Patrick Schopflin | Unsplash.com
Source: Patrick Schopflin | Unsplash.com

After 5 years of abstinence, a former alcoholic has approximately the same risk of relapse as a member of the general US population has of developing alcoholism.1 Let’s unpack this claim, and consider what it means for those who struggle with addiction. This article will review the academic literature pertaining to addiction and remission. For a more complete discussion, please read, “Risk of Relapse Declines Significantly after 5 years of Abstinence from Alcohol,” published on Neuraptitude.org.1

Alcoholic is a poorly defined colloquialism that we chose to include in our introductory proclamation for the simple fact that it is more widely known than the scientific term, alcohol use disorder.2 Instead of introducing more points of potential confusion, we will stick with the terms alcoholic and alcoholism rather than defining the more scientifically accurate, and precise term, alcohol use disorder. We will consider an alcoholic to be an individual for whom alcohol use causes significant biological, psychological, or sociological impairment in functioning.

The exact quantity of alcohol consumed is less important to the development of alcoholism than is the effect alcohol use has on an individual’s functioning. However, to get a ballpark quantification of hazardous consumption, we can consider the construct of risky alcohol use. Risky alcohol use corresponds with the amount of alcohol consumption that presents a risk to an individual’s health.3 Risky alcohol use is defined as >14 drinks per week or >4 drinks in a day for men <65 years old, and >7 drinks per week or >3 drinks in a day for women <65 years old.3

Greg Becker | Unsplash.com
Source: Greg Becker | Unsplash.com

There is a popular and prejudicial belief within our culture that an addict is always an addict, even after sustaining long-term abstinence. From a neurobiological standpoint, this belief does contain a kernel of truth in that the predisposing organic factors that render an individual susceptible to developing an addiction are unlikely to be completely corrected during the recovery process. This is why patients who are in remission from an addiction are strongly advised never to return to using the substance. However, the veracity of the addict is always an addict presumption begins and ends with the aforementioned caveat.

Addictive substances and behaviors hijack an evolutionarily ancient set of structures with the brain, which developed over millions of years to ensure our very survival. Thus, driving substance abuse into remission is an enormous, but not impossible, task. That being said, many do achieve and maintain remission.

Long-term remission from substance abuse is very difficult to study for numerous reasons, not least of which is the duration of follow up required to obtain valid results. There are only a small number of studies that have successfully gathered the data necessary to draw preliminary conclusions regarding the relationship between the duration of abstinence and the risk of relapse.1

Studies of remission in alcoholism have generally suggested that after 5 years of abstinence, the risk of relapse is around 15%.4,5 And in a cohort of patients who achieved remission from a wide array of substances, including alcohol, only 14% relapsed after 3 years of abstinence.6 There are clearly limitations to the cited data, and further study is required before any firm conclusions can be drawn, but the data available suggests that 5 years of remission seems to predict a relapse risk of around 15%.1

Now, let’s turn to the second part of our initial proclamation and examine the 1-year prevalence of alcoholism in the US.

In a recent study, Grant et al. found that the prevalence of alcoholism in the general US population over a 1-year period was 13.9% for 2012-2013.7 Data from the same data set circa 2001-2002 found the 1-year prevalence of alcoholism to be 8.5%.8 Although the prevalence of alcoholism is notably higher in the 2012-2013 data set, there are numerous reasons to believe that the more recent data is nonetheless valid.6

Elijah Hail | Unsplash.com
Source: Elijah Hail | Unsplash.com

So to summarize, the risk of relapse after sustaining remission for 5 years is around 15%, and the 1-year prevalence of alcoholism in the general population is 13.9% per our most recent estimates (range: 8.5-13.9%). We can revise our initial proclamation to more specifically assert that after 5 years of abstinence, a remitted alcoholic has approximately the same risk of relapse as a randomly selected member of the general US population has of experiencing alcoholism over a 1-year period.

Why is this particular formulation important? Patients require enormous courage and strength to achieve and sustain remission from any disease process. It is of enormous importance that we offer these patients hope during their struggle. A narrative that does not allow for a sustained remission does little to strengthen a patient’s resolve during their darkest hours and casts the narrator in a pessimistic and unhelpful role. If we can instead tell a story of hope, long-term remission, and a life beyond and within a given disease process, then we can truly stand with our patients and support their struggle.

References

  1. MacKinnon M. Risk of Relapse Declines Significantly after 5 Years of Abstinence from Alcohol. Neuraptitude.org. http://neuraptitude.org/2016/06/27/risk-of-relapse-declines-significantl.... Published June 27, 2016.
  2. American Psychiatric Association, American Psychiatric Association, eds. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C: American Psychiatric Association; 2013.
  3. Health UD of, Services H, others. Helping patients who drink too much: A clinician’s guide. Natl Inst Health Natl Inst Alcohol Abuse Alcohol NIH Publ. 2005;(07-3769).
  4. Jin H, Rourke SB, Patterson TL, Taylor MJ, Grant I. Predictors of relapse in long-term abstinent alcoholics. J Stud Alcohol. 1998;59(6):640-646.
  5. Vaillant GE. A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry. 1996;53(3):243-249.
  6. Dennis ML, Foss MA, Scott CK. An Eight-Year Perspective on the Relationship Between the Duration of Abstinence and Other Aspects of Recovery. Eval Rev. 2007;31(6):585-612. doi:10.1177/0193841X07307771.
  7. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72(8):757. doi:10.1001/jamapsychiatry.2015.0584.
  8. Hasin DS, Stinson FS, Ogburn E, Grant BF. 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. Arch Gen Psychiatry. 2007;64(7):830-842. doi:10.1001/archpsyc.64.7.830.

About the Author

Matthew MacKinnon MD

Matthew MacKinnon, MD is a psychiatric resident physician at the University of Washington.

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