Predictors of Remission
The trigger in many individuals’ decision to reduce or eliminate substance use is their growing recognition of the accumulation of health, psychosocial, and/ or legal problems associated with use.66 Although this awareness may grow gradually, it also can occur suddenly due to a particular event or crisis, such as a diagnosis of a serious health problem or a spouse threatening to leave.67 Not only may the costs of continued use mount, but an individual also may experience diminishing positive psychoactive effects (e.g., the “rush” or tranquility) from use as tolerance develops.
Eventually, costs outweigh benefits, and the individual decides to quit. One path to quitting is to enter treatment or join a mutual-help group. Participating in treatment or a mutual-help group, such as AA or Narcotics Anonymous (NA), is associated with positive short- and medium-term outcomes.68-71 Moreover, initial steps toward help-seeking (e.g., contacting an alcoholism information/referral center) and obtaining help relatively quickly, especially in the first year after problem recognition, are associated with improved drinking patterns and reduced problems. Individuals obtaining help quickly appear to both achieve remission and, having achieved remission, be less prone to relapse.
Few legal, employment, family/social, and psychiatric problems at entry to and after treatment are linked to better substance use outcomes. On the other hand, heavier substance use, more chronic use, and more psychosocial problems from substance use are linked with a lower probability of remission, as is having a perception that one’s alcohol problem is mild or moderate rather than severe.71-73
Other predictors of remission, in addition to impairment of functioning and severity of substance use, fall within four related sets of social and personal factors: (1) social bonding, goal direction, and structure; (2) abstinence-oriented norms and models; (3) involvement in rewarding activities other than substance use; and (4) self-efficacy and coping skills. Moos74,75 observed that these factors, as well as mutual-help groups, also account for the effectiveness of different treatment approaches for SUDs.
Family members, especially a spouse or partner who provides goal direction and supervision and family members who monitor an individual’s substance use, can help promote stable remission from alcohol and drug use disorders. In addition, family members can contribute to an individual’s remission by using problem solving to confront a patient’s substance use and marital problems, rewarding such positive activities as seeking employment, supervising the patient’s compliance with behavioral contracts or prescribed medications, and participating in the individual’s SUD treatment.76-78
Individuals who are married are more likely to experience stable remission from alcohol and/or drug use, 79 probably because marital status is associated with greater support, goal direction, and structure. Men appear to receive a greater benefit from being married, perhaps because wives tend to be more supportive toward their husbands than men are toward their wives’ alcohol problems.80 Likewise, friends and participation in traditional social contexts, such as work and religion, also can provide the support, goal direction, and supervision that increases the likelihood of remission. Thus, a cohesive and supportive social network can foster setting and progressing toward recovery goals.76,81,82 Similarly, for individuals without support from family and friends, structured, recovery-oriented, community-based housing enables them to bond with others who provide the support, goal direction, and monitoring that help to maintain abstinence.83,84
When an individual’s partner and other close family members are not substance users or do not provide positive norms about use, the individual is more likely to become and remain abstinent.85-87 Likewise, individuals whose social network members are more supportive of abstinence are more likely to achieve and sustain remission from alcohol and drug use.70,81,86,88-90
To the extent that individuals engage in rewarding activities that do not involve substance use, they are more likely to achieve long-term remission. Such activities include social participation and such conventional activities as regular employment, substance-free recreational pursuits, and involvement in enjoyable physical activities.72,76,91 Religious involvement may facilitate remission when it provides intrinsic rewards, leads to participation in pleasurable social and altruistic activities, provides meaning to stressful life circumstances, helps prevent or alleviate depression and anxiety, and provides an optimistic orientation to life.92 In behavioral economic terms, sustained remission often involves a shift in an individual’s behavioral allocation toward activities that provide rewards that substitute for rewards previously obtained from substance use.93
With regard to intrapersonal characteristics, an individual with a stronger sense of self-efficacy or confidence to not use substances when confronted by high-risk situations is more likely to refrain from substance use.71 72 80 Greater self-efficacy at treatment intake,94 termination, and follow-up has been linked to sustained remission and stable recovery.86,95
Likewise, both substance-specific coping directed toward managing cravings or temptation to use substances and general coping directed toward general life stressors have been linked to remission. Such substance-specific coping skills as focusing on the benefits of abstinence, staying away from high-risk situations, and self-reinforcement for maintaining abstinence, are helpful in managing substance-related temptations.8096 More reliance on general approach coping (such as positive reappraisal and problem solving) and less on general avoidance coping (such as cognitive avoidance and emotional discharge) help to manage stressors that may jeopardize stable remission.73 97