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We recently explored the idea of “recovery cascade”—a sudden surge in personal change that sparks recovery initiation in the heels of past efforts or a collective surge in recovery prevalence at a community or cultural level. While there are examples of the latter in U.S. history (e.g., the explosive growth of the Washingtonian Temperance Society in the early 1840s), the most recent and dramatic example of such a population-level recovery cascade is the growth of Narcotics Anonymous and other recovery communities (e.g., Congress 60) within the Islamic Republic of Iran.

As the toll of the opioid epidemic in the U.S. rises to ever-horrific levels, the question of how to promote a counter-surge of recovery initiation and stabilization is a critical public health issue. Much in this regard can be learned from what has occurred within the Islamic Republic of Iran. Few countries have experienced such sustained opioid problems (since the 16^th century), and no country has experienced as rapid a growth of Narcotics Anonymous as has Iran.

First introduced in 1990, there are now more than 24,000 NA meetings in Iran—a third of all NA meeting worldwide and, with the exception of the NA Basic Text, Iran consumes more NA literature than all other countries combined. The 2018 NA World Convention drew 24,000 participants; the most recent NA Convention in Iran drew 32,000 participants.

Exploring contextual factors and key strategies linked to exponential surges in recovery prevalence in Iran could aid strategic counter-responses to surges in drug addiction in the U.S. I was pleased to recently collaborate with Dr. Marc Galanter and Brooke Hunter on a comparative study of NA members in the U.S. and Iran that was recently published in the Journal of Addiction Medicine.  That study afforded an opportunity to explore some of the factors that have contributed to NA growth in Iran—an issue of import given the paucity of attention given to the potential role of NA in discussions of U.S. responses to the opioid epidemic.

Based on the history of NA in Iran and my study of growth patterns within other recovery mutual aid organizations, I would propose the following factors as critical to surges in recovery mutual aid membership and parallel population surges in recovery prevalence.

*Social Density of Addiction Exponential growth of recovery mutual aid follows periods of peak per capita addiction, e.g., Iran has the highest worldwide rate of opiate addiction.  Recovery prevalence rises after, not in tandem with, peak personal and social consequences of addiction within a community/culture. A major public health goal is to minimize the time lag between surges in addiction and surges in recovery initiation. Shortening addiction careers reaps untold rewards for individuals, families, communities, and societies.

*Population Demographics Addiction recovery mutual aid growth often crests during peak concentrations of populations reaching the age of cumulative consequences of youthful drug use (e.g. ages 25-44). The aging of Baby Boomers in the U.S. and tandem growth of treatment industry fed the growth of NA, AA, and other recovery mutual aid groups in 1980s and 1990s.

*Cultural Congruence Growth of a recovery mutual aid organization is influenced by the congruence between its core values and the cultural context in which it operates or the degree to which it represents needed values within that culture.  The congruence between NA values and the Persian value placed on family, mutual help, hospitality, and service helped fuel NA growth in Iran. Growth of recovery mutual aid groups is contingent upon rights of citizens to voluntarily assemble without governmental oversight and the absence or minimization of obstacles to such gatherings (e.g., early police surveillance of NA meetings in the U.S.; “loitering addict” laws in the U.S. in the 1950s and 1960s).

*Decentralization of Leadership NA, like other 12-Step groups, utilizes a leadership rotation scheme as a means of avoiding the pitfalls of centralized and charismatic leadership that can push organizations toward cult-like systems at risk of eventual implosion.  Multiple leadership roles and the ease with which new groups can be formed help fuel member growth and retention through these mechanisms of leadership development and succession.

*Minimization of Political/Religious Resistance Recovery frameworks that do not pose threats to existing political and religious institutions have increased probabilities of survival and rapid growth. NA’s position of “no opinion on outside issues” and NA leaders meeting with political, religious, and professional leaders minimized such resistance and set the stage for NA growth in Iran.

*Delineation of Peer and Professional Support Roles Aligning itself as a potential adjunct to professional treatment (e.g., post-treatment continuing care) rather than a competing alternative minimizes professional resistance to 12-Step groups and other recovery groups. Such positioning allowed NA to grow in tandem with professional treatment resources in the U.S. and Iran while maintaining NA independence from these institutions. Professional support is enhanced by scientific studies showing mutual aid participation elevates long-term treatment/recovery outcomes and quality of life of individuals and families. More scientific studies of NA have been conducted in Iran than anywhere in world, including in the U.S. and U.K.

*Local/National Mainstream and Social Media Coverage Recovery-focused media coverage can serve as a direct catalyst for recovery seeking, e.g., growth of AA following 1939 Cleveland Plain Dealer series and 1941 Jack Anderson Saturday Evening Post article in early AA spread nationally. Active NA PR (public relations) committees have played an important role in surges in NA membership.

*Recovery Literature  Codification of core recovery literature can spur exponential growth of recovery mutual aid organizations and protect program integrity (e.g., avoidance of dilution, and corruption). Publication of the AA “Big Book” and NA “Basic Text” were critical to subsequent AA/NA growth worldwide, and translation of the NA Basic Text into Farsi was a key catalyst for NA growth in Iran as was Iran’s extensive use of other NA literature.

*Sponsorship and Recovery Induction Use of “home groups,” sponsorship, guidance in completing core recovery activities, and celebrations of recovery milestones have all served to aid engagement and retention within recovery mutual aid groups.  NA in Iran has several unique adaptations that played a role in its unprecedented growth, e.g., sponsors regularly meeting with sponsees in groups distinct from regular NA meetings, focused attention on completing Step work, and celebrating completion of Step work rather than an exclusive focus on duration of abstinence.

*Service Ethic and Service Structure  Recovery mutual aid growth is greatest in settings with a strong service ethic and a service structure that allows frequent service opportunities via service committees and expectations of larger service to the larger community. Recovery surges are contingent on reaching a critical mass of people achieving sustained recovery—living proof within the overall culture and visible to those seeking help. Defining need for long-term recovery support combined with a strong service ethic assures such availability and visibility and enhances organizational stability and sustainability.

*Membership Diversification Recovery mutual aid growth is aided by the advent and expansion of demographic, cultural, and special interest groups, e.g., women, young people, cultural minorities. Diversification and growth of specialty meetings attracts new populations and retains populations that might otherwise be lost due to failure of mutual identification.

*Recovery Culture The growth of a recovery mutual aid society is aided by development of a distinct recovery culture with its own core ideas, language, rituals, symbols, history, iconic figures, memorial sites, etc. Distinct recovery mutual aid cultures are sometimes followed by emergence of an ecumenical culture of recovery within the larger society. This broader culture may set the stage for further population surges in recovery prevalence.

*Organizational Integrity Sustained growth within recovery mutual aid societies requires forging a set of principles of organizational management that help groups avoid the organizational pitfalls that can feed explosive growth in the short run only to then rapidly decline and experience institutional death, e.g., rise and fall of the Washingtonians, Synanon, and other recovery mutual aid groups.

Considerable time is invested within professional and public policy arenas exploring factors related to population-level surges in substance use and related disorders. Perhaps it is time similar attention was devoted to exploring the conditions and strategies that could spark population-level surges in recovery initiation.

Reference: Galanter, M., White, W., & Hunter, B. (In Press). Cross-cultural acceptability of the Twelve Step model: A comparison of Narcotics Anonymous in the USA and Iran.  Journal of  Addiction Medicine.