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CLINICAL
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 8, AUGUST 2012
593
The recovery paradigm
A model of hope and change for alcohol and
drug addiction
David W Best
Dan I Lubman
annual cost of addiction treatment per patient,
a 46% increase in the number of people treated
across the state, and a 62% reduction in hospital
admissions among addicted groups.3 This
suggests a recovery model may be a cost effective
model for alcohol and other drug (AOD) treatment.
Background
In 1986, O’Brien and McLellan4 characterised
addiction as a ‘chronic, relapsing condition’ and
challenged the short term treatments that were
routinely offered but frequently failed those
with long term AOD problems. They argued that
addiction was similar to diabetes or asthma in its
duration and management, and that only offering
short term detoxifications made relapse and
the ‘revolving door’ of treatment a self fulfilling
prophecy. Additional harms associated with
providing short term treatments to address a
chronic condition include the increasing physical
and psychological morbidity related to ongoing
substance use, the collateral damage to families
and communities, and the growing stigmatisation
of and discrimination toward those whose
relapses are seen as a ‘failure of will’. Indeed,
clinicians who hold pessimistic and stereotyped
views about their addicted patient’s prognosis
present a further barrier to delivering effective
treatment.5
O’Brien and McLellan were not arguing that
nobody gets better, only that the time course
is protracted. In 2005, Dennis et al6 published
longitudinal data from a sample recruited from
a public treatment program in the United States
suggesting that the average time from substance
initiation to stable recovery is around 27 years.
Likewise, in a prospective study of two community
samples of adolescent males, Vaillant7 reported
that by age 70 years, around two-thirds of once
alcohol dependent men from deprived inner
city backgrounds were abstinent (among those
still alive). Addiction careers can therefore be
Although addiction is a disorder
characterised by relapse and an extended
time course, approximately 58% of
addicted individuals will eventually
achieve lasting recovery.1 ‘Recovery’
has been defined in the mental health
field as a process represented by the
acronym CHIME – Connectedness, Hope
and optimism about the future, Identity,
Meaning in life, and Empowerment.2
Recovery confers benefits to affected individuals,
their families and local communities, and to
society as a whole. This article draws on the
successes achieved by the adoption of a recovery
paradigm in mental health and assesses the
potential benefits of a similar approach for alcohol
and illicit drug treatment and policy. The adoption
of recovery principles across the American state
of Connecticut led to a 25% reduction in the
Background
Alcohol and drug disorders remain major health and social problems in Australia,
contributing enormously to the global burden of disease and the everyday practice
of primary care. A recent growth in recovery research and recovery focused
policies are starting to have an impact in Australia, with implications for how we
attempt to resolve these problems.
Objective
In this article we discuss recent international findings in recovery research, and
explore their implications for primary care.
Discussion
Research indicates that over half of dependent substance users will eventually
achieve stable recovery. Key predictors of recovery are active engagement in
the community and immersion in peer support groups and activities. Recovery
requires a twin track approach: enabling and supporting individual recovery
journeys, while creating environmental conditions that enable and support a
‘social contagion’ of recovery, in which recovery is transmitted through supportive
social networks and dedicated recovery groups, such as mutual aid.
Keywords
substance related disorder; addiction; rehabilitation; models, theoretical
The recovery paradigm – a model of hope and change for alcohol and drug addictionCLINICAL
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Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 8, AUGUST 2012
characterised by episodes of relapse, but with
sustained change possible over long periods of
time. Lessons from parallel fields offer further hope.
Recovery from mental illness
and desistance from crime
Even among apparently intractable cases of
mental illness, longitudinal research offers
surprisingly encouraging results. Harding
et al8 conducted a 32 year follow up study of the
most difficult to place residents of a psychiatric
inpatient facility with severe, enduring mental
illness. At the final follow up assessment, 81%
were able to look after themselves, 25% had
fully recovered and 41% showed significant
improvements while only 11% did not show any
improvement and remained within the treatment
and support system. More recently, Warner9
reviewed the evidence for recovery and reported,
from over 100 studies, that 20% of people with
schizophrenia make a complete recovery and
40% a ‘social recovery’ (defined as economic
and residential independence and low social
disruption), with work and empowerment two of
the key features of the recovery process. Long
term treatments that focus on empowerment and
community engagement may not produce cures,
but can result in positive change in both quality of
life and active participation in community living,
including work and volunteering.
In 2011, Leamy and colleagues2 published
a systematic review that identified 97 relevant
papers and identified five key recovery processes:
connectedness, hope and optimism about the
future, identity, meaning in life and empowerment.
They identified 13 characteristics of the recovery
journey: that it is an active process; an individual
and unique process; a nonlinear process; that
recovery is a journey; that recovery occurs in
stages or phases; that recovery is a struggle; that
it is a multidimensional process; that it is gradual;
that recovery is a life changing experience; that
people can recover without cure; that recovery is
aided by a supportive and healing environment;
that recovery can occur without professional
involvement; and that it can be a trial and error
process. These characteristics have considerable
overlap with the AOD model outlined by Sheedy
and Whitter,1 presented in Table 1.
An equally important lesson comes from one
long term study of recidivistic offenders. Laub
and Sampson10 completed the final phase of a
55 year follow up study of adolescent offenders
recruited from a youth offending institution in
Baltimore. Their interviews of the cohort at the
age of 70 years (written up in the book Shared
Beginnings, Divergent Lives) identified a small
minority who continued to offend at the age of 70
years – the majority ended their criminal careers
by their late 30s. The primary reasons for ceasing
offending were stable employment, improvements
in life, coping and social skills, attachment to a
nonoffending spouse and changes in how they
saw themselves. The authors concluded that ‘the
stronger the adult ties to work and family, the
less crime and deviance among both delinquents
and nondelinquent controls’.8 In other words,
offending is not persistent across the life course,
and for most offenders what enables them
to ‘recover’ is adult responsibilities and the
emergence of skills to sustain them.
What is recovery from
substance abuse?
There have been two expert panel definitions
constructed in recent years. In the United States,
the Betty Ford Institute Consensus Panel11 defined
recovery as ‘a voluntarily maintained lifestyle
characterised by sobriety, personal health and
citizenship’, and further differentiated stages of
recovery by introducing the categories of ‘early
sobriety’ (the first year), ‘sustained sobriety’
(1–5 years) and ‘stable sobriety’ (more than
5 years). The British ‘vision’ of recovery, developed
by the United Kingdom Drug Policy Commission,12
is characterised as ‘voluntarily sustained control
over substance use, which maximises health
and wellbeing and participation in the rights,
roles and responsibilities of society’. Both expert
groups emphasised individual variation in terms
of timelines and pathways to recovery, with
recognition that, in most cases, recovery is an
ongoing journey rather than an accomplished state.
How often do people achieve
recovery?
According to a review of international evidence
conducted for the Centre for Substance Abuse
Treatment ‘epidemiologic studies show that,
on average, 58% of individuals with chronic
substance dependence achieve sustained
recovery’,1 although rates varied from 30–72%.
However, as Warner9 argued, for mental health,
this may not mean full remission. Rather, it may
involve transcending their symptoms to lead a
meaningful and fulfilling life, including making a
valuable contribution to family, community and
society.
What is the evidence for
recovery and long term
change?
Despite a paucity of research, there is evidence
supporting the notion of ‘remission’ from AOD
problems. In a recent systematic review, Calabria
and colleagues13 concluded that ‘almost one-
quarter of persons dependent on amphetamines,
one in five dependent on cocaine, 15% of those
dependent on heroin and one in 10 of those
dependent on cannabis may remit from active
drug dependence in a given year’.
In the UK, Hibbert and Best14 interviewed
former alcoholics who had been abstinent for at
least 1 year. Not only was there clear evidence
of ongoing recovery growth, but those who
were more than 5 years sober and in active
recovery had better social quality of life scores
Table 1. Principles of recovery from alcohol and other drug treatment (AOD)1
• There are many pathways to recovery
• Recovery involves a personal recognition of the need for change and transformation
• Recovery is holistic
• Recovery has cultural dimensions
• Recovery exists on a continuum of improved health and wellness
• Recovery emerges from hope and gratitude
• Recovery involves a process of healing and self redefinition
• Recovery involves addressing discrimination and transcending shame and stigma
• Recovery is supported by peers and allies
• Recovery involves (re)joining and (re)building a life in the community
• Recovery is a reality
CLINICALThe recovery paradigm – a model of hope and change for alcohol and drug addiction
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595
• actasa‘bridge’togroupsandindividualswho
successfully model recovery
• involvefamilymembersinsupportingtheir
recovery journey.
Having a good understanding of the recovery
support groups in your area (eg. Alcoholics
Anonymous (AA), Narcotics Anonymous (NA),
SMART recovery and other groups attached to
local treatment services) and helping people
to get to these groups is beneficial in reducing
post-treatment substance use (Table 2).25 Being
active in this process increases the likelihood of
effective linkages, and could involve your practice
nurse taking patients to their first few recovery
meetings or encouraging groups to actively recruit
or hold meetings at your practice. Not all patients
will be comfortable in a group setting, and for
some individuals recovery guides and mentors are
an essential preliminary stage. Building up the
basic confidence and self esteem to benefit from
group processes may be a necessary first step for
many addicted AOD users.
While specific co-occurring disorders,
such as brain injury or psychopathology, may
have an adverse impact on such processes,
attending mutual aid groups can benefit
psychiatric symptoms as well as substance
use.26 Practitioners should discuss with patients
that different support groups have different
philosophies and dynamics, and they may need
to try several different groups before they find
one that is consistent with their own beliefs and
whose members with whom they share common
characteristics.
One final issue for consideration is around
mapping the effectiveness of recovery-oriented
interventions, and using feedback from changes
in recovery functioning to support the patient’s
journey. Clinicians may consider outcome
monitoring tools such as the Treatment Outcome
Profile,27 a brief and validated measure that can
be completed in around 5 minutes and measures
recovery strengths as well as standard treatment
outcomes domains for AOD use.
Recovery as a social
movement
We have learnt in recent years that recovery does
not happen in isolation and that recovery can have
the strength of a social movement akin to the civil
rights movement. In both the US28 and the UK,29
build therapeutic alliances and initiate change
processes. There is no single strategy that will
work for all patients and a recovery approach will
only be suitable for those who are sufficiently
stable and motivated, and who aspire to the
CHIME principles as listed here.2
Additionally, taking lessons from the mental
health recovery movement, we can infer that
individuals can only make significant strides
to lasting recovery if basic enablers are met.
According to the mental health charity RETHINK,24
for recovery to commence, individuals need:
• asafeplacetolivethatisfreefromthreat
• freedomfromacutephysicalandpsychiatric
distress (including acute withdrawals and
intense cravings)
• freedomtomakechoicesandaclearsense
of self determination, which requires both
the provision of accurate information about
what the options are and no limits placed
on what is possible by professionals. In
other words, this includes information about
accessing educational and vocational courses,
community support groups and other forms
of professional supports, as well as clear
messages about what they involve.
However, this is only the start of the recovery
journey and ongoing support to achieve long
term change and aspirational goals are crucial
in helping people move beyond the initial
stabilisation of symptoms to a more enduring set
of life changes.
What does this mean for
general practice?
Managing immediate physical and mental health
issues, supporting housing applications and
providing medications that stabilise the addiction
(such as buprenorphine, methadone or anticraving
agents naltrexone or acamprosate) are important
first steps in assisting people to commence a
recovery journey. Linking people into counselling
and support services to help them deal with
underlying poor coping skills, self esteem and self
efficacy is a further step. But such interventions
may not be enough in themselves, with the
recovery model also requiring health professionals
to:
• instilhopethattheindividualcanrecoverandbe
mindful that their relationship can be a critical
‘turning point’ in the patient’s recovery journey
than the general public. This phenomenon has
also been reported for long term drug recovery
in Connecticut by Valentine,15 and is known as
being ‘better than well’, as individuals transcend
their addiction to play vibrant roles in their
communities.
In a follow up study in Glasgow of 205 former
alcoholics and heroin addicts in recovery,16
the strongest predictors of higher life quality
were engaging in more activities (volunteering,
education and training, work and family) and more
time spent with other people in recovery. Likewise,
in a sample of 354 recovering addicts in New York,
gradual improvements in overall life satisfaction
and reductions in stress ratings occurred over the
first 3 years of abstinent recovery.17
One of the most important things we know
about recovery is that other people matter. The
resolution of severe alcohol and other drug
problems is mediated by processes of social
and cultural support.18–20 Both general and
abstinence specific social support influence
recovery outcomes, but abstinence specific
support appears to be most critical to long term
recovery.21,22
In a randomised trial of alcoholics completing
residential detoxification, participants underwent
either ‘standard case management’ or ‘network
support’ – with the aim of the latter being to add
at least one sober person to the social network of
the detoxed drinker.22 Relapse rates in the network
support condition were 27% lower than in the
standard treatment condition, emphasising the key
role of peer support in enabling long term recovery,
and the core underlying principle of ‘social
contagion’. This is the idea, developed in the field
of social epidemiology by Christakis and Fowler,23
that complex social behaviours (including binge
drinking and smoking) are transmitted via social
networks through imitation and complex processes
of social control and influence.
What are the implications
for care and treatment?
As addiction careers typically exceed a quarter
of a century, a range of interventions will
be required at different times. It is crucial to
support and engage those with long term AOD
problems until they are ready to make lasting
changes. This includes offering harm reduction
approaches and evidence based interventions that
The recovery paradigm – a model of hope and change for alcohol and drug addictionCLINICAL
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the emergence of a visible social movement for
change has inspired and enabled people who have
recovered to come forward to act as guides and
mentors to others in earlier stages of addiction.
This process has gathered momentum and resulted
in coordinated marches of thousands of people
with the aim of celebrating recovery, challenging
stigma and bringing together those from a wide
range of motivations (people in stable recovery,
people in early recovery, addiction professionals,
general practitioners, family members and other
members of the community) to convey the message
that recovery is viable and sustainable. In Glasgow
in September 2010 and in Cardiff in September
2011, more than 1500 people participated in
recovery walks, which have had a role in changing
the perceptions of the general public and the
diverse array of participating health professionals
and policy makers. This model of recovery has also
drawn on an approach in public health, known as
‘asset based community development’,30 in which
the starting point for change is to map the assets
and resources that can enable change at a local
level. This would be physical assets (including
general practice surgeries), local community
groups (including AA, NA and other support
groups) and individuals (people who have managed
their own recovery and who can support others).
As a central component of local communities,
GPs have a critical role to play in both starting
and supporting personal recovery journeys and
sustaining community change.
Conclusion
Although addiction is a chronic relapsing disorder
most people recover, with flow-on benefits to both
individuals and communities. Within the mental
health field, adoption of a recovery model can
bring about significant benefits for individuals
and families, can inspire hope in communities
and is a cost effective approach to delivering
interventions. This approach readily lends itself to
the treatment of addiction.
Key points
• Themostrecentreviewofrecoveryrates
suggests that 58% of people with a lifetime
addiction eventually recover.
• Thetypicaltimefromfirstsubstanceuseto
stable recovery is 27 years.
• Whatpredictsrecoveryisexposuretorecovery
role models, and a sense of purpose and
meaning.
• Recoveryinvolvespersonalchangesinboth
beliefs (about the attractiveness of reduced
use, and abstinence where it is both desired
and a realistic objective) and skills (coping
skills, practical abilities), as well as social
capital (friends modelling recovery and support
for abstinence).
• Recoveryisalsoasocialmovementwhere
visible recovery champions can generate a
social contagion of hope.
Authors
David W Best BA(Hons), MSc, PhD, is Associate
Professor of Addiction Studies, Turning Point
Alcohol and Drug Centre, Eastern Health and
Monash University, Melbourne, Victoria
Dan I Lubman BSc(Hons), MB ChB, PhD,
FRANZCP, FAChAM, is Director and Professor of
Addiction Studies, Turning Point Alcohol and Drug
Centre, Eastern Health and Monash University,
Melbourne, Victoria. danl@turningpoint.org.au.
Conflict of interest: Dan Lubman has received
payment from Lundbeck, AstraZeneca and
Janssen for consultancy and lectures.
References
1. Sheedy CK, Whitter M. Guiding principles and ele-
ments of recovery-oriented systems of care: What
do we know from the research? HHS Publication No.
(SMA) 09-4439. Rockville, MD: Center for Substance
Abuse Treatment, Substance Abuse and Mental
Health Services Administration, 2009.
2. Leamy M, Bird V, Le Boutillier C, Williams J, Slade
M. Conceptual framework for personal recovery in
mental health: systematic review and narrative syn-
thesis. Br J Psychiatry 2011;199:445–52.
3. Kirk T. Connecticut’s journey to a state-wide
recovery-oriented health-care system: Strategies,
successes and challenges. In: Kelly J, White W,
editors. Addiction recovery management: theory,
research and practice. New York: Humana Springer,
2011.
4. O’Brien C, McLellan T. Myths about the treatment of
addiction. Lancet 1986;347:237–40.
5. Loth C, Schippers G, Hart H, van de Wijngaart G.
Enhancing the quality of nursing care in methadone
substitute clients using action research: a process
evaluation. J Ad Nurs 2007;422–31.
6. Dennis M, Scott C, Funk R, Foss M. The duration
and correlates of addiction and treatment careers. J
Subst Abuse Treat 2005;28(Suppl 1):S51–62.
7. Vaillant G. A 60-year follow-up of alcoholic men.
Addiction 2003;98:1043–51.
8. Harding C, Brooks G, Ashikage T, Strauss J, Brier
A. The Vermont Longitudinal Study of Persons with
Severe Mental Illness II: long-term outcomes of
Table 2. Accessing key recovery support groups
Name Purpose Contact details
Alcoholics
Anonymous
(AA)
AA is a fellowship of men
and women who share their
experiences, strengths and
hopes to solve common problems
and help others to recover from
alcoholism
For general information go to
www.aa.org.au
To find a local meeting, go to
www.aa.org.au/findameeting/
index.php
Narcotics
Anonymous
(NA)
NA is a nonprofit fellowship
or society of men and women
for whom drugs have become
a major problem. Attendees
identify themselves as recovering
addicts who meet regularly to
help each other stay clean
For general information go to
www.na.org.au/community/
index.php
A meeting directory is available
on this site
Alanon Alanon Family Groups Australia
aims to help families and friends
of alcoholics recover from the
effects of living with someone
whose drinking is a problem
For general information go to
www.al-anon.org/australia
A meeting directory is available
on this site
SMART
Recovery
SMART Recovery offers face-to-
face and online groups to people
in the community who want
and need help managing and
overcoming addictive behaviours
and their associated problems
For general information go to
http://smartrecoveryaustralia.
com.au
To find a local meeting go to
http://smartrecoveryaustralia.
com.au/what-we-do/find-a-
smart-meeting
CLINICALThe recovery paradigm – a model of hope and change for alcohol and drug addiction
Reprinted from AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 8, AUGUST 2012
597
28. White W. The mobilisation of community resources
to support long-term addiction recovery. J Subst
Abuse Treat 2009;36:146–58.
29. Best D. Addiction recovery: a movement for social
change and personal growth in the UK. Brighton,
East Sussex: Pavilion, 2012.
30. Kretzmann J, McKnight J. Building communities from
the inside out: a path towards finding and mobilis-
ing a community’s assets. Evanston, Illinois: ABCD
Institute, 1993.
subjects who retrospectively met DSM-III criteria for
schizophrenia. Am J Psychiatry 1987;144:727–35.
9. Warner R. Does the scientific evidence support the
recovery model? The Psychiatrist 2010;34:3–5.
10. Laub J, Sampson R. Shared beginnings, divergent
lives: delinquent boys to aged 70. Cambridge,
Massachusetts: Harvard University Press, 2003.
11. Betty Ford Institute Consensus Panel. What is
recovery? A working definition from the Betty Ford
Institute. J Subst Abuse Treat 2007;33:221–8.
12. UK Drug Policy Commission. The UK Drug Policy
Commission Recovery Consensus Group – A vision of
recovery. London: UK Drug Policy Commission, 2008.
13. Calabria B, Degenhardt L, Briegleb C, et al.
Systematic review of prospective studies investi-
gating “remission” from amphetamine, cannabis,
cocaine or opioid dependence. Addict Behav
2010;35:741–9.
14. Hibbert L, Best D. Assessing recovery and functioning
in former problem drinkers at different stages of their
recovery journeys. Drug Alcohol Rev 2011:30:12–20.
15. Valentine P. Peer-based recovery support services
within a recovery community organisation: the CCAR
experience. In: Kelly J, White W, editors. Addiction
recovery management: theory, research and practice.
New York: Humana Press, Springer, 2011.
16. Best D, Gow J, Knox A, Taylor A, Groshkova T, White
W. Mapping the recovery stories of drinkers and drug
users in Glasgow: quality of life and its associations
with measures of recovery capital. Drug Alcohol Rev
2012;31:334–41.
17. Laudet A, Morgen K, White W. The role of social
supports, spirituality, religiousness, life meaning
and affiliation with 12-step fellowships in quality of
life satisfaction among individuals in recovery from
alcohol and drug use. Alcohol Treat Q 2006;24:33–73.
18. Brady M. Culture in treatment, culture as treatment.
A critical appraisal of developments in addictions
programs for Indigenous North Americans and
Australians. Soc Sci Med 1995;41:1487–98.
19. Longabaugh R, Beattie MC, Noel N, Stout R, Malloy
P. The effect of social investment on treatment
outcome. J Stud Alcohol 1993;54:465–78.
20. Beattie MC, Longabaugh R. General and alcohol-
specific social support following treatment. Addict
Behav 1999;24:593–606.
21. Groh DR, Jason LA, Davis MI, Olson BD, Farrari JR.
Friends, family, and alcohol abuse: an examination
of general and alcohol-specific social support. Am J
Addict 2007;16:49–55.
22. Litt M, Kadden R, Kabela-Cormier E, Petry N.
Changing network support for drinking: initial find-
ings from the network support project. J Consult Clin
Psychol 2007;75:542–55.
23. Christakis N, Fowler J. Connected: the amazing
power of social networks and how they shape our
lives. London: Harper Press, 2010.
24. RETHINK. Getting back to the world. 2009. Available
at www.rethink.org/document.rm?id=9830.
25. Timko C, DeBenedetti A, Billow R. Intensive referral
to 12-step self-help groups and 6-month substance
use disorder outcomes. Addiction 2006;101:678–88.
26. Timko C, Sutkowi A, Cronkite R, Makin-Byrd
K, Moos R. Intensive referral to 12-step dual-
focused mutual-help groups. Drug Alcohol Depend
2011;118:194–201.
27. Marsden J, Farrell M, Bradbury C, et al. Development
of the treatment outcomes profile. Addiction
2008;103:1450–60.
