I assume the reader has heard the term “Recovery Oriented Systems of Care” and of the related clinical practices organized around what is called “Recovery Management.” Regardless, by way of review:
- ROSC was a specific macro-system inter-agency networking concept.
- RM was a micro-focused set of concepts and practices for services seated within and beneath ROSC.
Lately I seem to notice a trend among addiction professionals and recovery advocates. What trend do I seem to notice? It seems to me that a significant portion of addiction professionals and advocates are tipping toward privileging using over abstinence.
- That is to say, there seems to be a trend toward making using the more sacred goal and the more hoped-for experience, over sobriety.
- And it seems I notice a move toward defining recovery in a way that includes using as the normal and central feature of recovery.
It has been pointed out that historically, the primary mental health sector has had a strong partial recovery concept and a less robust full recovery concept, while the SUD sector has had a strong full recovery concept and less robust partial recovery concept.
While that is true, it is my opinion that for those with severe, chronic, and complex addiction illness, a framework centered in a goal of continuing using is fraught with peril.
I’ll go further and say that it seems to me that both the Recovery Advocacy Movement and the Recovery Orientation revolution for clinical services I personally witnessed spring up in the late 1990’s have now been shifted and repurposed by some into a:
- Using advocacy movement; and
- Using orientation for clinical services.
Among other things, I seem to notice the four ingredients of Addiction, Treatment, Sobriety/Abstinence, and Recovery are now thought of by some as producing a kind of Using Violation Effect – whereby those four ingredients are considered to add harms.
In this new world view I consider some additional concepts and practices. I’ve listed some below.
- Using for the sake of recovery
- Abstinence for the sake of using
- Recovery for the sake of using
- Abstinence is relieved by using
- Abstinence for the sake of recovery is relieved by using
- Recovery is relieved by using
- Recovery for the sake of recovery is relieved by using
- Recurrence of abstinence is a prequel of using
- Recurrence of use is relieved by using.
- Recurrence of recovery is relieved by using.
A background in ROSC and RM
The reader might ask, “What were ROSC and RM?”
These concepts and related practices were largely birthed and developed within the Behavioral Health Recovery Management (BHRM) Project. That project was begun and operated across a 10 year period within my previous workplace (Fayette Companies/Human Service Center). I served on the steering committee of the BHRM project for the entire ten years of its existence (roughly 1997-2007). The BHRM project was operated across all of our agency’s programs, and we became a living laboratory. As a result of this effort, various concepts and practices were innovated and developed within our agency during the BHRM project. “Recovery Coaching” is one example; for those that are interested, here’s our original Recovery Coaching manual.
And concerning Recovery Coaching itself you might have noticed it has seemingly been replaced by “Peer Support”. And in some current versions of Harm Reduction, one Peer Support method is the Peer Support worker using with the peer they are supporting while the peer is using.
What concerns me most in all of this is that it seems a Recovery Orientation for clinical services (study recovery and have those lessons inform treatment) is being replaced by a using orientation. That is, rather than adding an orientation and having an expanded menu of options, recovery orientation seems like it’s in danger of becoming obsolete.
- It seems like it’s been years since I’ve heard anyone even mention ROSC.
- It seems like managing using is becoming more popular in some clinical circles than managing recovery.
- It’s almost as if using with a good conscience is slowly becoming the sole marker of well-being.
For those that would like more about original…
- Recovery Orientation for clinical services;
- Recovery Oriented Systems of Care as a service framework; or
- Recovery Management as a set of principles and practices for services;
…I can make a few reading recommendations.
BHRM Statement of Principles This is a short read listing and describing the central BHRM concepts and practices.
Frontline Implementation of Recovery Management Principles This is a read of several pages. It’s an interview of our CEO who chaired our BHRM steering committee and includes the history and lessons learned inside our project.
Addiction Recovery Management: Theory, Research, and Practice. This is a book published by Springer. The two editors centered the book around Recovery Orientation, ROSC, and RM. The chapters are written by various authors from different backgrounds, settings, and service organizations.
Here are a few posts of my own that reflect my time in the BHRM project to a relatively greater degree than my other posts:
Planes, Car Repair Shops, and Dentists. This short read brings in lessons from outside the field.
Addiction and the Stages of Healing. This is a link to an entire series proposing a long-term research agenda and a unified model of thinking and clinical care.
The Four Pests: recovery, sobriety/abstinence, addiction illness, and treatment. Not a short read, but a relatively straightforward one noting some cautions from a project of the past outside of our field.
Recovery Orphans. Not a long read, but a challenging one. It consists of four separate short essays on the same topic. Each essay is a blend of philosophy and science. The essays become increasingly ambiguous and challenge the reader to reflect.
Study Betel Nut Before You Finalize Your Public Health or Harm Reduction Policy.
Peer Support, or Harm Reduction, or Recovery Coaching? This straightforward read presents a framework that blends these three practices within a Recovery Orientation perspective and a Recovery Oriented System of Care framework, while retaining Recovery Management purposes.
recoveryreview.blog 
Dear Brian, Thank you for this perspective and the resources. I am currently in research, studying policy, and work to develop recovery oriented programs and policies that encourage, as Best and Ivers suggested in their 2022 paper, “human flourishing” through individual, social, and community recovery capital building behaviors. I also have some experience in direct services as a peer and as a social worker. I am unaware of a trend where peers or counselors are, especially in cases of severe, chronic, and complex (SCC) SUD “tipping toward privileging using over abstinence.[…] a trend toward making using the more sacred goal and the more hoped-for experience, over sobriety. […and] defining recovery in a way that includes using as the normal and central feature of recovery.” This trend would be highly germane to my research as I would want to understand what forces are causing this to happen. Please let me know how you came to this general observation. And if this is more hypothesis, how you might suggest testing it? The implications of such a trend are profound as a shift to using in cases of SCC SUD would reduce the effectiveness of psychosocial and medication treatments. At the same time, we also know that meeting people where they are is far more effective at reducing hazardous use than is telling people where they need to be. This brings me to the trend I have noticed: some programs are, mostly because of the poor definition of SUD, seeking to treat people with less than SCC SUD and are modifying their programs accordingly. This is, I suspect, a function of some programs recognizing their inability to effectively support folks with SCC SUD. This inability to support these folks is a primarily a function of US policy, not of the programs. The US failure to provide those who live within it’s borders a basic social safety net drives providers away from providing services because they are unable to support people who do not have the bare minimum of recovery capital required to initiate recovery (i.e., they are unhoused, uninsured, lack status, can’t afford not to work even for a day, etc etc.) Please feel to reach out to me if you’d like to discuss a research strategy. -Kurt
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Kurt, thanks for your thoughtfulness. I’m going to take some time and pull together some thoughts that are worth using in a proper reply. In the meanwhile I just wanted to acknowledge your reply and thank you for it. Stay tuned for my actual reply down the road.
Brian
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Kurt,
Are you suggesting that you two may be observing similar trends but might have different explanations?
If I understand the implications of your observation, could we be looking at systems evolving to respond to mild to moderate SUD, because that’s what they have the resources to effectively treat? And, remission from mild to moderate SUD typically involves ongoing, non-problematic use. (Put another way, the appropriate endpoint for most patients will be moderate substance use.)
This is good for patients with mild to moderate SUD, but is likely to be bad for patients with severe SUD. Those endpoints aren’t clinically appropriate for this population.
You didn’t say anything about this, but it leads me to think that, in practical terms, these SCC SUD cases are clinically neglected and harm reduction programs have become the primary caregivers for the SCC population. These programs also don’t target full remission/recovery as an endpoint.
Thank you!
Jason
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Kurt, here are some thoughts that come to mind as I attempt to craft a reply.
First, in terms of testing this notion of mine as a hypothesis, what comes to mind is the work of John Caplehorn in Australia back in the 1990’s especially, related to methadone maintenance therapy (MMT). He did work to quantify clinician attitude and overall clinic attitude, and then collect that data to evaluate clinicians and clinics. His work comes to mind as an early example of the kind of research you describe. In his case, he was looking for an empirical answer to the question of what kind of clinician attitude, if any, would be associated with better or worse MMT patient outcomes – if they did differ on those variables. It’s also relevant as in MMT patients he found an abstinence-oriented clinician attitude was worse for outcomes, if my memory serves, and the best outcomes were associated with a more medical primary-care style of clinician attitude (even over a neutral case-management type of attitude). His work might give you some interesting insights or perhaps a bit of background for a jumping off point.
My statements in my blog post are my own, developed from direct observations of my own over the most recent 5 years or so.
1. I’ve seen long-standing multi-day addiction conferences no longer hold sessions on Addiction Illness itself (the SCC group per se), no longer hold sessions about addiction recovery per se, actively isolate and mention sobriety/abstinence as broadly problematic as clinical targets, and no longer have sessions about addiction treatment techniques. Rather, I’ve seen conferences that had such content for many years, shift entirely to content on helping bring about continuation of use, early engagement strategies, and improving safety of use.
2. I’ve noticed trainings and even clinical providing organizations don’t mention exclusion criteria for continuation of use strategies. And I’ve noticed a commensurate lack of listing the advantages and disadvantages of the continuation of use method, and of the abstinence or eventual abstinence method. That is to say, I hear advantages of continuation of use and disadvantages of abstinence, and nothing else.
3. I’ve heard at trainings, and various clinicians, describe continued safe use as ego syntonic, and working for abstinence and what we would think of as broad full recovery (even aside from abstinence) as ego-dystonic. In this, it’s almost as if 3rd wave CBT and its emphasis on mindfulness has been adopted toward not acknowledging SCC addiction illness when it exists, and “urge surfing” to overcome a craving has been shifted toward “use surfing” where successful use is a preferred clinical goal (less distressing).
4. I’ve noticed research reports and theoretical papers don’t seem to mention exclusion criteria for continuation of use, including on a per-substance class category basis, and/or on a SCC basis at all – with or without drug class distinctions.
5. Lastly, I’ve noticed a relative proliferation of new outpatient providers offering prescription medications (other than medications to treatment opioid use disorder) with addiction potential, and not mention exclusion criteria, not mention specifics by drug class for inclusion, and generally overlook continued use as an indicator (vs wellbeing) including for the SCC population.
Thanks again for your thoughtfulness, Kurt.
Peace.
Brian
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Here’s an example I just saw this weekend in this paper on PRC attitudes toward cannabis use among clients.
I think this paper (http://dx.doi.org/10.1177/00220426231176446) describes some fairly sophisticated takes from peer recovery coaches (PRCs). In particular, framing cannabis as an “exit drug” is an interesting take.
The authors included the following with their description of PRC attitudes:
“PRCs discussed several potential benefits of clients using cannabis during treatment or recovery. Consistent with evidence supporting cannabis as a harm reduction strategy (Siklos-Whillans et al., 2021), substitution with cannabis was considered preferable to using other drugs associated with a greater risk of fatal overdose. Many PRCs differentiated between ‘moderate’ and ‘problematic’ use and were generally accepting of cannabis use they did not perceive as leading to negative consequences.”
I’m struck with the sense that ambivalence with a supportive and cautious “wait and see” stance that affirms autonomy may be a pretty appropriate position.
Yet, the authors indicate a desire to train and supervise this ambivalence out of these recovering peers with their conclusion “Training and supervision for PRCs should aim to increase PRCs’ acceptance of non-abstinence recovery pathways. Additional training and technical assistance in this area will be important as cannabis use trends upward among treatment-seeking populations.”
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Thank you both for the thoughtful replies. And yes, I do think we are seeing the same trend but are looking at different causal factors. Over the last few days I’ve come to additional clarity in regard to what policy phenomenon I am speaking to: Diagnostic ambiguity, a lack of social safety net, and the undervaluing of treatment services (coaches, counselors, etc) for people who use insurance to pay are driving the market to instead provide what people want, and in a world that is genuinely hostile to people who are, for example, poor or unhoused, that is using. Diagnostic ambiguity makes arguing for sobriety hard because current assessments fail to capture the reality that virtually all severe and chronic SUD are incredibly complex. And that the medicalization of such a complex social and psychological set of problems and dynamics doesn’t help us develop interventions that reduce the social and community factors that make using more desirable than sobriety. As I’ve said before in comments on other posts on this blog, we (as providers and researchers) need to fight for those with SCC SUD who can’t imagine why being sober is critical to self-actualization. In so doing, we will learn much about how fortunate we are to have found a recovery that works for us — but moreover ‘why.’ At least for me, I’ve come to realize that my ‘why’ has/had very little to do with me and much more to do with my opportunities, privileges, and plain luck. My take away is that we need tools that understand addiction recovery as on a continuum that includes total abstinence to harm-reduction and everything in between while being extremely critical of the negative external factors that make using more desirable than sobriety or even, for those (I suspect) with less extreme cases, moderation.
As for further research, I would like to test the following policy hypothesis: low reimbursement, diagnostic ambiguity, and a failure to provide meaningful social and community oriented recovery capital building opportunities to those with severe, chronic, and complex SUD — NOT the science of recovery or addiction– are encouraging the treatment market to shift toward providing harm reduction instead of a complete continuum of care. AND that this shift (favored by Medicine) has created role ambiguity and drift for many of the providers, especially peer recovery coaches/specialists.
Thanks again, -kurt
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Kurt, I really do think I’m following you and as such I agree on all points. Well put. In my experience (which is limited to adults and almost all of which present with SCC SUD or something close to that) the social and environmental variables are extremely important. It’s all of the above, not “this” or “that”. Agreed.
Brian
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