends and to attribute successfulmaintenance of their abstinence to having reasonable accommodation. Al-though not quite significant (χ2 = 5.18, p = .08), users of alcohol only weremore likely than drug users to attribute successful abstinence to support fromtheir partners.
5. LIFETIME DAILY USE OF BOTH HEROIN AND ALCOHOL
There were 51 individuals in our sample who reported that they had usedboth heroin and alcohol on a daily basis at some point, a group with anaverage age of 43.2 years at the time of the interview. This group consistedof 43 males and 8 females. Forty-seven were of White ethnic origin (92.2%),1 was Black (2.0%), 1 was Asian (2.0%), 1 was of Mixed Race (2.0%), andthe information was missing for 1 individual. As shown in Figure 3, there arediffering career pathways across the substance profiles even for those whohave used both.
Within this group, age of first heroin use is strongly correlated with ageof initiating daily heroin use (r = .71, p < .001), and there is also a positivecorrelation between age of first drink and age of onset of daily drinking (r =.37, p < .01). However, there is no relationship between age of onset ofheroin use and alcohol or between first daily drinking and first daily heroinuse. There is, however, a positive correlation between the number of yearsof active heroin use and the number of years of active drinking (r = .51, p <
.05).It is interesting to note that the group of heroin and alcohol users
typically reported both later ages of last heroin use (mean of 34.5 yearscompared with 31.7 years; t = 2.23, p < .05) and longer heroin-using careers(mean of 13.6 years compared with 9.4 years; t = 2.07, p < .05) than those
FIGURE 3 Career Stages in Lifetime Daily Users of Both Alcohol and Heroin.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
300 D. Best et al.
who reported problem heroin use without drinking. There were no markeddifferences in onset ages for heroin use. In contrast, alcohol and heroin usershad their last alcohol drink at a significantly earlier age (mean of 34.2 yearscompared with 39.8 years; t = 3.21, p < .01) and also reported significantlyearlier onset of both first drink (mean of 11.1 years compared with 14.6 years;t = 4.75, p < .001) and first daily drinking (mean of 18.0 years comparedwith 22.3 years; t = 4.75, p < .001) than the desistance group who had usedonly alcohol.
DISCUSSION
The current study provides further analysis of a larger cohort of formersubstance users who can report on their recovery journeys from a positionof stable abstinence, having been abstinent typically for an average of 8 to10 years (depending on the substance used). Consistent with the frameworkof the life-course model (Hser et al., 2007), our data show differences in thetrajectory of heroin and alcohol careers and limited evidence of predictableoverlaps and links between onset and desistance in career trajectories amongthe subsample who report lifetime daily use of both substances. Nonetheless,in this combined group, final desistance from alcohol typically occurs ataround the same time as final desistance from heroin, yet the trajectories aredifferent from the sole users of alcohol or heroin, suggesting that multiple-drug use has implications for desistance and that desistance in a recoveredpopulation typically took place around the same time for alcohol and forheroin.
It is interesting to note that the heroin use careers described here aresimilar to the careers of the “early quitters” group described in outcomeresearch by Hser and colleagues (2007), but the careers of the multiple-drug users are longer and mimic certain aspects of alcohol careers and otheraspects of heroin careers. It is also notable that drinking onset is much earlierin the group of individuals who go on to be multiple-drug users than in thealcohol-only group, although we did not gather sufficient data to allow usto relate this to childhood circumstances or to reasons for initiating drinking,as the focus of the article was on careers in relation to desistance factors.
Our findings of differences in routes to recovery among differentsubstance-using populations are consistent with Cunningham’s (2000) re-ported rates of treatment use across substances, with natural recovery ratesvarying markedly across different substance types. Our data also offer someimplications for change as a function of substance used. The data presentedare consistent with previous work by McIntosh and McKeganey (2000) insuggesting the importance of differentiating between factors associated withstriving for and achieving initial recovery and factors associated with sus-taining that recovery journey. The article adds to the limited literature that
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 301
contrasts the experiences of alcohol and heroin users both in terms of theiractive use careers and in their recovery pathways and supplements this bylooking at the experiences of people who reported lifetime problems withboth alcohol and heroin. It is less surprising that illicit heroin users have amore rapid escalation and a shorter overall use career than daily drinkers,but it is more interesting to report the differing roles of social factors in therecovery journeys. Although this may reflect different life circumstances oreven differences in attributional styles between the populations, there areclear differences in explanations offered by the three groups examined forboth achieving and maintaining abstinence.
Although physical and psychological factors are widely reported in bothpopulations as motives for seeking recovery, criminal justice factors are moreimportant in abstinence journeys for drug users and employment for alcoholusers. As Klingemann (1991) reported in his study of natural recovery inheroin and alcohol populations, a wide range of motives are reported, andsocial reasons were particularly important in the long-term recovery journeys.However, it is in the factors that enable recovery to be sustained that thekey social differences arise. Although not significant, partner support wascited more frequently by former drinkers, while moving away from a socialnetwork of using peers is a more important recovery factor for heroin usersthan for drinkers. This is consistent with Blomqvist’s (1999) finding that“leaving the scene” is an important requirement for recovery among problemdrug users. Overall, Blomqvist reported that drug users were more likely toreport internal changes and changes in circumstances and social factors thanproblem drinkers, but social capital factors were important in recovery fromboth alcohol and drug problems.
The importance of social networks on behavior has been documentedin a series of studies based on the Framingham Heart Study conducted in theUnited States. Christakis and Fowler (2006) reported on the increased riskrates for obesity in up to three degrees of separation from a target individualsuch that a person’s chances of becoming obese increased by 57% if theyhad a friend who became obese, with a lower risk rate for friends of friends,lower again at three degrees of separation, and no discernible effect at furtherlevels of removal. What is more, if the friend is perceived to be a close friend,then the risk rate is increased. Repeating this social network model using thesame dataset for smoking, Christakis and Fowler (2008) found that smokingcessation by a spouse decreased a person’s chances of smoking by 67%,while smoking cessation by a friend decreased the chances by 36%. Theaverage risk of smoking (i.e., smoking by a friend) was 61% higher at onedegree of separation, 29% higher at two degrees of separation, and 11%higher at three degrees of separation.
Not only does this suggest that there is a hugely powerful social influ-ence for risk behaviors, it was also mediated by severity and relationship. Intheir key text, Connected, Christakis and Fowler (2010) assessed the effect
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
302 D. Best et al.
of social contagion in emotions and the extent to which this extends be-yond immediate social networks, which they refer to as hyperdyadic spread.Using happiness, they reported that if a person’s friend is happy, there isa 15% increase in the chances that the target will be happy, but that evenat a further degree of separation, there is an increase of around 10% andat three degrees of separation, the increased likelihood of happiness is 6%.This notion of contagion is entirely consistent with the spread of recoveryand the idea that recovery communities involve not only direct communica-tion of recovery effects but that there is a much wider potential for a socialinfluence of recovery transmission within and across communities.
In the subsample reporting multiple-substance use, this factor is partic-ularly prominent as was the move to stable accommodation in sustainingthe recovery endeavor. It is possible that this may imply more parlous do-mestic arrangements during their poly-substance career, and so stability ofaccommodation is not something that they can take for granted. It is alsonotable that in the poly-substance group, first quit attempts for alcohol typ-ically occurred relatively early in the heroin career and markedly precededthe first quit attempt for heroin. In spite of this, the final attempt at achievingabstinence was at roughly the same time for alcohol and for heroin. Thus, al-though the trajectories of the heroin and alcohol careers differ in this group,the final desistance attempt appears often to involve stopping the use of bothsubstances at the same time. This may provide some support for the ideasof integrated interventions for multiple-substance users rather than parallelor unrelated treatment processes for alcohol and illicit drugs.
There is a key policy relevance to this discussion in terms of the recoveryagenda prominent in both English and Scottish strategy documents (ScottishGovernment, 2008; UK Government, 2007). Our data would provide an initialand crude framework for mapping pathways to recovery and for focusingon the key issues that promote the maintenance of abstinence. Althoughthis work remains preliminary and we are attempting to improve both oursampling techniques and our ability to obtain robust measures and methods,it is apparent that the trajectories of alcohol and drug careers differ and thatthe turning points for recovery and the essential supports may also differ ina way that would question the wisdom of attempting to generate a singlemodel for “addiction recovery.”
As Laudet (2008) has argued, “Understanding recovery and identifyingfactors that promote or hinder it will require a number of paradigm shiftsfor addiction professionals, including moving from an acute care model to achronic or long-term approach, and shifting the focus of research and serviceprovision from symptoms to wellness” (p. 1682). Our aim in this study hasbeen to merge this recovery-focused switch to a long-term approach withthe developmental models used by Hser and colleagues (2007) as part ofthe process of assessing the posttreatment period in a range of substanceuse populations and to look at community and social factors associated
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 303
with long-term change. The importance of shifts in social networks acrossthe three substance use groups emphasizes the power of social influence,and a key future research question will be to assess further the temporaland causal relationship this has to structural changes in recovery such asachieving stable accommodation and employment.
This is an important area of further research that is likely to have sig-nificant implications for changing the culture of substance use stigma thatleads to discrimination for individuals in recovery. Fuller knowledge aboutalcohol and drug careers, supplemented with ongoing strength-based assess-ment, will help to facilitate availability and access to adequate and timelysocial resources and opportunities. While this is only one potential levelfor challenging stigma and the evidence base for reducing substance-relatedstigma is extremely limited, fulfilling social inclusion needs as they relate torecovery stages is likely to be critical in enhancing the recovery journeys ofa far wider group of problem substance users.
It is important to recognize, however, that there are a number of sig-nificant limitations to this study, particularly in relation to the sample. Thissample is entirely opportunistic (although it is difficult to imagine how onewould test “representativeness” in populations in recovery). Notwithstand-ing, alternative methods of administering the survey via other recruitmentpathways would also have limitations, and the true challenge is the one ofaccess to a wider group of recovering populations, including those hiddenfrom research investigation. Furthermore, the sample is relatively small (N =269), and our data are reliant on the self-reports of participants. While theinstrument was broadly focused on the developmental sequence of addic-tion onset and recovery and was developed with the assistance of a pilotprocess involving individuals in recovery, there was no attempt to validatethe instrument or to test its underlying conceptual basis.
Not only does this mean that they are subject to the reporting biasesaccruing from memory effects (Russell et al., 1997), the reports on bothrecovery and on key life events are post-hoc rationalizations and social con-structions of life transitions (Davies, 1997). In the current sample, the alcoholusers are reporting on their drinking careers at an average of 8 years aftertheir last use, and for heroin users, the time since last use was 10 years; thismay have significant impact on the accuracy of recall and on the resultingconstructions of events. The fact that we recruited people who regard them-selves as being in recovery, including a substantial proportion of peoplewho were working in the addictions field at the time of data collecting, mayalso have skewed their perceptions of their own problems, and all the datahave to be understood as seen through the lens of retrospective narrativeand the resulting biases this may imply. There is also marked variance in thecareer aspects of desistance within each of the substance use groups, andone of the key future research questions will be to examine predictors ofsuch variability in career aspects. Furthermore, this contrasts with the more
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
304 D. Best et al.
robust prospective studies cited in the introduction and discussion wherelongitudinal design offers significantly greater confidence about accuracy ofrecall and sequencing of events.
This also complicates the measurement and definition of what consti-tutes dependence on different drugs (the rationale behind using daily useas a proxy measure and perceived dependence as an inclusion criterionfor taking part in the study), while analysis and conceptual modeling arealso complicated by multiple-substance use issues. The finding that thereare differing average transition points in alcohol- and heroin-using careers isconfounded by differences in reported reasons for attempting and sustainingabstinence. Finally, the question of what “abstinence” means is also problem-atic in terms of a population who may use multiple substances functionallyat different points in their addiction careers.
So where does this leave us? Our aim is to increasingly switch our focusto a more detailed analysis of contextually based recovery by focusing onthe communities in which recovery occurs and the embedding of addictioncareer trajectories and recovery journeys in specific contexts. However, thedata presented here do start to offer us research challenges about replicationof these findings and more detailed qualitative and quantitative analysesof mapping and measuring recovery journeys. Our main aim has been toshow that it is possible to access populations who achieve enduring andsustained recovery from problematic substance use. Our next aims are toattempt to delineate the characteristics of recovery journeys and to improveour methodologies for mapping recovery processes.
NOTES
1. Addiction Today is published by the Addiction Research Foundation to provide advice, support,and guidance to anyone suffering from an addiction; to educate, teach,and train professionals; and toconduct and disseminate research into addiction treatment and care.
2. Daily use refers to whether the participant had ever been a daily user of that substance.
REFERENCES
Best, D., Ghufran, S., Day, E., Ray, R., & Loaring, J. (2007). Breaking the habit: Aretrospective analysis of desistance factors among formerly problematic heroinusers. Drug and Alcohol Review, 27(6), 619–624.
Bischof, G., Rumpf, H., & Hapke, U. (2001). Factors influencing remission withoutformal help from alcohol dependence in a representative population sample.Addiction, 96(9), 1327–1336.
Blomqvist, J. (1999). Treated and untreated recovery from alcohol misuse: Environ-mental influences and perceived reasons for change. Substance Use and Misuse,34, 1371–1406.
Christakis, N. A., & Fowler, J. H. (2006). The spread of obesity in a large socialnetwork over 32 years. New England Journal of Medicine, 357(4), 370–379.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
Completing Addiction Careers 305
Christakis, N. A., & Fowler, J. H. (2008). The collective dynamics of smoking in alarge social network. New England Journal of Medicine, 358(21), 2249–2258.
Christakis, N. A., & Fowler, J. H. (2010). Connected: The amazing power of socialnetworks and how they shape our lives. London, UK: Harper.
Cunningham, J. (2000). Remissions from drug dependence: Is treatment a prerequi-site? Drug and Alcohol Dependence, 59, 211–213.
Davies, J. (1997). Drugspeak: The analysis of drug discourse. Amsterdam, The Nether-lands: Harwood Academic.
Dennis, M., Foss, M., & Scott, C. (2007). An 8-year perspective on the relationshipbetween the duration of abstinence and other aspects of recovery. EvaluationResearch, 31, 585–612.
Gossop, M., Marsden, J., Stewart, D., & Treacy, S. (2002). Change and stabilityof change after treatment of drug misuse 2-year outcomes from the NationalTreatment Outcome Research Study (UK). Addictive Behaviors, 27(2), 155–166.
Granfield, R., & Cloud, W. (2001). The elephant that no one sees: Natural recoveryamong middle-class addicts. Journal of Drug Issues, 26(1), 45–61.
Hser, Y., Longshore, D., & Anglin, M. D. (2007). The life course perspective ondrug use: A conceptual framework for understanding drug use trajectories.Evaluation Review, 31(6), 515–547.
Klingemann, H. (1991). Research report: The motivation for change from problemalcohol and heroin use. British Journal of Addiction, 86, 727–744.
Laub, J., & Sampson, R. (2004). Shared beginnings, divergent lives. Cambridge, MA:Harvard University Press.
Laudet, A. (2008). Introduction to special issue on international perspectives onrecovery. Substance Use and Misuse, 43(12/13), 1681–1684.
McIntosh, J., & McKeganey, N. (2000). Addicts’ narratives of recovery from druguse: Constructing a non-addict identity. Social Science and Medicine, 50(10),1501–1510.
Moos, R., & Moos, B. S. (2006). Rates and predictors of relapse after natural andtreated remission from alcohol use disorders. Addiction, 101, 212–222.
O’Brien, C., & McLellan, A. T. (1996). Myths about the treatment of addiction. Lancet,347, 237–240.
Price, R. K., Risk, N. K., & Spitznagel, E. L. (2001). Remission from drug abuse overa 25-year period: Patterns of remission and treatment use. American Journal ofPublic Health, 91(7), 1107–1113.
Russell, M., Marshall, J., Trevisan, M., Freudenheim, J., Chan, A., Markovic, N., &Priore, R. (1997). Test-retest reliability of the cognitive lifetime drinking history.American Journal of Epidemiology, 146(11), 975–981.
Scottish Government. (2008). The Road to recovery: A new approach to tacklingScotland’s drug problem. Edinburgh, Scotland: Author.
Simpson, D. D., & Sells, S. B. (1990). Opioid addiction and treatment. Malabar, FL:Krieger.
Sobell, L., Cunningham, J. A., & Sobell, M. B. (1996). Recovery from alcohol problemswith and without treatment: Prevalence in two population surveys. AmericanJournal of Public Health, 7, 966–972.
UK Government. (2007). Tackling drugs, changing lives. London, UK: Author.Vaillant, G. (1988). What can long-term follow-up teach us about relapse and pre-
vention of relapse in addiction? British Journal of Addiction, 83, 1147–1157.
Dow
nloa
ded
by [
Ada
ms
Stat
e U
nive
rsity
] at
07:
49 2
1 N
ovem
ber
2014
