Abstinence has long been considered the defining feature of recovery from substance use disorder, with a focus on individual level factors associated with abstinence. This has promoted a narrow focus on the individual as the fundamental change agent in recovery (Heilig et al., 2021), and lack of consideration for the multiple pathways to recovery (Tucker & Witkiewitz, 2022), including non-abstinence recovery. Accordingly, changes in an individual’s substance use is often the primary target and behavior of concern, often to the neglect of other positive functional changes involved in recovery. Although some conventional recovery models emphasize the need for an individual to build a support system for recovery and identify high-risk situations for harmful substance use, these models have not addressed how an individual attempting recovery is situated within and dynamically influenced by broader social, community, economic, and policy forces that might make recovery more or less accessible. Greater consideration of dynamic socioecological influences on recovery is critical for understanding the process and developing multi-level interventions to promote change in multiple outcome indicators of whole person recovery.
Models of harmful substance use and recovery from substance use disorder should carefully consider individual-level factors that can be modified in conjunction with social, community, economic, and policy level factors in which harmful substance use may develop, be maintained, and ultimately resolved. These levels of influence on individual behavior are dynamically and bidirectionally changing over time, and recovery typically is not a straight linear change process. As such, any return to harmful substance use during a recovery attempt is part of a dynamic change process and offers an opportunity to learn about the multi-level factors that may be influencing the process. Change is inherently complex and multi-determined, and individuals exist within multi-layered contexts extended through time that can be more or less supportive of change.
Growing research offers numerous directions for pursuing a holistic contextualized approach to recovery. At the individual level, relatively stable characteristics, such as genetic influences, family history of substance use, adverse childhood experiences, and neurobiological factors can be a predictor of risk for developing substance use disorder and may hinder or promote recovery (Witkiewitz & Marlatt, 2004). Also at the individual level, numerous modifiable factors, such as experiences of mood and craving, self-efficacy for modifying behaviors, coping skills, and working toward future goals are associated with reductions in harmful substance-related behaviors (Sliedrecht et al., 2019).
At the broader interpersonal level, substance-free activity engagement, spending time with peers who do not participate in harmful substance use, engaging with recovery support services, and allocating time, money, energy, and other resources to substance-free activities are associated with improved functioning and reductions in harm. In general, enriched environments with substance-free rewards are associated with less substance use and related harm, and access to green spaces may improve mental well-being, reduce craving, and be associated with treatment engagement. Conversely, greater poverty and community disadvantage may reduce the probability of recovery, and ample evidence indicates that social determinants of health and policy actions affect health and well-being and, in turn, the odds of recovery. Areas with greater socioeconomic advantage, housing security, community-level income equality, and community-level access to health insurance are each associated with positive recovery outcomes (Witkiewitz & Tucker, 2024).
In many natural environments, easy access to substances remains unchanged, but recovery occurs as these other environmental features shift toward offering substance-free activities and commodities that can compete with substance use. Further, factors that promote harmful substance use may not be the opposite of factors that support recovery, and factors that promote recovery are not merely the absence of factors that maintain harmful substance use. Importantly, any one factor at a given level is likely insufficient for stable behavior change, and individuals vary in the extent to which they can access recovery supports. Greater economic resources, access to substance free reinforcement, social network support for recovery goals, and availability of community recovery resources may facilitate a less difficult recovery pathway. Lack of these resources, built environments with few substance-free reinforcers, social networks supportive of harmful substance use, and systemic biases in access to social, economic, and policy resources (e.g. due to racism, sexism, and agism) will likely make recovery more difficult (Witkiewitz & Tucker, 2024).
In sum, recovery is a dynamic process that occurs in dynamically changing contexts that can support or hinder positive outcomes, leading to many individual differences in recovery pathways. Future research, treatment, and policy agendas need to address how individual, interpersonal, family system, neighborhood, community, and broader policy factors can be changed or leveraged to improve recovery outcomes. The goal is to identify what interventions and when those interventions may be most effective for shifting patterns of behavior at the individual level, taking into consideration broader contextual factors associated with transitions in behavioral choices over time. The field needs to look beyond the individual, changes in personal consumption, and treatment as the primary foci of recovery models; expand recovery definitions; and study multilevel influences on recovery. This expanded view is essential for advancing the science and practice of substance-related behavior change. Researchers, treatment providers, peer support workers, and the recovery community can support multiple pathways to recovery by holding a more expansive view of how individuals recover from substance use may take a variety of different pathways and that an individual exists within a socioecological and dynamic context that may be more or less supportive of a recovery journey.
Read more about this expanded view of recovery here: https://www.tandfonline.com/doi/full/10.1080/16066359.2024.2329580
Heilig, M., MacKillop, J., Martinez, D., Rehm, J., Leggio, L., & Vanderschuren, L. J. M. J. (2021). Addiction as a brain disease revised: why it still matters, and the need for consilience. Neuropsychopharmacology, 46(10), 1715–1723. https://doi.org/10.1038/s41386-020-00950-y
Sliedrecht, W., de Waart, R., Witkiewitz, K., & Roozen, H. G. (2019). Alcohol use disorder relapse factors: A systematic review. Psychiatry Research, 278, 97–115. https://doi.org/10.1016/j.psychres.2019.05.038
Tucker, J.A., Witkiewitz. K (2022). Dynamic pathways to recovery from alcohol use disorder: meaning and methods. Cambridge: Cambridge University Press. https://doi.org/10.1017/9781108976213
Witkiewitz, K., & Marlatt, G. A. (2004). Relapse prevention for alcohol and drug problems: that was Zen, this is Tao. The American Psychologist, 59(4), 224–235. https://doi.org/10.1037/0003-066X.59.4.224
Witkiewitz, K., & Tucker, J. A. (2024). Whole person recovery from substance use disorder: a call for research examining a dynamic behavioral ecological model of contexts supportive of recovery. Addiction Research & Theory, 1–12. https://doi.org/10.1080/16066359.2024.2329580