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Recovery capital protective against relapse during the height of COVID-19 pandemic

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The increased stress, isolation, and other stressors related to the COVID-19 pandemic may negatively impact recovery. This study explored if pandemic-related stressors were linked with higher odds of relapse among American adults in recovery from alcohol use disorder.

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recovery science
with the free, monthly
Recovery Bulletin

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WHAT PROBLEM DOES THIS STUDY ADDRESS?

From increases in alcohol use and related deaths among the general population to an unprecedented increase in other drug poisoning deaths, the COVID-19 pandemic has had substantial consequences. With the mandatory stay-at-home orders and increased access to alcohol, experts voiced concern that adults in recovery from alcohol use disorder specifically would be at heightened risk of relapse due to increased stressors (e.g., isolation, unemployment), more unstructured time, and greater access to alcohol. Studies of the general U.S. population have found that alcohol consumption and the number of binge drinking days increased during the pandemic. However, the impact of pandemic-related stressors on those in recovery remains unknown. Thus, the researchers in this study sought to explore if adults in alcohol use disorder recovery were more likely to report relapse if they experienced a greater number of pandemic-related stressors and if there were differences between women and men.


HOW WAS THIS STUDY CONDUCTED?

This study used nationally representative survey data to examine adults that self-reported as being in recovery or having a resolved alcohol problem who were currently abstinent or lower-risk drinkers. Current drinkers were screened by the AUDIT-C to confirm their drinking was not hazardous. The final sample included 1,492 adults and is representative of the general U.S. population. Although screening occurred prior to the COVID-19 pandemic, the survey was conducted in the Fall of 2020, months after COVID-19 was declared a nationwide emergency and states began to shut down infrastructure to prevent its spread.

The primary outcome of interest was relapse during the COVID-19 pandemic (yes or no), defined as drinking alcohol since January 2020 if previously abstinent or increasing alcohol consumption since January 2020 if previously drinking at lower risk levels.

Predictor variables were grouped into four categories: lifetime alcohol use disorder characteristics, recovery threats, recovery supports, and demographic characteristics. Researchers also assessed lifetime alcohol use disorder symptoms via 11 structured questions based on DSM-5 criteria as time in recovery converted into three categories: early recovery (<1 year), intermediate recovery (1-5 years), and long-term recovery (>5 years). Participants were also categorized in three recovery groups based on reported lifetime use of 14 types of services: treated recovery (any use of specialty services, such as in- or out-patient rehabilitation), assisted recovery (any use of lay services, such as mutual-aid groups, and no use of specialty services), and independent recovery (no use of specialty or lay services).

Threats to recovery consisted of a 12-item list of COVID-related stressors based on the Environmental Influences on Child Health Outcomes COVID-19 questionnaire as well as an indicator of minor children in the household. Recovery supports were explored with a recovery capital measure, which provides a global measure of assets that can be leveraged to initiate or sustain recovery, and a general social support scale. There were five options for each item on the recovery support scales with each ranging from strongly disagree to strongly agree. Demographics included race/ethnicity, educational attainment, employment status, relationship status, and poverty status based on income. The researchers then tested how each characteristic was independently linked to the odds of relapse for both men and women.

In this nationally representative sample, among women, 63.7%, 13.2%, and 23.1% reported independent, assisted, and treated recovery, respectively. Among men 57.9%, 16.0%, and 26.1% reported independent, assisted, and treated recovery, respectively. Most women and men (73.4% and 76.5%) identified as being in recovery for more than 5 years. Women had higher average recovery capital and social support scores compared to men.


WHAT DID THIS STUDY FIND?

The COVID-19 pandemic did not impact relapse among most adults in recovery from alcohol use disorder.

Overall, relapse rates among this sample were low. Only 3.1% of participants reported a return to alcohol use after being abstinent, and only 2.7% of participants reported an increase from previously low risk drinking. Most women and men (88.9% and 88.8%) reported that the COVID-19 pandemic did not at all affect their relationship with alcohol or drugs and their recovery. Similarly, both women and men reported that the COVID-19 outbreak did not make it more difficult to resist alcohol or drugs (94.2% and 92.8%). Pandemic-related stressors were not associated with odds of relapse for women or men.

Recovery capital was protective against relapse for women and men.

That said, recovery capital was associated with lower odds of relapse, with similar protection for women and men. For women, a one unit increase in the recovery capital scale was associated with a 10% reduction in odds of relapse. For men, a one unit increase in recovery capital was associated with a 7% reduction in odds of relapse.

Predictors of relapse different for women vs. men.

Among women, each additional lifetime alcohol use disorder symptom was associated with 37% higher odds of relapse. Also, women in early recovery (<1 year) had 10-fold higher odds of relapse compared to those women in long-term recovery (>5 years). Being out of the labor force (e.g., retired, homemaker, full-time student) was linked with a nearly 5-fold increase in odds of relapse. Being never married compared to married or cohabitating was also associated with more approximately a 5-fold increase in odds of relapse among women. Men had fewer predictors that were associated with relapse. Men with a high school diploma or some college had 2/3 lower odds of relapse compared to those with a bachelor’s degree or higher. Men whose household income was below the federal poverty level has 3 times higher odds of reporting relapse compared to their peers above 200% of the federal poverty level. No other recovery barriers, recovery supports, or demographics were found to be linked with relapse for either women or men.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In the general U.S. population, alcohol consumption increased during COVID-19. Although local and state government responses were highly variable, many recovery experts warned that individuals in recovery were at heightened risk of relapse due to increased stress and less accessible treatment and recovery support services. Surprisingly, this study found that only 5.8% of individuals in recovery from alcohol use disorder relapsed. One explanation for these low rates may be that recovery capital protected individuals from pandemic-related stress by providing them with the necessary resources to cope with stressors. These findings are in line with a proposed biaxial formulation of recovery, which proposes a reciprocal relationship between remission from substance use disorder on the one hand and recovery capital, including health, housing, social relationships, education, employment, meaning and purpose in life on the other. Also, three quarters of those studied here had 5 or more years of recovery and thus may have been particularly well skilled at navigating life challenges, even those more radical ones presented by COVID. At the same time, the study was cross-sectional, and individuals were included in this study only if they self-reported having resolved an alcohol problem and were currently abstinent or drinking at lower risk levels (based on a validated screener for hazardous drinking). Some individuals may have been in recovery at the beginning of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020. Those individuals would not have screened into the study as they would not be abstinent or drinking at lower risk levels.

The “relapse” rates here are likely to be underestimates of all the types of problems experienced by individuals in alcohol use disorder recovery during the pandemic. The researchers in this study also found differences between men and women. For example, although men were more likely to relapse when below the poverty line, women were more likely to relapse when out of the workforce. The gender-differences found in this study echo previous work suggesting different mechanisms of behavior change among men and women in alcohol use disorder treatment and recovery. Furthermore, this study does not explore individuals that identify as non-binary or transgender. Transgender adults face increased levels of discrimination, which is linked to higher rates of substance use, substance use disorder, and substance use disorder treatment. Just as recovery pathways are not identical, the most salient protective factors and risk appear to vary across individuals, specifically along lines of gender.


  1. Most of the sample were in long-term recovery (>5 years), which may have prevented the authors from exploring the nuances among those with less time in recovery.
  2. The survey was only conducted at one time point during the COVID-19 pandemic. Recovery stability and the unique characteristics associated with recovery may vary over the course of the pandemic.
  3. Although the sample is nationally representative, the researchers did not control for local pandemic restrictions or cooccurring mental health conditions. Pandemic-related stressors may have been different in areas with more or less restrictions and those with co-occurring conditions my have been uniquely impacted by the pandemic.
  4. Several of the estimates had large confidence intervals, which signifies a high level of uncertainty around the accuracy of the estimates.

BOTTOM LINE

This study found that, among a nationally representative sample of adults in recovery from alcohol use disorder in the U.S., less than 6% of participants relapsed in the fall of 2020 following the beginning of the COVID-19 pandemic. Such a low relapse is surprising given the increase in alcohol use among the general U.S. population. The researchers also found that pandemic-related stressors were not linked with odds of relapse. These findings do not suggest that the pandemic has not been stressful for these individuals. Instead, it is more likely that aspects of recovery, and recovery capital specifically, enable individuals in recovery to view pandemic-related stressors as manageable and/or have the ability to cope with those stressors. Indeed, the researchers found that recovery capital was protective against relapse for both men and women. This study may also underestimate the “relapse” rates of problems experienced by individuals in alcohol use disorder recovery during the pandemic due to not including those who may have been in recovery at the start of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020 when the study was conducted.


  • For individuals and families seeking recovery: Being in recovery and the associated resources an individual can use to support their recovery are protective against relapse even during major events like the COVID-19 pandemic. If you or a loved one is in recovery from alcohol use disorder, it will likely help to continue developing the individual, social, and community resources to support recovery. If you or a loved one is seeking recovery, it would likely help to consider the available supports and consider how gender identity may necessitate different types of supports.
  • For treatment professionals and treatment systems: The COVID-19 pandemic is predicted to have a lasting impact. The nature of the impact on individuals in recovery specifically is still being delineated. This study found that the number of pandemic-related stressors were not predictive of relapse. They did find the recovery capital was protective against relapse for both women and men, yet some characteristics differed in the risk of relapse between women and men. It is likely to help and unlikely to hurt if recovery capital is assessed and linkages are made to appropriate supports. It is also likely to help recovery chances if treatment and treatment systems consider gender-specific needs and supports.
  • For scientists: This study found that recovery capital was shown to be associated with decreased odds of relapse for both men and women during the height of COVID-19. However, the sample was primarily adults with more than 5 years of recovery. With few adults in early recovery, the researchers did not have the statistical power to detect small to moderate effects for that group. Individuals in long-term recovery may have had the needed time to build their recovery capital and ability to cope with stressors. Future research would benefit from including more individuals in all stages of recovery as well as considering gender-specific supports and intervention designs. Designing interventions that target recovery capital may be an effective and efficient way to increase chances of maintaining recovery, especially during major events like COVID-19. Furthermore, future research could benefit from exploring how local policy responses to the pandemic and associated restrictions influenced recovery.
  • For policy makers: More research is needed to determine the exact impact of COVID-19 on recovery. However, the researchers of this study present findings that suggest adults in recovery from alcohol use disorder experienced low rates of relapse and that their recovery was not negatively impacted by the pandemic. The researchers also found that recovery capital was protective against relapse for women and men. Policy that funds individual, social, and community-level resources for adults in recovery would likely increase recovery chances. Supporting research that explores multi-level interventions is needed to establish the modifiable nature of recovery capital and its associated effect of recovery chances.

CITATIONS

Gilbert, P. A., Soweid, L., Kersten, S. K., Brown, G., Zemore, S. E., Mulia, N., & Skinstad, A. H. (2021). Maintaining recovery from alcohol use disorder during the COVID-19 pandemic: The importance of recovery capital. Drug and Alcohol Dependence, 229, 109142. doi: 10.1016/j.drugalcdep.2021.109142


Stay on the Frontiers of
recovery science
with the free, monthly
Recovery Bulletin

l

WHAT PROBLEM DOES THIS STUDY ADDRESS?

From increases in alcohol use and related deaths among the general population to an unprecedented increase in other drug poisoning deaths, the COVID-19 pandemic has had substantial consequences. With the mandatory stay-at-home orders and increased access to alcohol, experts voiced concern that adults in recovery from alcohol use disorder specifically would be at heightened risk of relapse due to increased stressors (e.g., isolation, unemployment), more unstructured time, and greater access to alcohol. Studies of the general U.S. population have found that alcohol consumption and the number of binge drinking days increased during the pandemic. However, the impact of pandemic-related stressors on those in recovery remains unknown. Thus, the researchers in this study sought to explore if adults in alcohol use disorder recovery were more likely to report relapse if they experienced a greater number of pandemic-related stressors and if there were differences between women and men.


HOW WAS THIS STUDY CONDUCTED?

This study used nationally representative survey data to examine adults that self-reported as being in recovery or having a resolved alcohol problem who were currently abstinent or lower-risk drinkers. Current drinkers were screened by the AUDIT-C to confirm their drinking was not hazardous. The final sample included 1,492 adults and is representative of the general U.S. population. Although screening occurred prior to the COVID-19 pandemic, the survey was conducted in the Fall of 2020, months after COVID-19 was declared a nationwide emergency and states began to shut down infrastructure to prevent its spread.

The primary outcome of interest was relapse during the COVID-19 pandemic (yes or no), defined as drinking alcohol since January 2020 if previously abstinent or increasing alcohol consumption since January 2020 if previously drinking at lower risk levels.

Predictor variables were grouped into four categories: lifetime alcohol use disorder characteristics, recovery threats, recovery supports, and demographic characteristics. Researchers also assessed lifetime alcohol use disorder symptoms via 11 structured questions based on DSM-5 criteria as time in recovery converted into three categories: early recovery (<1 year), intermediate recovery (1-5 years), and long-term recovery (>5 years). Participants were also categorized in three recovery groups based on reported lifetime use of 14 types of services: treated recovery (any use of specialty services, such as in- or out-patient rehabilitation), assisted recovery (any use of lay services, such as mutual-aid groups, and no use of specialty services), and independent recovery (no use of specialty or lay services).

Threats to recovery consisted of a 12-item list of COVID-related stressors based on the Environmental Influences on Child Health Outcomes COVID-19 questionnaire as well as an indicator of minor children in the household. Recovery supports were explored with a recovery capital measure, which provides a global measure of assets that can be leveraged to initiate or sustain recovery, and a general social support scale. There were five options for each item on the recovery support scales with each ranging from strongly disagree to strongly agree. Demographics included race/ethnicity, educational attainment, employment status, relationship status, and poverty status based on income. The researchers then tested how each characteristic was independently linked to the odds of relapse for both men and women.

In this nationally representative sample, among women, 63.7%, 13.2%, and 23.1% reported independent, assisted, and treated recovery, respectively. Among men 57.9%, 16.0%, and 26.1% reported independent, assisted, and treated recovery, respectively. Most women and men (73.4% and 76.5%) identified as being in recovery for more than 5 years. Women had higher average recovery capital and social support scores compared to men.


WHAT DID THIS STUDY FIND?

The COVID-19 pandemic did not impact relapse among most adults in recovery from alcohol use disorder.

Overall, relapse rates among this sample were low. Only 3.1% of participants reported a return to alcohol use after being abstinent, and only 2.7% of participants reported an increase from previously low risk drinking. Most women and men (88.9% and 88.8%) reported that the COVID-19 pandemic did not at all affect their relationship with alcohol or drugs and their recovery. Similarly, both women and men reported that the COVID-19 outbreak did not make it more difficult to resist alcohol or drugs (94.2% and 92.8%). Pandemic-related stressors were not associated with odds of relapse for women or men.

Recovery capital was protective against relapse for women and men.

That said, recovery capital was associated with lower odds of relapse, with similar protection for women and men. For women, a one unit increase in the recovery capital scale was associated with a 10% reduction in odds of relapse. For men, a one unit increase in recovery capital was associated with a 7% reduction in odds of relapse.

Predictors of relapse different for women vs. men.

Among women, each additional lifetime alcohol use disorder symptom was associated with 37% higher odds of relapse. Also, women in early recovery (<1 year) had 10-fold higher odds of relapse compared to those women in long-term recovery (>5 years). Being out of the labor force (e.g., retired, homemaker, full-time student) was linked with a nearly 5-fold increase in odds of relapse. Being never married compared to married or cohabitating was also associated with more approximately a 5-fold increase in odds of relapse among women. Men had fewer predictors that were associated with relapse. Men with a high school diploma or some college had 2/3 lower odds of relapse compared to those with a bachelor’s degree or higher. Men whose household income was below the federal poverty level has 3 times higher odds of reporting relapse compared to their peers above 200% of the federal poverty level. No other recovery barriers, recovery supports, or demographics were found to be linked with relapse for either women or men.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In the general U.S. population, alcohol consumption increased during COVID-19. Although local and state government responses were highly variable, many recovery experts warned that individuals in recovery were at heightened risk of relapse due to increased stress and less accessible treatment and recovery support services. Surprisingly, this study found that only 5.8% of individuals in recovery from alcohol use disorder relapsed. One explanation for these low rates may be that recovery capital protected individuals from pandemic-related stress by providing them with the necessary resources to cope with stressors. These findings are in line with a proposed biaxial formulation of recovery, which proposes a reciprocal relationship between remission from substance use disorder on the one hand and recovery capital, including health, housing, social relationships, education, employment, meaning and purpose in life on the other. Also, three quarters of those studied here had 5 or more years of recovery and thus may have been particularly well skilled at navigating life challenges, even those more radical ones presented by COVID. At the same time, the study was cross-sectional, and individuals were included in this study only if they self-reported having resolved an alcohol problem and were currently abstinent or drinking at lower risk levels (based on a validated screener for hazardous drinking). Some individuals may have been in recovery at the beginning of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020. Those individuals would not have screened into the study as they would not be abstinent or drinking at lower risk levels.

The “relapse” rates here are likely to be underestimates of all the types of problems experienced by individuals in alcohol use disorder recovery during the pandemic. The researchers in this study also found differences between men and women. For example, although men were more likely to relapse when below the poverty line, women were more likely to relapse when out of the workforce. The gender-differences found in this study echo previous work suggesting different mechanisms of behavior change among men and women in alcohol use disorder treatment and recovery. Furthermore, this study does not explore individuals that identify as non-binary or transgender. Transgender adults face increased levels of discrimination, which is linked to higher rates of substance use, substance use disorder, and substance use disorder treatment. Just as recovery pathways are not identical, the most salient protective factors and risk appear to vary across individuals, specifically along lines of gender.


  1. Most of the sample were in long-term recovery (>5 years), which may have prevented the authors from exploring the nuances among those with less time in recovery.
  2. The survey was only conducted at one time point during the COVID-19 pandemic. Recovery stability and the unique characteristics associated with recovery may vary over the course of the pandemic.
  3. Although the sample is nationally representative, the researchers did not control for local pandemic restrictions or cooccurring mental health conditions. Pandemic-related stressors may have been different in areas with more or less restrictions and those with co-occurring conditions my have been uniquely impacted by the pandemic.
  4. Several of the estimates had large confidence intervals, which signifies a high level of uncertainty around the accuracy of the estimates.

BOTTOM LINE

This study found that, among a nationally representative sample of adults in recovery from alcohol use disorder in the U.S., less than 6% of participants relapsed in the fall of 2020 following the beginning of the COVID-19 pandemic. Such a low relapse is surprising given the increase in alcohol use among the general U.S. population. The researchers also found that pandemic-related stressors were not linked with odds of relapse. These findings do not suggest that the pandemic has not been stressful for these individuals. Instead, it is more likely that aspects of recovery, and recovery capital specifically, enable individuals in recovery to view pandemic-related stressors as manageable and/or have the ability to cope with those stressors. Indeed, the researchers found that recovery capital was protective against relapse for both men and women. This study may also underestimate the “relapse” rates of problems experienced by individuals in alcohol use disorder recovery during the pandemic due to not including those who may have been in recovery at the start of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020 when the study was conducted.


  • For individuals and families seeking recovery: Being in recovery and the associated resources an individual can use to support their recovery are protective against relapse even during major events like the COVID-19 pandemic. If you or a loved one is in recovery from alcohol use disorder, it will likely help to continue developing the individual, social, and community resources to support recovery. If you or a loved one is seeking recovery, it would likely help to consider the available supports and consider how gender identity may necessitate different types of supports.
  • For treatment professionals and treatment systems: The COVID-19 pandemic is predicted to have a lasting impact. The nature of the impact on individuals in recovery specifically is still being delineated. This study found that the number of pandemic-related stressors were not predictive of relapse. They did find the recovery capital was protective against relapse for both women and men, yet some characteristics differed in the risk of relapse between women and men. It is likely to help and unlikely to hurt if recovery capital is assessed and linkages are made to appropriate supports. It is also likely to help recovery chances if treatment and treatment systems consider gender-specific needs and supports.
  • For scientists: This study found that recovery capital was shown to be associated with decreased odds of relapse for both men and women during the height of COVID-19. However, the sample was primarily adults with more than 5 years of recovery. With few adults in early recovery, the researchers did not have the statistical power to detect small to moderate effects for that group. Individuals in long-term recovery may have had the needed time to build their recovery capital and ability to cope with stressors. Future research would benefit from including more individuals in all stages of recovery as well as considering gender-specific supports and intervention designs. Designing interventions that target recovery capital may be an effective and efficient way to increase chances of maintaining recovery, especially during major events like COVID-19. Furthermore, future research could benefit from exploring how local policy responses to the pandemic and associated restrictions influenced recovery.
  • For policy makers: More research is needed to determine the exact impact of COVID-19 on recovery. However, the researchers of this study present findings that suggest adults in recovery from alcohol use disorder experienced low rates of relapse and that their recovery was not negatively impacted by the pandemic. The researchers also found that recovery capital was protective against relapse for women and men. Policy that funds individual, social, and community-level resources for adults in recovery would likely increase recovery chances. Supporting research that explores multi-level interventions is needed to establish the modifiable nature of recovery capital and its associated effect of recovery chances.

CITATIONS

Gilbert, P. A., Soweid, L., Kersten, S. K., Brown, G., Zemore, S. E., Mulia, N., & Skinstad, A. H. (2021). Maintaining recovery from alcohol use disorder during the COVID-19 pandemic: The importance of recovery capital. Drug and Alcohol Dependence, 229, 109142. doi: 10.1016/j.drugalcdep.2021.109142


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WHAT PROBLEM DOES THIS STUDY ADDRESS?

From increases in alcohol use and related deaths among the general population to an unprecedented increase in other drug poisoning deaths, the COVID-19 pandemic has had substantial consequences. With the mandatory stay-at-home orders and increased access to alcohol, experts voiced concern that adults in recovery from alcohol use disorder specifically would be at heightened risk of relapse due to increased stressors (e.g., isolation, unemployment), more unstructured time, and greater access to alcohol. Studies of the general U.S. population have found that alcohol consumption and the number of binge drinking days increased during the pandemic. However, the impact of pandemic-related stressors on those in recovery remains unknown. Thus, the researchers in this study sought to explore if adults in alcohol use disorder recovery were more likely to report relapse if they experienced a greater number of pandemic-related stressors and if there were differences between women and men.


HOW WAS THIS STUDY CONDUCTED?

This study used nationally representative survey data to examine adults that self-reported as being in recovery or having a resolved alcohol problem who were currently abstinent or lower-risk drinkers. Current drinkers were screened by the AUDIT-C to confirm their drinking was not hazardous. The final sample included 1,492 adults and is representative of the general U.S. population. Although screening occurred prior to the COVID-19 pandemic, the survey was conducted in the Fall of 2020, months after COVID-19 was declared a nationwide emergency and states began to shut down infrastructure to prevent its spread.

The primary outcome of interest was relapse during the COVID-19 pandemic (yes or no), defined as drinking alcohol since January 2020 if previously abstinent or increasing alcohol consumption since January 2020 if previously drinking at lower risk levels.

Predictor variables were grouped into four categories: lifetime alcohol use disorder characteristics, recovery threats, recovery supports, and demographic characteristics. Researchers also assessed lifetime alcohol use disorder symptoms via 11 structured questions based on DSM-5 criteria as time in recovery converted into three categories: early recovery (<1 year), intermediate recovery (1-5 years), and long-term recovery (>5 years). Participants were also categorized in three recovery groups based on reported lifetime use of 14 types of services: treated recovery (any use of specialty services, such as in- or out-patient rehabilitation), assisted recovery (any use of lay services, such as mutual-aid groups, and no use of specialty services), and independent recovery (no use of specialty or lay services).

Threats to recovery consisted of a 12-item list of COVID-related stressors based on the Environmental Influences on Child Health Outcomes COVID-19 questionnaire as well as an indicator of minor children in the household. Recovery supports were explored with a recovery capital measure, which provides a global measure of assets that can be leveraged to initiate or sustain recovery, and a general social support scale. There were five options for each item on the recovery support scales with each ranging from strongly disagree to strongly agree. Demographics included race/ethnicity, educational attainment, employment status, relationship status, and poverty status based on income. The researchers then tested how each characteristic was independently linked to the odds of relapse for both men and women.

In this nationally representative sample, among women, 63.7%, 13.2%, and 23.1% reported independent, assisted, and treated recovery, respectively. Among men 57.9%, 16.0%, and 26.1% reported independent, assisted, and treated recovery, respectively. Most women and men (73.4% and 76.5%) identified as being in recovery for more than 5 years. Women had higher average recovery capital and social support scores compared to men.


WHAT DID THIS STUDY FIND?

The COVID-19 pandemic did not impact relapse among most adults in recovery from alcohol use disorder.

Overall, relapse rates among this sample were low. Only 3.1% of participants reported a return to alcohol use after being abstinent, and only 2.7% of participants reported an increase from previously low risk drinking. Most women and men (88.9% and 88.8%) reported that the COVID-19 pandemic did not at all affect their relationship with alcohol or drugs and their recovery. Similarly, both women and men reported that the COVID-19 outbreak did not make it more difficult to resist alcohol or drugs (94.2% and 92.8%). Pandemic-related stressors were not associated with odds of relapse for women or men.

Recovery capital was protective against relapse for women and men.

That said, recovery capital was associated with lower odds of relapse, with similar protection for women and men. For women, a one unit increase in the recovery capital scale was associated with a 10% reduction in odds of relapse. For men, a one unit increase in recovery capital was associated with a 7% reduction in odds of relapse.

Predictors of relapse different for women vs. men.

Among women, each additional lifetime alcohol use disorder symptom was associated with 37% higher odds of relapse. Also, women in early recovery (<1 year) had 10-fold higher odds of relapse compared to those women in long-term recovery (>5 years). Being out of the labor force (e.g., retired, homemaker, full-time student) was linked with a nearly 5-fold increase in odds of relapse. Being never married compared to married or cohabitating was also associated with more approximately a 5-fold increase in odds of relapse among women. Men had fewer predictors that were associated with relapse. Men with a high school diploma or some college had 2/3 lower odds of relapse compared to those with a bachelor’s degree or higher. Men whose household income was below the federal poverty level has 3 times higher odds of reporting relapse compared to their peers above 200% of the federal poverty level. No other recovery barriers, recovery supports, or demographics were found to be linked with relapse for either women or men.


WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In the general U.S. population, alcohol consumption increased during COVID-19. Although local and state government responses were highly variable, many recovery experts warned that individuals in recovery were at heightened risk of relapse due to increased stress and less accessible treatment and recovery support services. Surprisingly, this study found that only 5.8% of individuals in recovery from alcohol use disorder relapsed. One explanation for these low rates may be that recovery capital protected individuals from pandemic-related stress by providing them with the necessary resources to cope with stressors. These findings are in line with a proposed biaxial formulation of recovery, which proposes a reciprocal relationship between remission from substance use disorder on the one hand and recovery capital, including health, housing, social relationships, education, employment, meaning and purpose in life on the other. Also, three quarters of those studied here had 5 or more years of recovery and thus may have been particularly well skilled at navigating life challenges, even those more radical ones presented by COVID. At the same time, the study was cross-sectional, and individuals were included in this study only if they self-reported having resolved an alcohol problem and were currently abstinent or drinking at lower risk levels (based on a validated screener for hazardous drinking). Some individuals may have been in recovery at the beginning of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020. Those individuals would not have screened into the study as they would not be abstinent or drinking at lower risk levels.

The “relapse” rates here are likely to be underestimates of all the types of problems experienced by individuals in alcohol use disorder recovery during the pandemic. The researchers in this study also found differences between men and women. For example, although men were more likely to relapse when below the poverty line, women were more likely to relapse when out of the workforce. The gender-differences found in this study echo previous work suggesting different mechanisms of behavior change among men and women in alcohol use disorder treatment and recovery. Furthermore, this study does not explore individuals that identify as non-binary or transgender. Transgender adults face increased levels of discrimination, which is linked to higher rates of substance use, substance use disorder, and substance use disorder treatment. Just as recovery pathways are not identical, the most salient protective factors and risk appear to vary across individuals, specifically along lines of gender.


  1. Most of the sample were in long-term recovery (>5 years), which may have prevented the authors from exploring the nuances among those with less time in recovery.
  2. The survey was only conducted at one time point during the COVID-19 pandemic. Recovery stability and the unique characteristics associated with recovery may vary over the course of the pandemic.
  3. Although the sample is nationally representative, the researchers did not control for local pandemic restrictions or cooccurring mental health conditions. Pandemic-related stressors may have been different in areas with more or less restrictions and those with co-occurring conditions my have been uniquely impacted by the pandemic.
  4. Several of the estimates had large confidence intervals, which signifies a high level of uncertainty around the accuracy of the estimates.

BOTTOM LINE

This study found that, among a nationally representative sample of adults in recovery from alcohol use disorder in the U.S., less than 6% of participants relapsed in the fall of 2020 following the beginning of the COVID-19 pandemic. Such a low relapse is surprising given the increase in alcohol use among the general U.S. population. The researchers also found that pandemic-related stressors were not linked with odds of relapse. These findings do not suggest that the pandemic has not been stressful for these individuals. Instead, it is more likely that aspects of recovery, and recovery capital specifically, enable individuals in recovery to view pandemic-related stressors as manageable and/or have the ability to cope with those stressors. Indeed, the researchers found that recovery capital was protective against relapse for both men and women. This study may also underestimate the “relapse” rates of problems experienced by individuals in alcohol use disorder recovery during the pandemic due to not including those who may have been in recovery at the start of the COVID-19 pandemic in March 2020 but had recurrence of symptoms or return to alcohol use disorder by Fall 2020 when the study was conducted.


  • For individuals and families seeking recovery: Being in recovery and the associated resources an individual can use to support their recovery are protective against relapse even during major events like the COVID-19 pandemic. If you or a loved one is in recovery from alcohol use disorder, it will likely help to continue developing the individual, social, and community resources to support recovery. If you or a loved one is seeking recovery, it would likely help to consider the available supports and consider how gender identity may necessitate different types of supports.
  • For treatment professionals and treatment systems: The COVID-19 pandemic is predicted to have a lasting impact. The nature of the impact on individuals in recovery specifically is still being delineated. This study found that the number of pandemic-related stressors were not predictive of relapse. They did find the recovery capital was protective against relapse for both women and men, yet some characteristics differed in the risk of relapse between women and men. It is likely to help and unlikely to hurt if recovery capital is assessed and linkages are made to appropriate supports. It is also likely to help recovery chances if treatment and treatment systems consider gender-specific needs and supports.
  • For scientists: This study found that recovery capital was shown to be associated with decreased odds of relapse for both men and women during the height of COVID-19. However, the sample was primarily adults with more than 5 years of recovery. With few adults in early recovery, the researchers did not have the statistical power to detect small to moderate effects for that group. Individuals in long-term recovery may have had the needed time to build their recovery capital and ability to cope with stressors. Future research would benefit from including more individuals in all stages of recovery as well as considering gender-specific supports and intervention designs. Designing interventions that target recovery capital may be an effective and efficient way to increase chances of maintaining recovery, especially during major events like COVID-19. Furthermore, future research could benefit from exploring how local policy responses to the pandemic and associated restrictions influenced recovery.
  • For policy makers: More research is needed to determine the exact impact of COVID-19 on recovery. However, the researchers of this study present findings that suggest adults in recovery from alcohol use disorder experienced low rates of relapse and that their recovery was not negatively impacted by the pandemic. The researchers also found that recovery capital was protective against relapse for women and men. Policy that funds individual, social, and community-level resources for adults in recovery would likely increase recovery chances. Supporting research that explores multi-level interventions is needed to establish the modifiable nature of recovery capital and its associated effect of recovery chances.

CITATIONS

Gilbert, P. A., Soweid, L., Kersten, S. K., Brown, G., Zemore, S. E., Mulia, N., & Skinstad, A. H. (2021). Maintaining recovery from alcohol use disorder during the COVID-19 pandemic: The importance of recovery capital. Drug and Alcohol Dependence, 229, 109142. doi: 10.1016/j.drugalcdep.2021.109142


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