The Trajectories of Opioid Addiction

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Dr. Yih-Ing Hser and her colleagues (Elizabeth Evans, Christine Grella, Walter Ling, and Douglas Anglin) have just published an important review--Long-Term Course of Opioid Addiction--in the Harvard Review of Psychiatry. Findings from their review of 28 long-term studies of opioid addiction have particular relevance for addiction professionals, recovery support specialists, and recovery advocates, include the following.

1. Studies of recovery from opioid addiction are plagued by a lack of consensus on measurable recovery outcomes. Data on opioid abstinence, for example, differs widely across studies in part because of different meanings of abstinence: continuous abstinence, abstinence at the point of follow-up, abstinence for a prescribed period of time prior to follow-up, and opioid abstinence with or without reference to abstinence from other drugs. If scientists obsessed with precise measurement fail to achieve consensus on measurable recovery outcomes, it is little wonder that clinicians and recovery support specialists follow in this same path.

2. The trajectory of long-term opioid use is marked by high rates of morbidity. Studies reviewed by Hser and colleagues reported death rates related to opioid addiction 6 to 20 times greater than such rates in the general population. Between 25%-50% of subjects in the longest term studies had died by the 20-year follow-up point. Social reform and public health movements require a sense of urgency; it is hoped the rising death rate from opioid dependence in the United States will stir such urgency.

3. There is a significant time delay between the onset of opioid use and help-seeking--6-10 years in the studies reviewed. This suggests a long window of opportunity for identifying, engaging, and treating people who are opioid dependent far sooner than is now occurring naturally.

4. The most common trajectory of opioid dependence is marked by cycles of active use, periods of remission, and return to opiate use and its related problems. The instability of opioid abstinence and the frequent failure to transition from recovery initiation to stable recovery maintenance suggests the need for prolonged monitoring and support and, when needed, assertive early re-intervention.

5. While opioid abstinence rates erode over time, there is evidence of stable and sustained recovery from opioid dependence. In the studies reviewed, the latter characterized about 30% of the samples studied for ten or more years. Recovery from opioid dependence varies in pattern from early quitters to late quitters, the latter often showing a pattern of slow deceleration of use prior to cessation of use. Neither age nor chronicity of use predicted recovery initiation in the studies reviewed. Those dependent on opioids for prolonged periods were more likely to die than to "mature out".

6. Achieving opioid abstinence for a period of five or more years is an important marker of recovery stability, but addiction recurrence can still occur after this benchmark--for 25% in one of the cited studies.

7. Professional treatment of opioid addiction, particularly prolonged treatment and higher cumulative doses of treatment, is associated with more positive outcomes, but these effects can be ephemeral. In the studies reviewed, resumption of opiate use often followed treatment, and multiple episodes of treatment were often required before stable recovery was achieved. This finding underscores the need for models of sustained recovery management (RM) in the treatment of opioid addiction. These RM models would employ creative treatment retention strategies, assertive linkage to indigenous recovery support institutions, recovery check-ups for at least five years, and sustained family support through these addiction/treatment/recovery careers.

8. Prolonged opioid addiction is also often marked by developmental trauma and co-occurring medical and psychiatric conditions, suggesting the need for care models that integrate and assure continuity of addiction treatment, psychiatric treatment, primary health care, and prolonged recovery support across these three arenas.

I am continually asked by local community leaders what they can read to gain a better understanding of opioid addiction. Hser and colleagues in their review, Long-Term Course of Opioid Addiction, have provided an invaluable service by synthesizing what we know about the trajectories of opioid addiction and their clinical import. Their review underscores the need to formulate a more comprehensive, science-grounded, and effective response to opioid addiction in the United States. In future blogs, I will try to explore some of the needed critical elements within that potential response.