In September 2023, the Substance Abuse and Mental Health Services Administration (SAMHSA) released a report, “Recovery from Substance Use and Mental Health Problems Among Adults in the United States.”
Although the definition and concept of recovery from addiction have been morphing for some time, the self-reported data contained in the report, coupled with SAMHSA’s definition of recovery, lays out starkly that what is considered recovery today is far different from what it has been considered historically. In some ways, it begs the question, then, “What is the purpose of addiction treatment?” What are the implications for addiction treatment providers, who for decades have operated with a mission of helping their patients stop their use of drugs and alcohol?
Using data from the 2021 National Survey on Drug Use and Health (NSDUH), SAMHSA’s report shows that 70 million adults aged 18 or older perceived that they ever had a substance use or mental health problem. For substance use specifically, of the 29 million adults who perceived that they ever had a substance use problem, 72 percent (or 20.9 million) considered themselves to be in recovery or to have recovered from their drug or alcohol use problem. (See SAMHSA’s press release.)
Of the 72 percent who considered themselves to be in recovery or to have recovered from their drug or alcohol use problem:
- 65 percent reported using alcohol in the past year;
- 68 percent reported using marijuana in the past year;
- 60 percent reported using cocaine in the past year; and
- 61 percent reported using hallucinogens in the past year.
Curiously, it doesn’t appear that respondents were asked whether they used illicit opioids in the past year. Encouragingly, substance use recovery was more prevalent among adults who received substance use treatment.
To the traditional addiction treatment provider and many in the recovery community today, recovery and drug and alcohol use cannot co-exist. One possible but unlikely explanation for the SAMHSA-reported data is that all of the respondents who identified as being in recovery but having used drugs or alcohol in the past year is that their recovery began within the last year.
This would presume that their definition of recovery includes abstinence. But this is not likely. Consider SAMHSA’s definition of recovery:
“Recovery is a process of change through which individuals improve their health and wellness, live a self-directed life; and strive to reach their full potential.”
No mention of abstinence from drugs and alcohol. What this means is that for millions of people, recovery can and does include moderated use of drugs and alcohol.
In 2004, SAMHSA’s Center for Substance Abuse Treatment said, “Treatment for substance use disorders is designed to help people stop alcohol or drug use and remain sober and drug free. Recovery is a lifelong process.” Twenty years later, it’s a far different message coming from SAMHSA.
As recently as 2019, the Pennsylvania Certification Board defined recovery as highly individualized, requiring abstinence from all mood and mind-altering substances, and may be supported by using medication that is appropriately prescribed and taken.
Talk about evolution and conflict.
When I began my recovery from substance use disorder (SUD) nearly 12 years ago, I went to treatment with the intention of stopping my drug use. I came to believe at that time from those who helped put me on this path, including those within the treatment facility as well as peers outside of it, that the foundational element of recovery was abstinence from all drugs. In fact, my first few years of recovery were so philosophically rigid that I even believed medications to treat opioid use disorder (MOUD) disqualified an individual from recovery.
I’ve drastically changed my views and beliefs since those early years, because I’ve seen the power of MOUD and, conversely, the grave danger anti-MOUD stigma poses. Sadly, though, many still believe the way I once did. I’ve held true to my own definition of recovery, which does include the foundational element of life without drugs or alcohol. But I am not so self-righteous as to believe that those who choose another path or definition of recovery should be discounted or forced to “recover” in a particular way.
For many in the treatment system and recovery community, abstinence remains a cornerstone of recovery. But for many other stakeholders in the broader addiction treatment ecosystem — payers, regulators, and policymakers in particular — although abstinence may once have been the goal for them, the purpose of treatment and definition of recovery have moved far afield of those historical tenets.
Nora Volkow, Director of the National Institute on Drug Abuse, said, “Healthcare and society must move beyond this dichotomous, moralistic view of drug use and abstinence and the judgmental attitudes and practices that go with it.”
So what does this mean for addiction treatment providers philosophically and operationally? If the purpose of addiction treatment is not necessarily to stop drug and alcohol use, what is it? One managed care organization in Pennsylvania recently talked about the purpose of addiction treatment in much the same way as SAMHSA defines recovery, addressing health, home, purpose, and community. This would seem to mean that providers are now expected to address not only addiction but mental and physical health, too, at least to some extent, as well as myriad social determinants of health. In fact, it is what payers expect providers to do today.
This is an attempt to integrate various human services and incorporate harm reduction into the addiction treatment system, and it is a sea change. The addiction treatment system was not built in this way. This is not to say that this movement is wrong, or that the treatment system is not evolving or cannot evolve along with the definitions of treatment and recovery. But to do so will require an ongoing cultural shift with which many in the treatment system — from the front line to the CEO office — struggle. It will also require a much broader systemic change than simply within addiction treatment organizations. Regulation, oversight, and payment structure must also change to reflect the changing expectations and demands placed on providers.