What is recovery from addiction? Is it simply abstinence? Can it include successful moderation? How about use of maintenance medications? Am I in recovery if I haven’t taken heroin or cocaine since 1988, but have used alcohol in moderation for more than twice as long as my initial addictions? What if I smoke marijuana, in a state or country where it is legal—or use it medically?
The addiction field has struggled with defining recovery at least as long and as fiercely as it has with defining addiction: Since we can’t even agree on whether it’s a disease, a learning disorder, or a criminal choice, it becomes even harder to figure out what it means when we say someone has overcome an addiction problem. Indeed, for some, addiction, by definition, can’t be overcome, merely managed.
According to one frequently cited survey, some 23 million people in the U.S. say that they once had a problem with drugs or alcohol but no longer do.
But because “recovery” in popular culture has become synonymous with abstinence through a 12-step program, representing this statistic as “recovery” can be misleading. In fact, although the term “in recovery,” as opposed to “recovered” or “ex-addict,” is part of the language of the 12-step community, 12-steppers are actually in the minority of people who have kicked at least one type of drug problem.
If history had played out differently, with marijuana remaining legal and tobacco illegal, marijuana might be seen as an acceptable part of recovery, while tobacco would clearly be a relapse.
This confusion makes the debate extremely emotional. People in 12-step recovery often feel that the term belongs to them: If you say you are in recovery and abstinent but not “in the program,” you may be dismissed by some as a “dry drunk” who hasn’t done the necessary psychological and spiritual work to qualify for the term “sober,” making you at extra high risk of relapse.
And if you say you are in recovery and have moderated an addiction or still take maintenance medications, many of the same 12-steppers will be angry about the appropriation of a term that they perceive as offering high status in direct proportion to the length of time someone has spent abstinent and in the program.
The argument has gotten so fierce that some advocates want to drop the term entirely and start afresh.
Two major groups, the Betty Ford Institute Consensus Panel (BFICP) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have tried to resolve the debate in recent years. But neither has done so satisfactorily, to my mind. Addiction, as I see it, is compulsive use or behavior despite negative consequences—and if you have resolved that condition in any way that leaves you socially and occupationally healthy in a stable way, you are “in recovery.”
But the experts place more conditions on it. The BFICP published its definition in the Journal of Substance Abuse Treatment in 2007. Their short version labels recovery as a “voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship.”
To their credit, this panel of experts, which included notables like psychologist Tom McLellan, once deputy drug czar under Obama, who now heads the Treatment Research Institute, and recovery historian William White, does include people who take maintenance medications like methadone and Suboxone as prescribed as being “in recovery.”
Historically, abstinence-based programs regarded maintenance patients—even those who didn’t drink or take other drugs and were otherwise healthy—as “still using,” only counting recovery once maintenance drugs have been stopped. Now, however, even Hazelden sees maintenance as a form of recovery, as do all the major health organizations from the WHO to the CDC and NIH. The BFICP is in line with these groups.
Troublingly, however, the BFICP excludes everyone who may use alcohol or drugs responsibly. For example, an alcoholic who never drinks, but smokes pot once a month or so without compulsion or consequences is automatically excluded, as is someone who goes from dangerous drinking to moderate drinking. For me, such people, if they have sustained their moderation for the appropriate time periods, must be included in any sensible definition of recovery. I don’t see any reason to keep them out other than prejudice: If they are no longer engaging in addictive behavior related to substances, to me, they’re in recovery.
Moreover, BFICP argues that “citizenship,” which it defines as “working toward the betterment of one’s community through participation, volunteer work, and efforts to improve life for all citizens” is a critical part of recovery.
I think this is asking too much. While obviously admirable—and clearly essential to many people’s recovery, including my own—I don’t see how we can exclude from recovery people who have functional work and social relationships but don’t see “giving back” to the community at large as part of their lives. We don’t say that heart disease patients need to be volunteers to be in recovery from that condition—nor do we make this claim for depression. There’s no need to make an exception for addiction, particularly since it implies that we need to make up for our past sins—and carries a strong suggestion that 12-step recovery must be the best type because of its recommendation of service as part of the steps.
Another attempt at defining recovery came from the Substance Abuse and Mental Health Services Commission in 2010. SAMSHA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential.” It includes four dimensions that support recovery, which are health, having a home, having a sense of purpose, and being part of a community. The agency also stresses that there are “many pathways” to getting better.
It’s rather hard to argue with that, but as with the BFICP, the devil is in the details. While SAMHSA does allow people on maintenance into the club, it excludes any other non-abstinence pathways, saying that anyone with addiction must abstain from “alcohol, illicit drugs and non-prescribed medication,” to be counted among the recovering.
Someone who goes from dangerous drinking to moderate drinking must be included in any sensible definition of recovery. I don’t see any reason to keep them out other than prejudice.
While SAMHSA at least doesn’t require all the supporting elements as essential to recovery—it would be rather unfair if a homeless person, say, were excluded for that reason if he or she met the other criteria—it once again rejects any pathway beyond abstinence from everything except cigarettes and caffeine.
Like addiction, recovery is tightly bound by time and culture: If history had played out differently, with marijuana remaining legal and tobacco illegal (something that would almost certainly have saved millions of lives), marijuana might be seen as an acceptable part of recovery, while tobacco would clearly be a relapse. The same holds true for caffeine.
High-dose caffeine—as anyone who has gotten jittery, talkative, and paranoid from it can attest—is a serious stimulant, and the fact that we don’t see it as a drug relates more to history than to science. Similarly, although marijuana can cause immediate impairment while tobacco does not, the serious long-term effects of tobacco use make it a good candidate for being named the single most powerfully addictive drug known.
And soon, the question of marijuana use in recovery from other substances will have to be addressed as states continue to legalize and particularly if the federal government follows suit.
Today, we also face the issue of behavioral addictions: Are you in recovery from heroin addiction if you have a ruinous gambling problem or have so lost control of your Internet use that you can’t hold down a job? What about sugar binges or obesity or inappropriate sexual behavior?
When it comes down to it, it’s clear that requiring perfection will make most definitions of recovery too exclusive—but ignoring addiction switching can also be a problem. Similarly, one can be rigidly abstinent from everything—and completely socially isolated and unhappy and unproductive, which is not quite what we mean by recovery, either.
Years ago, Dan Bigg, of the Chicago Recovery Alliance, told me that his organization defines recovery as “any positive change,” which I like, but find perhaps a bit too inclusive. With both addiction and recovery, however, it’s really hard to draw that invisible line.