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Review Article
Narrative review: The Meaning of “Recovery” for Addiction Treatment and Research
Mimi Rosealie Borrelli1, Suna Mantori2, Stephen Kaar3*, Mike Kelleher4 and James Bell5
1Stanford University School of Medicine, USA
2Guy’s and St Thomas’, NHS Foundation Trust, London
3Department of Psychosis Studies, King’s College, London
4Lambeth Addictions Consortium, South London and Maudsley NHS Foundation Trust, London
5King’s College, London

ABSTRACT
Background
“Recovery” has been made the focus of UK drug policy. It is a term that means different things to different people and is difficult to operationalize. In this narrative review a discourse analysis was conducted on the use of the term “Recovery” and its many associated connotations in the literature on addiction treatment.

Key findings
“Recovery” has been most commonly equated with abstinence. It is also often associated with participation in 12-step fellowships. When used in this context, and increasingly as the word is used in academic literature, “recovery” goes beyond abstinence to incorporate transformation and growth in many areas of life. “Recovery” is neither a clearly defined state of being nor a single path or programmed. However, there is reasonable consensus on factors associated with or facilitating recovery. Social reintegration, stable housing, relationships, employment and a meaningful social role have long been recognized as key markers of good treatment outcomes and have recently been rebranded ‘recovery capital’.

Conclusion
Use of the term “recovery” involves an ideological shift, based on the limitations of professional treatment and the greater importance of family and societal support. It is widely understood as a long-term process. Funding treatment services based on clients achieving “recovery” narrowly defined as abstinence from all drugs not only misses the broader meaning of “recovery” but potentially compromises the effectiveness of treatment in reducing harm from drug dependence.
KEYWORDS
Addiction; Alcohol; Cocaine; Crack; Drugs; Heroin; Opioid; Recovery; Substance abuse; Treatment

Introduction
‘Recovery’ has become an increasingly important term in policy statements and research on addiction in the UK. For the previous decade, pragmatism dominated drug policy, with the main objectives of drug treatment including crime reduction [1], harm reduction in reducing blood borne viruses and creating stability in ongoing drug users. In 2010 the UK government published a new drug strategy which places “recovery” as the central aim of treatment [2]. ‘Recovery’, however, is a hard term to define and research papers often refer to differing meanings of the word [3]. “Recovery”, as a vague and distant ideology may provide inspiration for some individuals, but without defined operational criteria it is a difficult topic for empirical research [4]. This paper conducted a literature review to identify the current attempts at defining “recovery”, to provide an overview of the diverse ways in which the term “recovery” has been understood, helping to clarify its meaning and usage.
Methods
A comprehensive literature review of the Medline and Embase databases using Ovid was conducted from 2011 to August 2017. The following terms were searched for as keywords: “recovery” and “addiction” and “substance abuse”, “alcohol”, “drugs”, “cocaine”, “crack”, “opioid” or “heroin”. The terms “recovery” or “treatment” had to be included in the title to ensure that the concept of “recovery” was the focus of the article and minimize the number of articles which focused on outcomes of interventions. There were no language restrictions imposed, and the Ovid ‘human’ subjects filter was applied. 349 studies were identified in the initial search. The title and abstract of all studies were read for their suitability by two independent authors. Articles were included if they:

1. Defined recovery as an outcome measure
2. Described research conducted on alcohol or substance use disorders
3. Described research in human subjects.

Articles were excluded if they were not original research studies. Both qualitative and quantitative studies were accepted. Full text was obtained for the 122 studies. A qualitative assessment of these articles identified recurring themes for meanings and uses of the word “recovery”. These themes have been organized into subsets, which are outlined in the following section.
Results
Different meanings of “Recovery”
Recovery as abstinence: There is a pervasive assumption that recovery is a state of sustained abstinence achieved by someone who has previously been dependent on a drug or drugs; the American public overwhelmingly believes that recovery is ‘trying to stop using’ alcohol or drugs [5]. Messages in the media refer to recovery exclusively in terms of substance use [5]. According to the American Society of Addiction Medicine [6], recovery includes “a commitment to abstinence-based sobriety”. In the UK, individuals seeking treatment also often identify abstinence as their primary goal [7], and even the only change they hope to achieve [8]. In a recent survey, the majority of staff and clients in a treatment programmed in Australia were of the opinion that to remain in recovery means to remain abstinent from all drugs and alcohol [9]. In a multiple-choice survey, more than three quarters of individuals in America and Australia who self-identified as in recovery endorsed ‘total abstinence’ as their personal goal and definition of recovery [5,10].

However, among former addicts, there is considerable testimony that abstinence from drugs is not sufficient for recovery. This is well recognized in Alcoholics Anonymous (AA); ‘A man who is on the wagon may be sober physically but mentally he may be almost as alcohol-minded as if he were drunk’ [11]. Denzin [12,13], in an analysis of Alcoholics Anonymous notes, states that the key to recovery and sustained effective change is not merely abstinence, but rather a complete transformation of the self. Prolonged alcohol and drug misuse can lead to disruptions in functioning in almost all aspects of life [14,15]. Individuals often continue to face challenges relating to employment, housing and relationships [16] despite no longer using alcohol or drugs. Many report things ‘are not going fast enough’, meaning other areas of their lives were not improving as fast as they had hoped [17]. White [4] argues that the resolution of drug and alcohol problems is not the focal point but a by-product of a larger personal and interpersonal process of developing a healthy, productive and meaningful life.

Recovery as Moderation or Controlled Use of Drugs: Many individuals, especially those with mild-to-moderate substance dependence, manage to achieve moderated substance use [18,19].

The UK Drug Policy Commission Consensus Group defines “recovery” to mean “voluntary sustained control over substance use which maximizes health and wellbeing and participation in the rights, roles and responsibilities of society” [20]. Interviews with former heroin addicts in the UK who had been 4 years abstinent from heroin revealed that over half had since used alcohol, cannabis or crack cocaine, which they did not perceive to be inconsistent with their recovery [21]. This is consistent with the simple definition of “recovery” as a state in which drug abuse and related behavior are no longer problematic in life [22]. Although abstinence is always seen as an essential part of recovery through Alcoholics Anonymous, the Big Book comments ‘if he can drink like a gentleman our hats are off to him’ [23].

Recovery as health: Recovery as a medical term connotes return to health after illness or trauma [24]. WHO [25] conceptualizes health as a complete state of physical, mental and social well being and not merely the absence of disease? Three overarching principles emerge in the most recent definitions of recovery: The freedom from dependence; restoration of health; and the contribution to society, where, through recovery people are able to live, work and learn to participate in their communities [20,26-28]. The focus is not only on the elimination of pathology (substance use) but on global health and quality of life, the same measures applied in other areas of chronic disease management. Many people with substance use problems (especially those who seek treatment) often have poor quality of life, and people with a poor quality of life are more vulnerable to substance use disorders [29,30].

The Centre for Substance Abuse Treatment [31] suggests the term ‘remission’ depicts the elimination of problems related to abuse or dependence, and ‘recovery’ conveys remission plus the achievement of global health.

Recovery as a process: Laudet and Storey [10] found overwhelmingly that individuals experience recovery not as an endpoint, but as a process of ‘change and growth’ in multiple areas of life. Metaphors of recovery often involve ‘steps’ or ‘pathways’ and recovery is seen as a process in common usage and in professional and mutual aid circles [4].

The Oxford English Dictionary [32] defines recovery as a process of retrieval or return to a previous state. This implies something of value, lost through addiction, can be regained. In response to open-ended questions, recovering individuals describe recovery as a process of regaining an identity lost in addiction: ‘Recovery is going back to me’; ‘I was never born with a drink in my mouth’ [33]. For individuals such as the Alcoholics Anonymous founders who typically were professional men who previously ‘had a life’ (job, family, reputation) and lost much of it to alcohol, this makes sense. However, defining recovery as a process of regaining oneself may be inappropriate for individuals who come from marginalized and disadvantaged backgrounds. Many of the clients presenting to treatment programmers have little positive to recover [5]. A survivor of childhood sexual abuse states, ‘recovery implies you return to something you were before the illness, but I have no before’ [34]. This has led some writers to suggest that ‘recovery’ may be better understood as recovering the lost opportunity of becoming what they were meant to be before they started using drugs and alcohol [4]. Such a conception involves elements of psychological growth, healing, self-redefinition and recognition of the need for change and transformation [21,35]. The latter is often triggered by one or more ‘rock-bottom’ events which reveal the unacceptable extent to which their identity has been damaged by addiction [36].

Recovery as affiliation with self-help groups: Religious and spiritual affiliation, such as 12-step fellowships, emphasizes recovery through the growth of spiritual awareness. It is an aim in the 12-steps models of recovery to help individuals undergo a profound personality change [37], a ‘transformation of the self’ [12]. Involvement in religious and self-help groups in the community consistently shows a modest positive relationship with abstinence [38-40]. Religious and spiritual factors have been said to be amongst the three most important factors in recovering from heroin use in Glasgow [21,41] and are rated more important as time in recovery increases [9]. However, many individuals entering addiction treatment show lower levels of spiritual or religious involvement relative to the general population. Some report that the ideological base of self-help programmers is inconsistent with their own life philosophies [42,43].

Factors facilitating recovery

Despite the diverse elements that have been identified as constituting “recovery”, and the various paths by which it may be reached, there is rather more agreement over the factors which facilitate recovery, or indicate that it is occurring. Recovering individuals report that there is a distinction between negative factors (adverse consequences of drug dependence), which are important in initiating change, and positive factors, which help to maintain change [44,45]. As people address their substance abuse there is an initial focus almost entirely on staying abstinent, but the longer an individual is in recovery the less important abstinence and more important other components become [9,46]. Non-abstinence factors include employment, education, family reunification, emotional health, physical health and spirituality. McLellan and colleagues [47] argue that the immediate focus of reducing substance intake is necessary, but once this foundation is established, individuals can concentrate on living a ‘normal life’. Best and co [21] found that a group of successfully recovered former heroin and alcohol users within completely different contexts all highlighted similar non-abstinence factors as crucial in their recovery.
Complexity and heterogeneity make “recovery” a difficult phenomenon to measure. Granfield and Cloud [42] have attempted to capture the individuality and yet commonalities in recovery journeys by coining the term ‘recovery capital’. Recovery capital comprises the internal and external resources that can be drawn upon to initiate, sustain and maintain recovery from alcohol and drugs problems [48,49]. It does not wholly reside within the individual, but in varying degrees at different times in individuals, families and communities [50]. Recovery capital is said to accumulate with time spent abstinent and is essential for sustained recovery [51-53]. Subsequently, quality of life and life satisfaction increase linearly with time in “recovery” [17,54]. Laudet [33] created a composite measure of recovery capital by combining measures of social support, spirituality, meaning, and religiousness factors and 12-steps affiliation and reported that this composite score accounted for 60.6 % of the variance in quality of life.

Internal recovery resources: Granfield and Cloud [42] sub-categories ‘recovery capital’ broadly into social, human and cultural capital. Human capital refers to the internal resources such as personal health, self-efficacy, confidence and more broadly, personal development and growth [49]. The inclusion of ‘voluntary lifestyle’ and ‘voluntary control over substance use’ in definitions of recovery highlights the importance of volition in the recovery process, which is compromised in addiction but can be recovered [55]. Motivation for change and coping skills to deal with temptations and stress, are protective in recovery [42,56]. Self-efficacy and psychological wellbeing predicted abstinence in heroin users [57]. Finding a sustained source of hope, inspiration and self-esteem in fundamentalist religion or the Alcoholics Anonymous 12-step programmed predicted abstinence in former drinkers [58]. Changes in psychological resources including interpersonal skills, life coping skills and personal identity are among the key predictors of long-term development, transformation and desistance from offending. Ability to visualize an alternative and more desirable and feasible future alongside a desire and determination to restore a spoiled identity is what distinguished successful from unsuccessful recovering heroin users. This concept of a ‘spoiled identity’ was central to a successful recovery strategy, most importantly being able to reflect upon their drug-using identity and its negative consequences. On the other hand, those who attempted to stop using purely for the sake of others were less likely to be successful [36].

Kaskutas et al., [59] investigated the importance of specific internal elements to those in recovery when describing their own personal definition of ‘recovery’. Popular elements included “Handling negative feelings without drinking or using drugs like I used to”, “Taking responsibility for the things I can change” and “ Being honest with myself”, signifying a strong concordance between the personal significance of these resources and their proven utility in the recovery process. External recovery resources: External resources in recovery include emotional and social support from friends, family, peers, community, spirituality and faith. Individuals develop their identity within a social context, and many severe and prolonged substance abusers migrate towards substance-using cultures, influencing access and attitudes towards drugs, and intensifying the associated problems [60]. Recovery involves social re-integration; disengagement from one culture and entry into another [61]. Supportive relationships with peers, families and communities are critical for ongoing recovery as virtually all outcomes of interest are affected by the social networks in which individuals are embedded [17,62].

Other external resources include housing, employment, education, training, and volunteering. Substance misuse can increase the risk of homelessness [63]. Residential instability in turn can increase substance misuse, lead to treatment re-administration and represent significant obstacles to social reintegration [64,65]. Employment increases legitimate income and can improve standards of living with better access to housing, food and leisure [42,66]. Education, employment and housing are also reported as important priorities at all stages of recovery [16,41]. Secure accommodation is associated with reduced substance use, fewer arrests, less crime and increased likelihood of obtaining permanent housing and employment [67-70].

Engagement in meaningful activities is protective against relapse [42] and is the single most powerful predictor of quality of life and improved day-to-day functioning amongst those in recovery. Those involved in activities that are meaningful report being happier, less anxious or depressed, having a greater sense of self-esteem and self-efficacy and fewer health symptoms [7,71,72]. As individuals engage with the community they can build social networks, which facilitates the transition between social groups.

Medication-assisted recovery: In the US, the concept of “Medication-Assisted Recovery” has been an attempt to promote access to self-help movements for people receiving methadone. This inclusive approach involves bridging the traditional ideological divide between abstinence-oriented and maintenance-oriented treatment, and reducing the stigma associated with opioid substitution treatment. Two decades ago, with self-help fellowships the centrality of abstinence from all drugs extended to rejection of use of methadone for heroin addiction. In the US few individuals previously considered those maintained on methadone to be ‘in recovery’ [73]. Narcotics Anonymous ( NA) meetings, although inclusive of those still using or on ‘drug replacement therapy’, could with hold the right of these participants to speak at meetings so to not confuse the message of ‘recovery’ being centered on total abstinence [74]. Similarly, SMART Recovery (Self-management and Recovery Training) works on fostering a mutual-aid group environment and does not incorporate medication management into their vision of recovery, although they do support the appropriate use of prescribed addiction medication [75]. However, denying medically and socially stabilized methadone patients the status of “recovery” can have undesirable and stigmatizing consequences [76], as well as denying users the benefit of the long-term community support which self-help fellowships offer. The central argument has been that it is not the use of a specific medication, but rather the motivation and setting for using the drug which determines whether a person is in recovery [4]. Abstinence may be an unattainable goal for some using medication [21].

In the US the legitimacy of opioid substitution treatment has been recognized by professional and advocacy organizations [73]. Likewise, with the shift in UK drug strategy towards recovery-orientated treatment goals, the UK government clearly recognizes opioid substitution treatment as an important facilitator in a patient’s recovery process [77]. To address the objectives of the 2010 UK Drug Strategy, an expert working group published The ‘Recovery Orientated Drug Treatment’ report which acknowledges the well-documented reduction in harm associated with remaining in treatment [78]. The report also recognizing its limitations, namely the risk of drifting in to long-term medication-assisted treatment. To address this, it is suggested that treatment should be delivered in a dynamic and personalized way within the framework of a four-step recovery journey [79]. Importantly, medication-assisted recovery should function as a means of stabilizing patients so that they may build recovery capital [80].
Conclusion
Defining “Recovery”
In common usage, “recovery” is a state-usually abstinence, sometimes controlled drug use, sometimes improved health and well-being. “Recovery” also refers to a process, commonly involving affiliation with self-help fellowships and involving a change in outlook and relationships as well as social reintegration, a process sometimes conceptualized as rebirth [10].

White has proposed that any definition of recovery should avoid restricting the framework to a particular strategy or style [4]. Individuals differ in vulnerability, drug exposure, motivations and circumstances, making a unitary concept of recovery difficult. Some individuals require extensive professional treatment or medication, and others no assistance at all aside their own volition [65,81]. Recovery can be part of a drift minimally impacting life or result from a sudden and permanent quantum change [82-84].

More than 30 years ago McLellan and colleagues developed the Addiction Severity Index (ASI) [85], a multi-domain instrument by which to assess both the severity of an individual’s problems, and their need for assistance in treatment settings. The domains of the ASI-medical, employment, alcohol use, drug use, legal, family and psychological-differ little from the domains of life now referred to as “recovery capital”.

What has changed since the ASI was developed has been an increasing recognition of the limits of professional treatment-whether drug free or opioid substitution treatment. The ASI was developed as a treatment tool, but the important implication of the literature of the last decade is that “recovery” should not be thought of primarily in relation to formal treatment services-rather, recovery in its many manifestations occurs in the community [65]. White [50] proposes that ‘destabilization of addiction’ and ‘recovery initiation’, can occur within an artificial environment, but ‘recovery maintenance’ can only be fully achieved within a natural environment.
Measuring “Recovery”
In the UK “recovery” has acquired salience when it was placed at the centre of drug policy in 2010 [20]. Measures of the quality and effectiveness of recovery services have been based predominantly in a short-term outcomes framework. For example, one measure of effectiveness in early pilots of “Payment by results” was “Discharged from treatment successfully (free of drug (s) of dependence) and do not re-present in either the treatment system or in the criminal justice system in the following 12 months” [86]. Although there has been a clear shift in UK drug policy away from the notion of abstinence, the emphasis on evidence-based healthcare and the primacy accorded to randomized trials of interventions in evaluating evidence means that most treatment studies cover relatively short time periods [87]. This skews our evidence base towards short-term outcomes of structured interventions, however short-term abstinence is poorly predictive of long-term remission [88].

Vulnerability to relapse is ongoing, and recovery is best understood as a long-term undertaking [4]. Treatment studies should thus reflect this, incorporating longer follow-up periods and assessment of the many quantitative and qualitative domains as discussed in this review to more accurately capture the individual and heterogeneous experience of recovery. This in turn can inform treatment programmers and support services on which aspects of recovery they should be focusing that are relevant to recovering individuals [59]. Many individuals themselves feel recovery is endless, describing themselves as ‘recovering’ as opposed to ‘being recovered’ and that ‘there is no such thing as graduating’ [5]. It is questionable whether the available research can inform the complex processes of stability and change over a life course [89].

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Citation: Borrelli MR, Mantori S, Kaar S, Kelleher M, Bell J (2017) Narrative review: The Meaning of “Recovery” for Addiction Treatment and Research. J Addict Addictv Disord 4: 012.