Last month, the Substance Abuse and Mental Health Services Administration (SAMHSA) set forth a working definition of recovery. After consulting the behavioral health community and soliciting comments, SAMHSA declared that recovery is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”
According to SAMHSA, the four dimensions that support recovery are health, home, purpose and community. The administration also enumerated 10 guiding principles, which explain that recovery:
• Emerges from hope;
• Is person-driven;
• Occurs through many pathways;
• Is holistic;
• Is supported by peers and allies;
• Is supported through relationships and social networks;
• Is culturally based;
• Is supported by addressing trauma;
• Involves the individual, family and community; and
• Is based on respect.
Several of these guiding principles align with the values many of us in the treatment field have long held, including hope, respect, and the importance of individualized treatment and social support. Although some critics assert that recovery must have an endpoint – a measure of success by which someone knows definitively if they have recovered or not – SAMHSA embraces the well-researched and now widely accepted disease model of addiction. Because addiction is a chronic, progressive illness similar to heart disease and diabetes, recovery is a lifelong process; it is a journey, not a destination.
What Is Abstinence?
SAMHSA’s definition is an important advancement that will help treatment providers, insurers and the public better understand the process of recovery. Still, some questions remain unanswered.
SAMHSA’s statement asserts that “abstinence is the safest approach for those with substance use disorders,” yet its definition fails to clarify what abstinence means. Is a recovering opiate addict abstinent if they take methadone or buprenorphine to manage cravings and guard against relapse? Or does abstinence mean being free from the influence of all addictive drugs?
In Narcotics Anonymous, the only requirement for membership is the desire to be free from addictive drugs. While individuals who are on agonist opiate therapy are welcome, they are often relegated to second-class status (e.g., they are not allowed to open or close meetings or hold positions of responsibility).
There is a great deal of inconsistency in the way we in the medical community view agonist therapies. Most physicians working in the addiction field would endorse methadone or buprenorphine maintenance therapy either broadly (as an appropriate first line treatment for opiate addicts), or selectively (for clients who have relapsed following other treatments). However, these same physicians rarely advocate for medically supervised heroin therapy for heroin addiction. But why? From a pharmacological perspective, aren’t these very much the same?
Even stranger is the virtually complete acceptance by the medical and recovery communities of nicotine replacement therapy (e.g., patches, gums and lozenges) for nicotine dependency. It seems that the treatment community views agonist therapy differently when it is nicotine that is involved rather than opiates. This raises the question: Why are certain addictive drugs acceptable for replacement therapy and others are not?
For some people, long-term maintenance may be the only viable option for sustained abstinence from their drug of choice (e.g., heroin). But physicians are often too quick to rely on replacement therapy, depriving recovering addicts of the opportunity to be truly drug-free. Many people on methadone or buprenorphine maintenance ultimately look for other solutions because they find that the drugs still dull their emotions and make them feel intoxicated.
Two Steps Forward, One Step Back
SAMHSA’s definition of recovery offers a great deal of clarity to individuals with mental health disorders, their families and their health care providers, but it obscures the rift between 12-Step recovery and replacement therapy programs. The definition incorporates many beliefs that are already widely held by the 12-Step community and the community mental health movement, specifically to live a self-directed life and to reach one’s full potential. But a modernized and cleaned up definition will not bridge the chasm between certain treatment models and community-based 12-Step support programs.