Pathways to Recovery from SUDs

Behavioral Health Care Substance use disorders (SUDs) are associated with heavy costs to affected individuals, their families, and society. Engaging in recovery provides affected individuals with opportunities to manage their problems and make changes to support their recovery.

There are many pathways to recovery from SUDs, including professional treatments; medications for opioid, alcohol, or nicotine addiction; mutual-support programs (Twelve Step and other); other forms of peer-assisted recovery (e.g., navigators, coaches, certified recovery specialists); family recovery (for those affected by loved ones’ SUDs); and solo recovery in which professional services or mutual-support programs are not used (Flaherty, Kurtz, White, & Larson, 2014; Kelly, Bergman, Hoeppner, Vilsaint, & White, 2017; Laudet, 2013; White, 1996, 2017). The latter is usually appropriate for less severe forms of SUDs. These pathways can be secular, spiritual, or religious (Flaherty et al., 2014).

The recovery of given individuals is affected by the severity of their SUDs; the negative effects on their families; motivation and readiness to change; the availability of support; and relevant coping skills. The focus depends on the phase of recovery these individuals are in.

If a particular recovery pathway does not help, another can be recommended. Some individuals need multiple pathways to manage their SUDs, especially those with more severe problems. Many people experience years of active addiction before they embark on recovery, and it is not unusual to make multiple attempts before they can sustain it.

This article reviews the evidence that many effective pathways to recovery are available, any of which can lead to significant improvements in the lives of individuals and families affected by SUDs. Despite the media focus on negative outcomes of active SUDs or addiction, there is good news as well: many people make significant changes in their lives by following one or more of these recovery pathways.

Evidence that Recovery is Effective

Many studies, surveys, and publications document the physical, dental, psychological, family, social, legal, work, school, or financial problems caused or worsened by SUDs (Daley & Douaihy, 2019a; Laudet, 2013; White, 2017).

On the other hand, recovery often leads to improvements in many areas of life and more benefits accrue over time. The evidence that recovery is effective for millions of Americans comes from results of clinical trials, population surveys, mutual-support program membership surveys, and other reports. Following is a summary of multiple sources of this evidence that there are many pathways to recovery (NIDA, 2012).

Source 1: Studies of SUD Treatment

Hundreds of clinical studies funded by the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and other organizations document significant improvements from evidenced-based behavioral, medication, or combined treatments. NIDA and NIAAA have documented the efficacy of individual, group, couples, and family treatments for individuals and families affected by SUDs. In addition, NIDA and NIAAA studies have identified medications for recovery from opioid, tobacco, and alcohol use disorders. These treatments help individuals with SUDs stop or reduce substance use and improve the quality of their lives.

Clinicians have access to a substantial array of evidenced-based treatment literature to improve their clinical practices. Many of these interventions are described in papers, reports, and therapy manuals published by NIDA and NIAAA, and in more than sixty Treatment Improvement Protocols (TIPs) published by SAMHSA. These TIP manuals describe behavioral, family, or medication treatment for SUDs, and related problems such as child abuse and neglect, co-occurring psychiatric disorders, suicidality, physical and cognitive disabilities, HIV/AIDs, viral hepatitis, and chronic pain. Furthermore, most of these materials are available at no cost in hard copies or .pdf files on the NIDA, NIAAA, and SAMHSA websites.

SAMHSA also publishes “Pocket Guides” on the use of medications for treatment of alcohol use disorders (AUDs) or opioid use disorders (OUDs). Medications are considered the first-line treatment for most opioid use disorders and decrease in overdose deaths, criminal behaviors, risky sexual behaviors, transmission of HIV or hepatitis C, and drug cravings. These improve physical and mental health, functioning at home or work, help individuals focus on using behavioral therapy, and increase retention in treatment. Medications for AUDs are moderately effective, but underutilized.

Source 2: Studies of Family Treatment

SUDs are associated with many adverse effects on family members, including children. Family interventions can help engage individuals with SUDs in treatment (Daley, Smith, Balogh, Toscolani, 2018; Szapocznik, Zarate, Duff, & Muir, 2013). Even if the family member with the SUD refuses help, treatment can help families deal with the impact of a SUD on the family unit or on individual members. Studies of treatment of couples or families show positive effects on the members with the SUDs, the family unit, and individual family members (Klostermann & O’Farrell, 2013; Smith & Myers, 2004). Family studies involving adolescents with SUDs also show academic improvements in addition to improvements in the family and functioning of adolescents (Szapocznik et al., 2013).

Source 3: National Survey of Prevalence of Recovery

This was a nationally represented community population survey conducted by Dr. John Kelly and colleagues from the Harvard Recovery Research Institute (Kelly et al., 2017). Results showed that 9.1 percent of the adult population (over 22 million adults in the US) who once had an alcohol or drug problem are in recovery and no longer have a problem. Many different pathways to recovery were used, including professional treatment, medications, mutual-support programs, other community supports and services, and self-recovery methods. Nearly two-thirds of the sample had over five years of recovery, and nearly a third had over fifteen years. Nearly half of this sample did not use professional treatment or mutual-support programs.

Source 4: Life in Recovery Surveys

In recent years the US, UK, Canada, and Australia administered “Life in Recovery” surveys to thousands of individuals with addictions. Results showed that recovery is associated with dramatic improvements in all areas of life and that there are multiple routes to recovery. Recovery is beneficial for individuals with addictions, their families, their communities, and their country’s health and economy.

Over three thousand individuals in the US completed this survey (Laudet, 2013). They were active in their addictions for an average of eighteen years and entered recovery at an average age of thirty-six. Over half achieved more than ten years or recovery, which is impressive because once people achieve five years of recovery (i.e., remission), the odds of relapse are no different than the odds of new people developing addictions.

There were huge differences when individuals’ functioning in active addictions were compared to their functioning when they were in recovery. Following is a summary of these improvements.

Family and Community Involvement

Becoming victims or perpetrators of violence (450 percent reduction)
Removing children from the home due to abuse or neglect (600 percent reduction)
Regaining child custody for those who gave up children during active addiction (110 percent increase)
Participating in family activities (50 percent increase)
Engaging in volunteer work (170 percent increase)
Voting (40 percent increase)

Improved Health and Increase in Healthy Behaviors

Emergency department visits (800 percent decrease)
Hospitalizations for medical problems or to be medically withdrawn from addictive substances (100 percent decrease)
Cases of hepatitis C or HIV (500 percent decrease)
Medical checkups (nearly 200 percent increase)
Dental checkups (120 percent increase)
Receiving health insurance (100 percent increase)
Getting a primary care physician (65 percent increase)
Engaging in regular exercise (125 percent increase)
Having healthier eating habits (250 percent increase)
Having untreated mental health disorders (450 percent increase)

Work or School Improvements

Fewer instances of getting fired or suspended from work (nearly 500 percent decrease)
Fewer instances of missing work (nearly 1,400 percent decrease)
Higher rates of steady employment (60 percent increase)
Having positive job reviews (80 percent increase)
More involvement in school or training (75 percent increase)
Starting a business (80 percent increase)
Losing a professional or occupational license (55 percent decrease

Legal Improvements

Less criminal involvement with fewer arrests (1,000 percent decrease)
Time in jail or prison (730 percent decrease)
Fewer driving under the influence charges (1,930 percent decrease)
Less likely to damage a car or property (1,280 percent decrease)
Less likely to lose a driver’s license (825 percent decrease)
Regaining the right to vote (510 percent increase)

Financial Improvements

Lower rates of filing for bankruptcy or not being able to pay bills (50 percent increase improvement)
Owing back taxes (30 percent decrease)
Restored credit (80 percent increase)
Paid debts (100 percent increase) or taxes (45 percent increase)\
Saved for retirement or other reasons (215 percent increase)

Source 5: Studies and Membership Surveys in AA or NA

Many studies document the positive effects of active participation in mutual-support programs for SUDs, especially Alcoholics Anonymous (AA; Donovan, Ingalsbe, Benbow, & Daley, 2013; McCrady & Tonigan, 2015). Some individuals show steady involvement in AA or Narcotics Anonymous (NA) over years, others taper off over time, and others are variable in how they use these programs.

Membership surveys of AA and NA document improvements in health, mental health, relationships, work, and quality of life. Many members remain engaged in these programs for years (AA, 2015; NA, 2014).

There are over 56,000 AA and fifteen thousand NA groups and online meetings, thousands of other Twelve Step groups and online meetings, and over one thousand non-Twelve-Step groups in the US such as SMART Recovery, Women for Sobriety, LifeRing, and Secular Organization for Sobriety (SOS; Kelly et al., 2017). A survey of over six thousand members in AA found the average length of sobriety to be ten years, and a survey of over 22,000 members of NA found the average length of sobriety to be over eight years (NA, 2014). Many members of AA and NA also engage in professional treatment or take medications. Active involvement in these mutual-support programs, with or without concurrent professional care, leads to improvement in health, relationships, work, and quality of life.

Source 6: Membership Survey of Al-Anon Members

The most recent survey of Al-Anon found that 92 percent of members reported their lives were “very positively” affected by being members (Al-Anon Family Group, 2016). They reported improved physical and mental health, daily functioning, and fewer work-related problems. Other mutual-support programs for families are unique to specific communities.

Recommendations for Practitioners

Become familiar with the many pathways of recovery and offer options to clients in a shared decision-making process
Be flexible when discussing mutual-support programs and do not take the rigid stance that there is only one program that works. Practitioners in recovery especially have to be aware that what worked for them may not necessarily work for others or be an approach others desire
Offer medications for clients with OUDs or more severe AUDs, for clients who struggle sustaining sobriety from alcohol use, and for nicotine use disorders
Consider the family perspective and offer education and linkages to services when appropriate
Engage individuals and families in recovery in educational programs so that they can share what helped them. My colleagues and I include individuals and family members in recovery at our conferences, other educational programs, and some of our workgroups
Disseminate information and share resources. My colleagues and I share resource information to providers, clients, and families who are not conversant with the broad range of clinical, mutual-support, or other services for individuals or families affected by SUDs

References

Al-Anon Family Group. (2016). 2015 membership survey. Retrieved from https://al-anon.org/pdf/2015membershipsurvey.pdf
Alcoholics Anonymous (AA). (2015). 2014 membership survey. Retrieved from https://www.aa.org/assets/en_US/p-48_membershipsurvey.pdf
Daley, D. C., & Douaihy, A. (2019a). A family guide to coping with substance use disorders. New York, NY: Oxford University Press.
Daley, D. C., Smith, E., Balogh, D., & Toscolani, J. (2018). Forgotten but not gone: The impact of the opioid epidemic and other substance use disorders on families and children. Commonwealth, 20(1), 93–121.
Donovan, D. M., Ingalsbe, M. H., Benbow, J., & Daley, D. C. (2013). Twelve Step interventions and mutual support programs for substance use disorders: An overview. Social Work in Public Health, 28(3–4), 313–32.
Flaherty, M. T., Kurtz, E., White, W. L., & Larson, A. (2014). An interpretive phenomenological analysis of secular, spiritual, and religious pathways of long-term addiction recovery. Alcoholism Treatment Quarterly, 32(4), 337–56.
Kelly, J. F., Bergman, B., Hoeppner, B. B., Vilsaint, C., & White, W. L. (2017). Prevalence and pathways of recovery from drug and alcohol problem in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence, 181, 162–9.
Klosterman, K., & O’Farrell, T. J. (2013). Treatment substance abuse: Partner and family approaches. Social Work in Public Health, 28(3–4), 234–47.
Laudet, A. (2013). “Life in recovery”: Report on the survey findings. Retrieved from https://facesandvoicesofrecovery.org/wp-content/uploads/2019/06/22Life-in-Recovery22-Report-on-the-Survey-Findings.pdf
McCrady, B. S., & Tonigan, J. S. (2015). Recent research into Twelve Step programs. In R. K. Ries, D. A. Fiellin, S. C. Miller, & R. Saitz (Eds.), The ASAM principles of addiction medicine 5th ed., pp. 1043–59). New York, NY: Wolters Kluwer.
Narcotics Anonymous (NA). (2014). NA 2013 membership survey. Retrieved from https://www.na.org/admin/include/spaw2/uploads/pdf/PR/NA_Membership_Survey.pdf
National Institute on Drug Abuse (NIDA) (2012). Principles of addiction treatment: A research-based guide (3rd ed.). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition
Smith, J. E., & Meyers, R. J. (2004). Motivating substance abusers to enter treatment: Working with family members. New York, NY: The Guilford Press.
Szapocznik, J., Zarate, M., Duff, J., & Muir, J. (2013). Brief strategic family therapy: Engaging drug using/problem behavior adolescents and their families in treatment. Social Work in Public Health, 28(3–4), 206–23.
White, W. L. (2017). Recovery rising: A retrospective of addiction treatment and recovery advocacy. Meadville, PA: CreateSpace Independent Publishing Platform.
White, W. L. (1996). Pathways from the culture of addiction to the culture of recovery: A travel guide for addiction professionals (2nd ed.). Center City, MN: Hazelden.

Dennis Daley, PhD

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Dennis C. Daley, PhD, served many roles at the University of Pittsburgh School of Medicine. He is the author of many articles, treatment manuals, books, and guides for families and children affected by addiction. He helped facilitate B2H programs at two hospitals.