30 Years Later: Factors that Predict Who’s Most Likely to Remit from Alcohol Use Disorder

Many individuals who develop an alcohol use disorder will eventually enter remission, including 60% within the time-frame of this study.

This was a rare 30-year follow up of alcohol using men who did not have an alcohol use disorder at the start of the study, at around age 20, but developed one by age 30.

Researchers tested which factors predict sustained remission in a group of males from San Diego, California.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

Drinking practices and alcohol-related problems can fluctuate substantially from adolescence through middle age. For example, across a 2-year period, alcohol use disorders have been shown to have only moderate levels of diagnostic stability.

Cross-sectional studies of alcohol problems describe correlates of alcohol use disorder remission, but longitudinal studies can better capture the complex, chronic, often fluctuating course of problematic alcohol use.

Most longitudinal research has focused on active alcohol use disorder and little is known about the trajectories of remission from alcohol use disorder.

This study aimed to obtain a better understanding of behavior and genetic factors related to remission from alcohol use disorder over time to help identify which problematic drinkers are likely to improve and what behaviors should be targeted by intervention.

HOW WAS THIS STUDY CONDUCTED?

The San Diego Prospective Study (SDPS) is a longitudinal dataset of approximately 400 men (98% Caucasian) who were recruited as healthy 18 to 25-year-olds who drank alcohol but did not have alcohol use disorder. Half the sample had an alcohol dependent father and the other half did not have a biological parent or grandparent with alcohol dependence.

No participants met criteria for a major depressive or major anxiety disorder when tested at baseline. Only the 129 participants who met DSM-IV criteria for abuse or dependence by age 30 were included in the analysis. The men were followed every 5 years for over 30 years to see how social and biologically-based characteristics from approximately age 20 related to the development and course of alcohol use disorder.

The goals of these analyses were:

to examine rates of both first (e.g., no longer met criteria for alcohol use disorder for the first time) and sustained remission (e.g, no subsequent alcohol use disorder diagnosis) over a 20+year period
to identify characteristics that predicted both first and sustained remission

WHAT DID THIS STUDY FIND?

By age 50, first or sustained remission was reported by 60% of participants. Specifically, sustained remission was reported by 45% of this 60%

The greatest incidence of remission from alcohol use disorder occurred between age 30 and 35.

There were several factors that predicted sustained remission most strongly:

One was having a “lower response to alcohol” (i.e., meaning a person who needs to drink more to get the same effect as a person without this trait, even when they first initiate alcohol use as a young person), sometimes referred to as having “a hollow leg” as the person appears to be immune to the effects of high amounts of alcohol. For these individuals, remission rates were 68% lower compared to individuals who initially had a “high response to alcohol.”
Individuals who had lower drinking frequency were more likely to be in remission. Specifically, individuals with a 1-day higher drinking frequency had a sustained remission rate 8% lower than those with a lower drinking frequency.
Also, having received alcohol treatment was associated with higher remission (rates of sustained remission were about 10 times greater among individuals who received treatment early on). The predictive factors and alcohol use disorder diagnostic criteria were measured at age 30.

The factors that predicted first remission were:

higher education (the odds of achieving remission increased by 16% with every year of higher education)
lower drinking frequency (the odds of achieving remission increased by 6% with 1-day less of drinking per week)
meeting criteria for DSM-IV alcohol abuse rather than alcohol dependence diagnosis (odds of achieving remission increased by 66% for those who met alcohol abuse criteria compared to dependence)

Importantly, family history of alcohol use disorder did not predict either first or sustained remission.

In addition, the diagnosis of alcohol abuse (vs. dependence) was associated with first, but not with sustained remission. Abuse (requiring 1 of 4 criteria items) has a more easily fulfilled threshold than does dependence (requiring 3 of 7 items). Having a drug use disorder did not decrease the odds of first or sustained remission (but was almost significant for sustained).

WHY IS THIS STUDY IMPORTANT?

This study highlights the importance of factors that predict the likelihood of achieving first and sustained remission in a sample of men who had no alcohol use disorder around age 20 (but still drank).

Lower drinking frequency and early alcohol use disorder treatment were the most consistent predictors (e.g., predicted both first and sustained remission).

The results indicate that characteristics associated with better outcomes early in the life span, such as less frequent drinking and early treatment, are associated with remission from alcohol use disorder across adulthood.

Although, it is hard to infer causal relationships in a naturalistic study such as this, this could mean that seeking alcohol use disorder treatment, or harm reduction strategies which might help reduce how often someone drinks (but may not eliminate drinking), may increase the likelihood of achieving remission.

Equally important to consider, is the possibility that men with a greater drive to recover were those who sought out help earlier in life; perhaps because they had more severe forms of the illness earlier or somehow had easier access to treatment or both.

Finally, the finding that abuse vs. dependence was not predictive of sustained remission implies that stable long-term recovery may be accessible for all individuals with an alcohol use disorder, even those who are more severe.

LIMITATIONS

The results are not generalizable to early onset alcohol use disorder (e.g., before age 18) which tends to be more severe and associated with other drug problems and has a poorer prognosis. The men in this sample developed alcohol use disorder by approximately age 30. They were healthy men who had factors associated with a relatively good prognoses including higher education, good job skills, generally supportive families, absence of severe antisocial behaviors, lower rates of drug dependence, and few psychiatric disorders.
It is worth noting the high rate of remission in these participants. Therefore, the participants in this study, and the rates of remission, may be more likely to occur among individuals of a similar background. In other words, participants from treatment centers that serve individuals with multiple psychosocial stressors may or may not have similar rates of remission.

NEXT STEPS

Family history of alcohol use disorder was not predictive of first or sustained remission in this sample of highly educated men.

Future research should determine if different demographic groups (e.g., those of lower socioeconomic status vs. higher or women vs. men) have a more difficult time getting into or sustaining remission due to family history. This could improve accurate assessment of risk factors for targeted intervention.

Other studies examining the course of remission and recovery from alcohol use disorder could include and compare individuals with early onset alcohol use disorder.

BOTTOM LINE

For individuals & families seeking recovery: Know that remission is the most likely outcome from alcohol use disorder regardless of treatment. However, consider seeking treatment as soon as possible if you or your family member has a problem with drinking. In this study, men who sought treatment were 10 times more likely to report sustained remission, however, understand that other unmeasured factors (e.g., severity, motivation to recover, and other factors) may also help explain their more successful recovery outcomes.
For Scientists: This was an important and rare study given the 30-year follow-up. It was also made difficult by the long follow-up windows (5 years) and absence of characteristics known to be clinically important (e.g., addiction severity, motivation for change). More work is needed to determine the factors associated with and contributing to first and sustained remission over extended periods of time.
For Policy makers: This study showed the utility of longitudinal datasets to address the factors that predict (and do not predict) first and sustained remission. However, the bulk of research aims to address factors associated with active alcohol and other drug disorders. To address this knowledge gap, allocation of resources to expand the research base on the course of recovery and long-term remission, will inform this important area.
For Treatment professionals and treatment systems: If your client has not achieved abstinence from alcohol and is unwilling to abstain completely, it may be helpful to encourage them to reduce their drinking as this may increase their odds of attaining later remission.