Developing Broad Consensus on How We Conceptualize the Resolution of Substance Misuse  

The first major effort to define recovery in America was in 2007, when the Betty Ford Foundation, now the Hazelden Betty Ford Foundation published What is recovery? A working definition from the Betty Ford Institute. The paper noted that “recovery is a voluntarily maintained lifestyle composed characterized by sobriety, personal health, and citizenship.” Our understanding of the continuum of substance use, from social use without consequence to addiction has improved significantly in the years since it was first published. A myriad of recovery definitions of recovery have been penned as our understanding of the dynamics in play have improved. As a house divided, none have achieved broad consensus.

Copious amounts of ink have been spilled in academia over the years on defining recovery. The defining of recovery has become a cottage industry, everyone seems to have a different one, none of which broadly resonates across our society. This is a matter of deep contention an increasingly a front in our larger culture war. It is a formidable barrier to forward progress. As Bill White noted in Addiction Recovery: Its Definition and Conceptual Boundaries has consistently failed to achieve consensus, is not just an academic question, but it has economic and political context as industries have formed around harm reduction, addiction prevention, treatment and recovery support. We are awash in definitions that have become increasingly broad and used to define any positive outcome for any person experiencing any form of substance misuse. How you define recovery is almost like a Rorschach test on where you stand in respect to your experience of substance misuse and your orientation to any of the related fields of interest.

Science is revealing that resolving a substance use condition is quite nuanced, even as we increasingly lump all of what can occur in respect to healing under the term recovery. This last point will inevitably create additional challenges in how the general public understands substance misuse and its spectrum of resolution. It may serve us well as this juncture to assigning the spectrum of resolution of varying severity or forms of substance misuse distinct terms in order to assist society in understanding the complex dynamics in play across the continuum of healing. A taxonomy of healing.

NIDA had taken an all-encompassing strategy to define all resolution under the term recovery. In its 2022 to 2026 Strategic Plan, NIDA notes that “Recovery from SUDs means different things to different people. Broadly speaking, it is a process of change through which people improve their health and well-being while abstaining from or lessening their substance use or by switching to less risky drug use. For some, this may mean complete abstinence; for others, recovery could be ceasing problematic drug use, developing effective coping strategies, improving physical and mental health, or experiencing some combination of those or other outcomes.”

The NIDA strategic plan is reflective of our current scientific understanding of the continuum of substance use from non-harmful use, through misuse to severe substance dependence. Severe SUD typically leads to loss of control. For those of us whom who experience it, refraining from all use is often indicated. It is not an uncommon experience for persons on the far end of the spectrum to die attempting to moderate their use in the way that a person with a less severe form or one in an earlier stage of progression can manage with moderation efforts. It is important to remember that point.

NIDAs approach is consistent with the most recent definition of recovery from NIAAA. “Recovery is a process through which an individual pursues both remission from AUD and cessation from heavy drinking. Recovery can also be considered an outcome such that an individual may be considered ‘recovered’ if both remission from AUD and cessation from heavy drinking are achieved and maintained over time. For those experiencing alcohol-related functional impairment and other adverse consequences, recovery is often marked by the fulfillment of basic needs, enhancements in social support and spirituality, and improvements in physical and mental health, quality of life, and other dimensions of well-being. Continued improvement in these domains may, in turn, promote sustained recovery.” It includes cessation of heavy drinking as characterized by drinking no more than 14 drinks a week as recovery if sustained over 90 days.

My own views on recovery have certainly evolved, although it also true that the first definition of recovery from Betty Ford is the one that resonates the most deeply with me. I am grateful for this space at Recovery Review for those sharing views and challenging our collective thinking. In Mid-December, Brian Coon posted How Helpful is the 2022 Definition of Recovery from the NIAAA?  His overall perspective is favorable. He noted that he liked it for several reasons including that it seems to hold space for harm reduction approaches, incrementalism of long/slow change, and addressing people at different stages of change, and of treatment, on a per-problem basis.

A few days later, Jason Schwartz posted More on the NIAAA definition of recovery. His post links this NIAAA Webinar: Using New Definitions and Tools to Support Alcohol Recovery. Jason notes that he has some dissonance with it and describes how recovery has cultural and well as scientific connotations and that people in recovery can and do develop a recovery identity. He asks if it make sense to develop research definitions that create discord with cultural understandings (even if their boundaries are poorly defined). He explores the discord and considers how research and cultural understandings interact and influence each other when there are such rifts.

This dissonance plays out with vitriol in the harm reduction, treatment, and recovery support space. People calling those who have pursued full abstinence in order to not die from addiction as elitists. On another “side” there are still far too many people in abstinence-based recovery who continue to view any properly taken medication as inconsistent with recovery despite all the evidence to the contrary. Our lack of consensus-based terms to describe the resolution of substance use conditions across a continuum of severity and type are at the heart of much of the conflict.

Drug policy, including the defining of recovery is now a front in our larger culture wars. Jason highlights this in his recent piece Liberalism? Or libertarianism?  There has been public backlash to these approaches. Under the NIDA definition, a person using a clean needle to use drugs may be considered to be in recovery as they are reducing the risk of infection. While polices that seek to keep people alive and improve their overall health are certainly evidenced based and a good thing to be embraced, I don’t think our society is at the point in which using a clean needle is equivalent to the types of systemic changes people in more recognizable recovery undergo. Low threshold engagement and harm reduction efforts make sense and should be expanded but lumping it all under the term recovery is a bridge to far.

From a 50,000-foot level, this is causing our collective interests a great deal of harm. We can ill afford the polarization of the stakeholder groups interested in saving more lives from the impact of substance use across our communities. We need broad consensus that bridge the gap between the scientific and society. We must bridge science and culture to move forward with a nuanced taxonomy that describe reduced risk stages and forms of substance use resolution.

Lumping all change under the term recovery obscures our capacity to understand the continuum of SUD resolution. The term was historically embraced to express the experience of persons with the most severe forms of substance use. A term indelibly linked to the kind of lifestyle that hundreds of thousands of people like me with the most severe form of substance use experience, which includes no recreational or misuse of substances as a life sustaining imperative.   

How does this differ from an interventional or process of changes people undergo from a less severe form of the condition? What we call things matters and improves our capacity to positively affect change.

From a science perspective:

• How would a more nuanced model of substance misuse resolution inform work done in the field?
• Can we develop more granular understanding of resolving a substance use condition in order to provide better weatherproofing for recovery remission?
• What course of strategies would recommend to a person based on the severity of their presenting condition if we could articulate it better and work to understand individual risk factors and level of recovery capital?

From a cultural perspective:

• What value would a consensus definition of the continuum of substance use and the resolution of a substance use condition have for our whole society?
• How can improved insight and more concise definitions of resolving a substance use condition support better targeting of interventions earlier in problem resolution?
• What can we learn from the past about the collective outcome of all of our infighting?

We should stay consistent with the historic use the term recovery to describe those who have found resolution of a severe form of the condition requires cessation of use and systemic life changes. We can then describe the resolution of less severe forms consistent with both our scientific and broader cultural understanding of what this looks like and under which conditions and for whom moderation or other interventions may be an effective healing strategy.

It is an imperative to develop a conceptual SUD healing framework with broad consensus. To assign the resolution of a substance problems of varying severity and type distinct terms within a taxonomy of healing. It would help us understand the complex dynamics involved in resolving a substance use condition. For policymakers and researchers out there for whom this resonates, perhaps it is time to convene a focus here and take action.

For those of you who may disagree, I hope you continue the dialogue in respectful in open ways in order to assist all of us in developing a conceptual framework that fosters broad consensus and greater public understanding of the complexity of substance use conditions and their resolution.

While challenging, the prize is well worth the effort.