Our broader society, as well as communities of recovery have both limited understanding of (and access to) the many pathways an individual can take to address a substance use disorder. Furthermore, there are prejudices that exist between pathways, limiting our understanding of alternatives, of each other and our ability to help those seeking or are new to recovery. For too long society has had a singular idea of what recovery looks like. We’ve pictured individuals in a circle of chairs encouraging each other and sharing about life’s difficulties. While this form of recovery has worked for countless millions across the world, it is neither the only nor the ultimate way for all. The prejudices that exist between mutual-aid groups and others can only serve to divide the recovery community and alienate those seeking help.

In order to solve this problem, we must educate ourselves about the importance of allowing individuals, in some cases with the help of a treatment professional, to choose the pathway that is best for the individual. Once we’ve begun to understand the importance of choice, we need to develop a basic understanding of the various pathways so that we might help to bridge the gap in understanding. Bridging that gap can help us assist those in or seeking recovery to sustain it; no matter which road they take to get there. Anyone can develop a substance use disorder, so everyone deserves to find and take the path that is right for them.

Defining Recovery

It’s helpful to have a solid foundation upon which to broaden our understanding of the many paths individuals take to enter and sustain their recovery. The traditional understanding of recovery from substance use disorders (SUD) is complete abstinence from substances. This understanding grew out of the mutual aid support group model, namely Alcoholics Anonymous. In fact, there are a variety of accepted definitions of recovery that range from complete abstinence from any and all mind-altering substances to managing/moderating use and everything in between. When working with peers, coming from a place of understanding and honoring the different definitions of recovery often enhances each respectively. It’s important to remember that our own definitions of recovery may be different from someone else’s, but it’s really up to the individual to determine which is best for them.

If a cancer patient only had access to one kind of treatment and that treatment wasn’t working, we wouldn’t tell them, “they must not want to get better.” The patient would be given a list of options and then, usually with the guidance of a qualified provider, would choose the option that appeared best suited to them and their condition. If that treatment didn’t work, there would be another conversation leading to a different path to find the treatment that may ultimately work better.

We must have the compassion and courage to provide those struggling with substance use disorders the same options. Unfortunately, we run into this conflict in some shared spaces in programs of recovery. Specifically, 12-step and mutual aid groups. While there has been conflicting perspectives in the field, emerging from valid life experience within these programs, we must remain mindful that these support groups are facilitated by human beings, and like any secular group of people, informal culturalized norms develop. Unfortunately, there are some norms that have not been conducive of all pathways to recovery. While these are not the formal standards of these programs, they are attitudes and behaviors that have created prejudiced belief systems of multiple pathways to recovery and have not created comfortable atmospheres for all persons in recovery. In fact, it has done the exact opposite and deters some individuals from believing they have the capacity to recover. While this is not attributed to each and every space that mutual aid groups occupy, it does for some. What we must conclude from this truth individuals have experienced is this is yet another motivating force to change public opinion and embrace all of the multiple pathways to recovery. That shift can, in turn, influence the informal set of standards for these mutual aid programs so the individuals participating do not carry their own individualized prejudice into spaces meant to be safe and welcoming for all persons whom are on the path of their own journey in recovery.

This challenge then has the capacity to compound when treatment providers, often publicly funded, utilize approaches exclusively shaped by single pathways. In addition, options continue to remain limited for all pathways when these providers are the only choice for disenfranchised populations. Often, if an individual has access to costly, private treatment options, it’s more likely they’ll be presented with options for the route they take to enter, sustain and maintain their recovery. Unfortunately, a large number of those struggling with active addiction have limited options available due to lack of accessibility and many of the low or no cost providers available adhere exclusively to abstinence-based pathways of recovery.

 

A Cultural Shift in Recovery

“We must accommodate for differences among people; just as there are many different reasons people begin to use, there must be different ways for them to address their use.” – Irina Bogomolova, Founder, Choice in Recovery

The movement for recovery has already been successful in making an impact. With the passage of major federal legislation like the Mental Health and Addiction Parity Act, the Comprehensive Addiction Recovery Act and the 21st Cures Act combined with progressive state and local legislation to better equip communities to address SUD and assist those in recovery, we see how important it becomes to work together despite our pathway. When we as a community understand and embrace the many pathways, a cultural shift begins in recovery, treatment and our broader communities. This shift is necessary to reduce the prejudice and shame experienced by those with substance use disorders while seeking or emerging in their recovery and those trying to assist them in that journey.

 

Mutual-aid Support Groups

“The steps are to be lived through hard work and commitment to the process. In the end, finding a spiritual awakening in step twelve says you’re supposed to give back to the Fellowship that you are now a member of. Today I’m a proud member of Narcotics Anonymous. I have sponsors. I go to meetings. I do service work and it has saved my life.” -Thomas Hernandez

Mutual-aid support groups have become the most visible of the many pathways. They focus on sharing experience between individuals to provide support. Many details between these groups differ, but common threads like volunteerism (service) and self-sustenance can be found throughout; and most seem to follow a similar process:

Process Utilized in Many Mutual-Aid Support Groups

1. Acknowledging substance use-related problems and their severity

2. Admission past efforts have failed

3. Expression of commitment to change

4. Inventory of assets and vulnerabilities

5. Development of recovery action plan

6. Recovery initiation, resource mobilization, recovery stabilization

7. Management of continuing patterns of negative thinking or behavior

8. Character and identity reconstruction (who we were and what happened, who we are what we’re doing now)

9. Reconciliation and reconstruction of key relationships

10. Recovery maintenance rituals (e.g., fellowship, service to the community,

Of mutual-aid support groups, AA and the many other 12-step groups it inspired, are the most widely known and the basis for similar programs. Beyond 12-step groups there exists many other forms of mutual-aid groups. Self Management And Recovery Training (SMART Recovery) and LifeRing are secular (or nonreligious) groups; while others like Wellbriety, Celebrate Recovery and Refuge Recovery are based on spiritual models. Women for Sobriety exists to provide a mutual aid group exclusively for women suffering from alcoholism. Moderation Management serves those for whom alcohol use specifically has caused a problem and now want to achieve moderation in their use. These groups adhere primarily to the recovery process outlined above in some form or another.

Unfortunately, because prejudices can and do exist between the mutual aid groups themselves, there’s often a struggle to identify one’s own recovery identity from others struggling with active use. “All recovery meetings” provide a space where all those who struggle with addiction or are affected by it can come together to discuss recovery, promote understanding and benefit from fellowship.11 All recovery meetings provide a neutral space for individuals to come together regardless of pathway to honor differences and help each other.

The opportunity for individuals to choose the group that best suits them (i.e. severity of their condition and openness to spiritual practice) may not only improve individual outcomes, but also how the community views the diversity between mutual-aid groups.

Natural Recovery

“I did it on my own. I did not attend support groups, I didn’t go to therapy. I practiced being with people, without depending on a copious amount of alcohol in my system to make that possible. With that, I also practiced not blacking out, not passing out, not throwing up. It took a lot of personal work; it took getting comfortable with being uncomfortable. It took going on a mindful run before going out to a big party. It took owning my choices, treating lapses in my moderation not as something wrong with me, but as awareness around why I drank too much that time, and what I needed to put into place in the future. I attained my ability to drink in moderation, by addressing all of those things that led to me to drink excessively in the first place. These days, I stand in my fear; I deal with whatever response my body produces when I get nervous. If I am uncomfortable, I experience the discomfort. I drink when I am not escaping or numbing. And it takes something, and I don’t recommend it for everyone, but I know for some, it can work because I am walking proof.” -Irina Bogomolova

While rarely discussed, natural recovery is estimated to account for between 50-90% of those in recovery from alcohol use disorders.12 While this statistic may come as a shock to the traditional recovery community, most of us have likely heard others describing a time they addressed problem behaviors independently, including substance use. Natural recovery includes individuals who have not sought help formally through mutual-aid support groups or medical/therapeutic treatment. Factors like severity of condition, “recovery capital” and co-occurring mental health conditions ultimately impact the success of those seeking recovery without formal treatment or mutual-aid.13 Recovery capital is both an emerging term in the field, and a collective element that is breaking the stigma of addiction. It is defined as including social support, emotional well-being, financial stability, values and aspirations.

While the movement for recovery continues to grow, access to recovery capital grows as well. We are finding more resources available to further support self-actualization, confidence and strength, creating communities conducive to natural recovery. Abstinence or moderation can also be achieved by individuals engaging in faith communities and addressing the issues leading to their substance use through spiritual practice. It is crucial to remember those engaged in natural recovery can benefit greatly from recovery support, including peer interactions. Individuals seeking recovery through this pathway usually find help in the same factors that contribute to successful abstinence in mutual aid groups, like a sense of belonging within a community, accountability and service. It’s important to note that individuals sustaining recovery via the natural pathway often begin moderating their use instead of achieving abstinence. This is important because while those who have sought help in a self-directed manner are, by CCAR’s definition, in recovery, but they may face stigma from within the abstinence-based recovery community. These individuals may not accept this pathway because moderation of use cannot be reconciled within their own individual pathway. Understanding the prejudice existing even amongst the many pathways in the recovery community is extremely important when making strides to unify all persons in recovery for a holistic goal of recovery-ready communities.

 

Harm Reduction

“Harm reduction provides hope, high fives, disease prevention, hugs, keeps people alive, mourns those we have lost, and fights like hell for a healthier and safer tomorrow.”
-Lisa Raville, Harm Reduction Action Center

Defining harm reduction as a pathway to recovery is a relatively new concept when compared to mutual aid support or natural recovery. It can be argued that any pathway to recovery could be considered harm reduction as it’s purpose is to limit harm in social, physical and psychological factors, but it’s main goal is to reduce risk arising from substance use as much as possible.17 This includes providing access to clean syringes and tools for IV users, medication-assisted treatment, access to and educating on the use of the overdose reversal drug naloxone, testing for party drugs like MDMA, and any form of mitigating exposure and/or transfer of disease. There is a contradictory perception that this method is counterproductive and enables the individual by providing people who use drugs with all that is necessary to use, thus, further supporting their addiction. However, in the progressive recovery community it is believed that harm reduction provides a safety net of medical care, pro-social interactions with health workers, and compassionate support for people actively using substances to live long enough to engage in treatment when they are well enough to do so. Harm reduction allows individuals to live healthier lives, further develop recovery capital, and often, reduce negative consequences associated with substance use, meeting the modern, more inclusive, definitions of recovery.

Syringe Access & Safe Injection Programs

Syringe access and safe-injection programs (also known as supervised consumption services, safe injection facilities, or drug consumption rooms) are contentiously rejected in our communities, usually because the general public hasn’t been provided the opportunity to learn about the benefits and safeguards they offer. Syringe Access, commonly referred to as, “needle exchanges” provide the tools necessary to inject drugs as safely as possible to mitigate the risk of contracting or spreading diseases like HIV or Hepatitis and the risk of unnecessary bodily harm, like abscesses. Safe injection programs take syringe access a step further by providing everything necessary to mitigate that harm within the safe confines of a medical facility in which to use drugs. This allows people who use drugs to eliminate not only the spread of disease or unnecessary physical consequences, but also protects against overdose, as they are monitored by trained professionals who can utilize overdose reversal medications and readily call for help. There are 90 safe injection facilities around the world, some operating for as long as 29 years, and there has never been an overdose death in one of these facilities.1819 Syringe access and safe injection sites provide an opportunity to connect those who use drugs with services such as enrollment in health care, referral to social services, and in many cases, referral to treatment. These programs create an opportunity for some of the most vulnerable to step out of an often isolated lifestyle, and be exposed to wellness support.

 

Medication-Assisted Treatment (MAT), Pharmacotherapy

“About 5 years ago I started on a MAT program, I had been in and out of jail and using IV heroin for the past 7 years. Some people talk about how going cold turkey or into a quick medical detox is the way to go, but for me personally I could never just stop using if I wasn’t in jail. All that changed once I started on methadone. Once I was on methadone, my relapses got shorter, and shorter, and the time between using became longer. Methadone allowed me to quit using once I had started and that was completely new to me, and as I reached my therapeutic dose I could stop using altogether. Today I have successfully tapered off methadone and have remained clean and sober off everything since. I truly believe today that methadone saved my life. It allowed me the time, and support to turn my life around, and to find a new way to live.” -Darrin Morrison

Of the many pathways, Medication-Assisted Treatment (MAT) and Medication-Assisted Recovery (MAR) are emerging as some of the most controversial. The prescription of medications like methadone, buprenorphine (Suboxone, Subutek), naltrexone (Vivitrol) and disulfram (Antabuse) used to assist treatment like counseling and stabilizing individuals has proven to be an effective route for some. MAT is considered a pathway of harm reduction as it reduces harm in social, physical and psychological aspects; though the same can be said of any pathway to recovery. MAR is considered a pathway of recovery, as individuals live for extended periods in recovery while taking supportive medications.

Unfortunately, many from abstinence-based pathways are critical of MAT, citing concerns that individuals utilizing these medications are merely “substituting one drug for another.” For example, while those on MAT can indeed be members of Narcotics Anonymous, some groups may limit the individual’s ability to honestly share during meetings or even hold service positions. It’s extremely important to note that between 2002 and 2010, utilization of MAT fell from 35% to 28%, despite medication’s use in conjunction with therapy proving effective for many.

There is a very real difference between MAT and MAR. MAT refers to the use of medication in conjunction with acute therapies both in inpatient and outpatient settings. MAR is a term developed to describe individuals engaged in sustained recovery and under the care of a physician prescribing medications like buprenorphine, methadone, etc. As a result of prejudices held by both the potential MAT patient and the community, many individuals are hesitant to utilize medications, even when necessary to limit harm. When an individual does make the decision to pursue medication-assisted recovery, they often face barriers to joining the recovery movement via traditional methods like mutual-aid support groups. Structured peer support with an aim to directly provide services for the MAT and MAR communities were established in part, as a result of discrimination experienced by individuals in the recovery community.

In addition to assisting individuals in entering recovery, MAT and MAR also aim to:

  • Keep individuals alive
  • Increase the chances they’ll stay in treatment
  • Decrease illicit substance use and criminal activity
  • Assist individuals to secure employment

When I first entered recovery, I had a clear and concise understanding of recovery. In short, I believed recovery meant abstinence from any and all mind-altering substances. I remember discussing the idea of medication and denouncing it because I “didn’t want to replace one substance for another.” I thought those on suboxone and methadone were weak; that they didn’t really want “recovery.” As I grew in my recovery, I began to explore what recovery looked like for others trying to sustain their recovery; those experiences and time spent with those on MAT specifically, began to shift my perspective. Then, as a result of many different factors, I had a recurrence of my use. Becoming physically dependent again meant that though I desperately wanted to stop using heroin, I couldn’t without experiencing the pain of withdrawal. I reached out for help, a doctor at a treatment facility began a regimen of buprenorphine. Once I reached a therapeutic dose and was engaged in additional therapy, I was on my way to wellness again. The experience of personally utilizing MAT in concert with therapy changed my outlook completely. Today I understand entering recovery is an intensely personal experience, each individual has their own path to take and if medication prescribed by a physician with an understanding of addiction is a part of that path, I will honor that journey.

If medication used in conjunction with therapy and additional resources allows those with SUD to lead more self-directed and fulfilling lives, we must should support that effort for those who determine it is the right choice for them.

Where does this leave us?
We have a responsibility as a community to support recovery, no matter which pathway an individual chooses to get there. In order to live up to this responsibility, we must understand not only the importance of choice, but also of the choices available. As put forth in the introduction to this paper, both broad society and the recovery community possess limited access to and understanding of the different pathways to recovery. We also have a tendency to stigmatize pathways that differ from our own, thereby building a wall between those of us in recovery and those experiencing substance use disorders, keeping them from the help they deserve.

The recovery movement must continue to fight for equitable access to treatment and recovery support for all. We cannot accomplish this if we each remain in our own respective silo, believing our way is best. Our chances of making a lasting impact are multiplied when we set aside our differences and work towards common solutions, together.

When we begin to understand one size does not fit all, a shift occurs. When someone says “I need help,” this shift allows us to answer, “You’re taking the first step, let’s look at your options.”