A pressing challenge to address the current overdose crisis is to facilitate the translation of evidence-based programs and practices into widespread use by communities (Blanco, et al., 2020; Cerda, et al., 2023; Krausz, et al., 2024; Sprague, et al, 2020). Centering community perspectives through skilled implementation support is critical to accomplish this goal. However, one potentially underacknowledged group that may facilitate translation of research into practice are researchers with lived (and living) experience with substance use disorders (RLE). Often, people think of people with substance use disorders and researchers as distinct, non-overlapping groups of people (Banks, et al., 2023; Miller, et al., 2024). RLE, however, exist and our team is a living example. The purpose of our work to help the field understand how we can use both our research and lived expertise to help translate research into practice. Our ultimate goal is to use what we have learned to help build trust and shared knowledge between communities and researchers and bridge gaps to improve program outcomes.
In our paper we describe how RLE can contribute to the successful implementation of evidence-based interventions by building strong community partnerships, engaging in effective knowledge translation, providing community-defined evaluation best-practices , and aiding in dissemination and sustainability efforts (Gartner, et al., 2018; Maiter, et al., 2008). Readers may be interested in how to purposefully include researchers with lived experience but wonder, what does this look like in practice?
Prior to Implementation
Integration of RLE during the pre-implementation stage can support the development of community building.
Preparing for Implementation
Intentional integration of RLE may support implementation preparation efforts to more quickly move research into practice.
During and Following Implementation
Considerations for Collaboration
We suggest that the intentional inclusion of RLE in research can accelerate the pace of science, improve the quality and outcomes of implementation science research, and make it more responsive to community needs. Strategies for collaborating with RLE to ensure meaningful participation in research and reduce stigma related to substance use disorders include creating a supportive climate where RLE feel safe and valued in disclosing relevant personal experiences. This involves:
These strategies can help ensure meaningful participation, reduce stigma related to substance use disorders, and ultimately improve implementation process and outcomes specific to evidence-based programs and practices related to SUD.
References
Banks, D. E., Brown, K., & Saraiya, T. C. (2023). “Culturally responsive” substance use treatment: contemporary definitions and approaches for minoritized racial/ethnic groups. Current Addiction Reports, 10(3), 422-431.
Blanco C, Wiley TRA, Lloyd JJ, Lopez MF, Volkow ND. America's opioid crisis: the need for an integrated public health approach. Transl Psychiatry. 2020 May 28;10(1):167. doi: 10.1038/s41398-020-0847-1. PMID: 32522999; PMCID: PMC7286889.
Cerdá, M., Krawczyk, N., & Keyes, K. (2023). The future of the United States overdose crisis: challenges and opportunities. The Milbank Quarterly, 101(Suppl 1), 478.
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Gartner, K., Elliott, K., Smith, M., Pearson, H., Hunt, G., & Martin, R. E. (2018). “People in regular society don’t think you can be a good mother and have a substance use problem”: Participatory action research with women with substance use in pregnancy. Canadian Family Physician, 64(7), e309-e316.
Krausz, R. M., Westenberg, J. N., Tai, A. M., Fadakar, H., Seethapathy, V., Mathew, N., ... & Ignaszewski, M. (2024). A call for an evidence-based strategy against the overdose crisis. The Canadian Journal of Psychiatry, 69(1), 5-9.
Maiter, S., Simich, L., Jacobson, N., & Wise, J. (2008). Reciprocity: An ethic for community-based participatory action research. Action research, 6(3), 305-325.
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Sprague Martinez L, Rapkin BD, Young A, Freisthler B, Glasgow L, Hunt T, Salsberry PJ, Oga EA, Bennet-Fallin A, Plouck TJ, Drainoni ML, Freeman PR, Surratt H, Gulley J, Hamilton GA, Bowman P, Roeber CA, El-Bassel N, Battaglia T. Community engagement to implement evidence-based practices in the HEALing communities study. Drug Alcohol Depend. 2020 Dec 1;217:108326. doi: 10.1016/j.drugalcdep.2020.108326. Epub 2020 Oct 6. PMID: 33059200; PMCID: PMC7537729.
Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+)* Pride Month is celebrated annually in June to acknowledge sexual minority and gender-diverse people and their contributions to this nation (Library of Congress, 2024). Approximately 5.5% of U.S. adults (13.9 million people) identify as LGBT, with significant differences in the proportion of the population identifying as LGBTQ+ across different states, regions, and age groups (Flores & Conron, 2023). 9.5% of youth (ages 13-17) across the nation identify as LGBT (Conron, 2020). Regardless of our age or location, Pride Month can represent many things for LGBTQI+-identified people. For those of us in substance use disorder (SUD) recovery or who support others in recovery, it offers an opportunity to reflect on how we cultivate LGBTQI+ pride in our recovery communities, healthcare and service centers, and larger communities; for those of us who identify as LGBTQI+, we can reflect on how we encourage and support our community members in recovery. The origins of the Pride celebration date back to 1969, in the context of the Stonewall Uprising, as LGBTQI+-identified people of color engaged in protest to create change (Tandon & Rao, 2021). Addressing substance use disorder disparities among LGBTQI+ people will require further change in 2024 and beyond.
LGBTQ I+ Behavioral Health Equity
Health equity is a state in which “everyone has a fair and just opportunity to be as healthy as possible” (Braveman, 2022). Progress toward achieving health equity is measured and monitored through population health research, involving multidisciplinary and multilevel examinations of the prevalence, causes, and consequences of disparities in health conditions, including SUDs (Beck et al., 2024). Multiple studies have demonstrated that LGBTQI+-identified people report substance misuse, substance use consequences, and are diagnosed with SUDs at rates significantly higher than cisgender and heterosexual people (Bränström & Pachankis, 2018; Day et al., 2017; Hughto et al., 2021; McCabe et al., 2013, 2022). Subgroup differences within the LGBTQI+ population in substance use exist (e.g., between cisgender and nonbinary people relative to transgender people; Cascalheira et al., 2023). Experiences of minority stress (Meyer, 2003), such as discrimination, also explain differences between LGBTQI+ people in terms of substance misuse and related mental health concerns (Dyar et al., 2020, 2022; Katz-Wise et al., 2021; Lee et al., 2016; McCabe et al., 2010). These studies suggest that LGBTQI+ people use substances, in part, to cope with the unique stressors they encounter from others in their environment (e.g., bullying, abuse, violence, rejection), who act in harmful ways because they disapprove of LGBTQI+ people’s sexual orientations and gender identities and expressions. Thus, effective treatment must consider LGBTQI+ patients’ experiences of minority stress and address LGBTQI+ patients’ SUDs and related mental health concerns in an affirming and responsive manner (Hughto et al., 2021). This requires treatment providers and recovery support specialists to recognize that SUD recovery, and LGBTQ+ behavioral health equity, is forestalled by unchecked experiences of minority stress (Burger & Pachankis, 2024), which LGBTQ+ people face outside of and within treatment settings and recovery communities.
LGBTQI+ Experiences in Treatment and Recovery
A large study of adults who identify as being in SUD recovery suggests over 11% of the US recovery population identify as sexual minorities (Haik et al., 2022) and a recent study found that sexual minority people utilize recovery community centers in ways that are similar to heterosexuals (Bernier et al., 2024). Yet research suggests that the experiences of LGBTQI+ people in recovery communities can be mixed. For instance, LGBTQ+ people who participate in Twelve Step recovery groups reported forming beneficial connections with other Twelve Step members but also indicate experience bullying, marginalization, and even violence in some meetings (McGeough et al., 2023). LGBTQI+ people who have sought professional SUD treatment services have also reported witnessing and experiencing a range of negative and hurtful behaviors from peers in recovery and even from treatment staff, including “name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants’ sexuality” (Paschen-Wolff et al., 2024). These experiences were reported as distressing, and triggering a desire to use substances to cope, yet LGBTQI+ people also identify having a number of valuable experiences in treatment such as forming relationships with other LGBTQI+ peers in recovery, witnessing openly LGBTQI+ treatment staff advocating for equity, and receiving treatment services that were holistic in nature and responsive to their unique needs as LGBTQI+ people (Paschen-Wolff et al., 2024). Finally, research has also documented efforts to make recovery housing more inclusive and responsive to the needs of LGBTQ+ people (Mericle, Carrico, et al., 2019; Mericle et al., 2020; Mericle, Hemberg, et al., 2019). These trends in designing LGBTQI+-affirming spaces for SUD recovery will require continued support and investment from the LGBTQ+ and recovery communities, and effective allyship from providers.
Effective Allyship for LGBTQI+ People in Recovery
There are a number of actions you can take – whether you identify as LGBTQI+, in recovery, both, or neither – to support LGBTQI+ people in recovery and advance LGBTQI+ behavioral health equity.
Conclusion
By recognizing and affirming the importance of Pride Month and using this time to reflect on how to better support LGBTQI+ people living with SUDs and other mental health disorders, everyone can contribute to increasing LGBTQI+ behavioral health equity and serving as effective allies to LGBTQI+ people in recovery. Reach out to your regional SAMHSA-funded Addiction Technology Transfer Center, the SAMHSA-funded Peer Recovery Center of Excellence, and the SAMHSA-funded Center of Excellence on LGBTQI+ Behavioral Health Equity for further support in implementing LGBTQI+ affirming practices, policies, and procedures in your treatment or service setting.
*The authors of this article have chosen to use the acronym LGBTQI+ since it is consistent with SAMHSA’s Office of Behavioral Health Equity. The authors also note the omission of two-spirit as an identity that is often included within the acronym. In specific instances where studies are being cited, the acronym used matches what used in the study.
Author Biographies
Ryan E. Flinn, PhD, is an Assistant Professor at the University of North Dakota. Their scholarship aims to address the syndemic of trauma, substance use, and legal system involvement by promoting mental health and substance use disorder recovery. They currently co-direct the SAMHSA-funded Mountain Plains Addiction Technology Transfer Center (Region 8) and direct Region 8’s Opioid Response Network - Technical Assistance team.
Adam Viera, PhD, MPH, is a Research Assistant Professor with the University of Missouri Kansas City, serving as a director with the Collaborative Center to Advance Health Services. In this role, he acts as the co-director of the SAMHSA-funded Peer Recovery Center of Excellence. His long-term goals are to continue to build the selection of evidence-based harm reduction and recovery support interventions to address substance use and related health issues and to support their implementation across the United States.
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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
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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