This column was written by Eugene Rubin, MD, Ph.D., and Charles Zorumski, MD
Alcohol use disorder (AUD) is common. Over 14.5 million Americans meet the criteria for this disorder. AUD is responsible for many serious medical conditions and contributes to 95,000 deaths a year in the United States. AUD can lead to a variety of occupational, legal, and interpersonal problems. Recovery from AUD is possible, but data related to recovery are limited.
One reason for limited data is the lack of a research definition of recovery. A recent paper in the American Journal of Psychiatry by Brett Hagman, Daniel Falk, Raye Litten, and George Koob describes a definition of recovery from AUD that was developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in order to facilitate such research.
The NIAAA definition of recovery was through a multi-step process that involved an extensive review of the literature, careful evaluation of earlier definitions of recovery, discussions by an expert scientific team, and feedback from a variety of stakeholders. Following this process, the National Advisory Council on Alcohol Abuse and Alcoholism conducted a final review.
The final definition of recovery involves two components. First, an individual in recovery no longer fulfills the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for AUD. Second, the person does not fulfill the criteria for heavy drinking.
So, what do these two components of the new definition of recovery entail?
In the DSM-5, a diagnosis of AUD requires that an individual has at least two of 11 symptoms leading to significant impairment over a 12-month period. These 11 symptoms include difficulty with controlling drinking, social and occupational consequences of drinking, medical consequences due to drinking, the development of tolerance (ie, more alcohol is needed to obtain the same effect), and the occurrence of withdrawal symptoms when abruptly cutting down on drinking. In order to be in recovery, a person must no longer demonstrate any of these symptoms other than reporting a craving for alcohol.
The second component of the NIAAA definition of recovery is that a person has stopped heavy drinking. Heavy drinking is defined as more than 14 drinks per week and/or more than four drinks on a single day for a male. For a female, heavy drinking is defined as more than seven drinks per week or more than three drinks per day. One drink is considered a 12 oz. beer, a 5 oz. glass of wine, or 1.5 oz. of distilled spirits or hard liquor.
Prior definitions of recovery involved the demonstration of several other criteria, such as sobriety, paying attention to personal health, being a good citizen, living a self-directed life, and striving to reach one’s full potential. The NIAAA acknowledges that such factors may facilitate recovery, but they are not necessary to fulfill the NIAAA’s definition.
Furthermore, in the NIAAA definition, several duration milestones of recovery are recognized: an initial phase (up to 3 months), an early phase (3 months to one year), a sustained phase (1 to 5 years), and a stable phase (more than 5 years).
Several issues are important to point out about this new definition of recovery.
First, full abstinence is not required. Recent data have demonstrated that some individuals with AUD are able to fulfill the criteria for recovery and partake in an occasional drink. Certainly, many individuals with a history of AUD would relapse if they returned to occasional drinking, and these persons would need to maintain total sobriety to remain in recovery.
In addition, elements considered integral to previous definitions of recovery that involve various aspects of psychosocial functioning and well-being are not included in this definition. Growth in these areas facilitates recovery, but they are difficult to measure in research or clinical settings. The NIAAA definition was developed to facilitate research to better understand the mechanisms (both biological and psychosocial) that underlie the process of recovery.
AUD is common, destructive, and potentially lethal. A definition of recovery that facilitates research to better understand this process hopefully will lead to better ways of helping individuals conquer this addiction.