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People seeking help for the resolution of alcohol and other drug (AOD) problems in the United States encounter not comprehensive systems of care but silos of care based on single pathway models of addiction with narrow menus of derived services, each highly critical of competing silos. Far too often, people with the most severe, complex, and enduring AOD problems traverse multiple silos without finding a sustainable recovery solution. Below are some reflections on why these single pathway approaches to addiction and recovery are so troublesome and a few thoughts on how we may escape entrapment in such ideological prisons.

Since the early promulgation of addiction as a brain disease, I have warned that such a model could increase rather than decrease addiction-related stigma if not also accompanied by a parallel understanding of the neurobiology of addiction recovery. To that end, I joined several colleagues in calling for a recovery research agenda that includes a focus on the degree to which brain functioning is restored during the recovery process. In the intervening years, significant research has illuminated such healing processes and their implications for recovery management. The most significant of this work has been done on alcohol use disorders. The extent to which these findings are applicable to other substance use disorders remains unclear.

Addiction recovery is best viewed as a process rather than an event, but the transition into recovery can sometimes be more a cataclysm than a product of incremental steps—more a lightning strike than a process of maturational learning—and the factors that sustain recovery over time may be quite different than those that trigger recovery initiation. Where recovery stability is achieved in gradual stages and within later stages of enhanced global health and functioning in recovery, there are can be surges in growth that exert profound effects on personal identity and character and one’s relationship with the world.

Considerable efforts are underway at federal, state, and local levels to extend acute and palliative care models of addiction treatment to models of assertive and sustained recovery management (RM) nested within larger recovery orientated systems of care (ROSC). As that work proceeds, a critical question has emerged about the application of RM and ROSC to the design, delivery, and evaluation of services for children, adolescents, transition age youth, and families (CATAYF).

The FIRST STEP Act was recently passed and was signed by the President. This was historical.  Federal passage of the FIRST STEP Act provides action on criminal justice reform. Ultimately, the FIRST STEP Act is one step in the right direction for reducing mass incarceration in the United States. The Second Chance Act reauthorization was recently included in the FIRST STEP Act. The changes will reduce incarceration for a number of lesser offenses, many involving drugs.

Addiction recovery is far more than the removal of drugs from an otherwise unchanged life. Recent definitions of recovery transcend radical changes in the person-drug relationship and encompass enhanced global health and social functioning. The authors have carried on a decades-long interest in what has been christened full recovery or amplified recovery—a state of enhanced quality of life and personal character in long-term recovery. We each know individuals we believe have achieved such status and have asked ourselves what unique characteristics distinguish such persons. Here are some of our initial reflections on this question, offered here as an expression of gratitude to such people who have enriched our own lives.      

Radical hope—a radiant vision of new possibilities in the face of personal or collective devastation—is the catalytic ingredient at the heart of personal transformations and successful social movements. Such hope has been spread contagiously by charismatic figures like Handsome Lake, Frederick Douglass, Susan B. Anthony, Mahatma Gandhi, Rosa Parks, Martin Luther King, Jr., Malcolm X, and Cesar Chavez, to name a few. Radical hope, at a personal level, allows one to rise from the ashes of addiction-related collapse and step into an unknown recovery future.

I have been closely observing the addiction recovery process for half a century. I have been struck by two extremes: people whose fragile recovery is forever frozen at a primitive stage of development, and people who go through metamorphic changes that transform their character, values, and the quality of their interpersonal relationships. In the former, drug use has ceased or radically decelerated in frequency, intensity, and consequences, but this change remains nested within the same self-centeredness, resentfulness, dishonesty, and intolerance that often characterizes active addiction. This former pattern has been referred to as the “dry drunk” syndrome. In the latter style, the radically altered person-drug relationship is accompanied by dramatic enhancements in global health and functioning, as well as changes in character and identity—changes AA co-founder Bill Wilson characterized as “emotional sobriety.”

Efforts by professionals to “treat” alcoholism and other addictions have a long and colorful history. Alcoholics have been forced to drink their own urine and forced to drink wine in which an eel had been suffocated. They have been surreptitiously dosed with everything from mole blood to sparrow dung and subjected to the “Swedish treatment” in which everything they consumed and even their clothes and bedding were saturated with whiskey. They have been prescribed dietary treatments that included the apple, salt, grape, banana, onion, and watermelon cures. They have been fed gold, iron, and bark to quell their appetite for alcohol.

High degrees of variability in the pathways and styles of addiction recovery obscure shared mechanisms of change across such healing processes.