INTRODUCTION

Young adults (18–29 year olds) have the highest prevalence of substance and alcohol use compared to all age groups.1, 2 Substance use disorder (SUD) continues to be a leading cause of morbidity and mortality for this population,3 with rates of opioid overdose increasing more than 250% since 1999,4 yet young adults have lower engagement and retention in SUD treatment than any other age group.5–7 One barrier contributing to low rates of treatment engagement may be that SUD treatment is based on a chronic disease model of SUD that does not resonate with young adults.8 There is a gap in the literature describing how young adults define and think about their recovery from SUD.

In the general adult literature, there are multiple definitions of recovery, with a general understanding that recovery is unique to the individual.9–12 SAMHSA defines recovery as “A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”13 However, the concept of recovery has primarily been studied in older adults. In those studies, recovery is viewed as an ongoing process, which involves abstinence, improving quality of life, and engagement in mutual health groups such as 12-step programs.10, 12, 14 In one study of individuals who use harm reduction services, individuals spoke to recovery as a personal journey, with an emphasis on coping with their SUD rather than finding a cure.15 In another study of methadone treatment program patients, participants noted multiple kinds of recovery: of self-identity, from infectious diseases, and from the physical dependence on substances.16 In one study of over 9000 adults in recovery, individuals endorsed a recovery that emphasized honesty with self, handling and enjoying life without using drugs, and taking responsibility for the things that were within one’s control. However, only 17% of respondents in this study were 20–35 years old.17

Some studies suggest that young adults may have different conceptions of recovery and need different support than adults in recovery.18–21 In prior qualitative work, adolescents (14–18 years old) perceived a lack of fit in traditional Alcoholics Anonymous and Narcotics Anonymous spaces where group attendees were much older (average age of members is 48 years old),22 and recovery-focused discussions about severe medical complications of substance use, parenthood, and employment did not resonate with where adolescents were developmentally.18 In another study of 12–24 year olds in SUD treatment, youth described recovery as the choice to make better decisions. In that study, youth linked their substance use to their current life phase, one that they would grow up and out of given their younger age. They disagreed with a chronic disease treatment model and felt that it implied they did not have control over their actions.8, 23 A necessary step in developing treatment models that resonate with young adults is to understand what goals this age group has for their recovery and create models of evidence-based wraparound care that meets the needs of the young adult age group served.

The low rates of treatment engagement and retention and lack of understanding of how young adults think about recovery highlight a need to create developmentally appropriate treatment models. Like “recovery,” the construct of “treatment” is broad; for the purposes of the current analysis, treatment is used to refer to the constellation of evidence-based pharmacotherapies, psychological and psychiatric supports, and other activities involved in recovery, including mutual support groups and job skills training.24 The objective of this study is to describe perspectives of recovery among young adults with substance use disorder to inform treatment approaches that meet the developmental needs of young adults with SUD.

METHODS

The analysis was conducted as part of a secondary analysis of a mixed-methods study of experiences of MOUD stigma among young adults with SUD in Boston, Massachusetts. The institutional review board of Boston University Medical Campus approved all study protocols.

Study Design and Population

This was a qualitative study of young adults who use opioids, recruited from outpatient substance use programs at Boston Medical Center, an urban safety-net hospital in Boston from June 2019 to February 2020.

Eligibility and Sampling

Eligible participants were 18–29 years old, had SUD (as diagnosed by their clinician), and were able to speak and understand English, and provide informed consent. Eligibility for the mixed-methods study that these interviews were drawn from included patients who had opioid use disorder (OUD); however, recovery was discussed as a “whole” rather than specific to their opioid use. We therefore refer to SUD and SUD recovery in general in this manuscript. Having had previous experience with MOUD was not required for eligibility for the current study; however, 19 out of the 20 young adults recruited for this study endorsed current and/or previous treatment with MOUD.

Recruitment

Clinicians introduced the research study and initiated a warm hand-off to research assistants. Research assistants completed a 2-question eligibility screener with interested participants, and if eligible, obtained verbal informed consent in a confidential study room. Participants received a $25 debit cash card for interview completion.

Data Collection

The guide for semi-structured interviews was developed based on clinician expertise and refined with input from study team members. The guide included open-ended questions covering the domains of addiction and recovery. Interviews ranged in length from 40 to 70 min.

Interviews were recorded, and Audacity (version 2.4.2, 2020) software was used to change the pitch and tone of audio recordings before sending them to a third-party vendor for verbatim transcription. Research assistants reviewed transcriptions against audio files for fidelity and removed any remaining identifiers from transcripts. All names used in this paper are pseudonyms.

Data Analysis

Four members of the research team adopted a hybrid inductive and deductive approach to complete initial coding of transcripts.25 Deductive codes were developed based on the interview guide, and inductive codes were identified through emergent themes. The research team then developed a codebook, and four coders completed open coding of the remaining transcripts using NVivo software (QSR International Pty Ltd., version 11, 2017). Each transcript was coded independently by two coders in parallel with regular meetings to resolve discrepancies and modify the codebook as needed. Two authors (Schoenberger and Bagley) then completed a thematic analysis using an iterative categorization technique to identify key themes.26

RESULTS

Participants ranged from 21 to 29 years old (average age 26 years). Fifteen identified as non-Hispanic Caucasian, two participants identified as Hispanic/Latino, two participants identified as mixed race, and one participant identified as Asian American. Twelve identified as male, 7 as female, and 1 as non-binary. Four themes framing how participants with SUD characterized “recovery” are described below.

Theme 1: Growing Up and Returning to “Normal”

For 13 participants, normalcy was the goal of recovery—they spoke to the desire to meet the goals of other individuals in their age group, such as finishing school, finding purpose, and a community of individuals who do not use drugs. Participants wanted an identity distinct from their SUD. As Eitan (non-binary, 23) reflected:

“They don't want their life to continue to be defined by their substance use, including if that means being defined by not using substances…Because having your identity be centered around being in recovery is also not, like your life is still being centered around substance using … I think the conversation isn't just about … people won't die … It's like people will be present for their lives again.”

Jerome (male, 29) shared examples of what was possible when one’s life no longer revolved around their substance use. “ By recovering … You’re just conforming to become normal… And when it’s normal, it’s working, self-supporting. Ideally you find someone to settle down with... About time to grow up … and benefit because I have a good mind and I can be a benefit to society in some way. Not go to waste.” According to Jerome, their SUD had caused them to fall behind in some of the milestones that other people their age experienced.

SUD was described as an all-consuming cycle with substance use linked to the debilitating effect of cravings, and cycles of self-hatred as both a motivation for and consequence of use. Recovery was viewed as breaking this cycle. In this return to “normalcy,” participants saw their recovery as a way to move beyond their substance use. As Clayton (male, 25) stated: “I mean, I really wish I could just get back into… academia… I’d really like to just finish college… Get back into writing. I play music. I’d really like to explore some of my artistic abilities in conjunction with my experience and see if maybe there’s something I have to offer the world… A purpose… I’d like to find a purpose.” Finding a “purpose” was a common goal once participants were in recovery. Since their SUD had caused them to fall behind in other aspects of life, participants like Clayton spoke to the opportunity to make a valuable contribution to society. Often inherent in this was the hope that substance use would no longer shape behavior or define their identity.

Theme 2: Recovery as Multidimensional

Thirteen participants stressed that recovery had to include multiple components to optimize success. They stated that it was not enough to stop using, that a motivated individual needed to engage in a variety of recovery-related activities. As Felix (male, 27) shared:

“Because every little piece, the AA and NA does something for me… the halfway house with all the resources does something else for me. The Suboxone does something for me. If you utilize everything around you… you’re going to have the most successful chance of getting out of this and making a better life. If you only utilize one, for me, I’ve always struggled. And yeah, it’ll solve one problem in my life but then I still got the other 10 problems.”

Participants spoke specifically to the need to augment taking MOUD with other recovery activities, such as counseling, job training, and finding a community of other individuals who do not use drugs. Several participants were critical of those who did not engage in other recovery activities beyond stopping from using drugs, citing the need to develop coping skills and healthy ways of dealing with emotions.

Consistent with this emphasis on treating underlying psychological distress, five participants connected SUD with mental health. In viewing their substance use as a way to treat their mental illness, these participants put an emphasis on learning how to deal with their emotions as critical to sustain a long-term and successful recovery.

Myles (male, 25) spoke to a difficulty in processing feelings and using substances as a way to respond to a range of life situations. “I don’t know how to deal with emotions like being sad or being happy. I celebrate when things go good by using drugs and alcohol, when things go bad I cope by using drugs and alcohol... It makes it very tough to feel emotion the way that our brain is designed to do.” Rose (female, 28) described the isolation that both contributed to and resulted from their SUD. She said:

“Addiction… is just the umbrella. And everything else is underneath that… You’re going through the same feelings of emptiness, loneliness, hopelessness, feeling useless, feeling like you have nobody, feeling like you’re lost in general. You go through all these similar feelings no matter what you’re using... we all share this feeling different ‘as I grew up something, something wasn’t right’ story.”

She commented that all people who use drugs, regardless of their substance of choice, share a common impression that they were different than the other people in their age group as they were growing up.

Theme 3: Recovery as a Self-Motivated Process

For eleven participants, it was important that recovery was self-motivated, the desire to change patterns of use up to the individual. Participants spoke to the incredible amount of self-work involved in recovery, specifically in getting to a place where they did not have to live in a state of internal struggle. For Tania (female, 25), recovery was about confidence in self. “I think it’s just building your self-esteem because if you hate yourself when you hear someone talk about you, you’re going to believe it…You’re going to be like yeah, they’re right. I do suck…But now it’s like I know I don’t.” Participants were critical of institutions, groups, and supports impinging on their individualism, and spoke to the role of identity-building in recovery. As Charlie (male, 26) stated:

“I’d say recovery is based on the individual. I think too many people in recovery try to push this thing… it’s a culty feeling. It’s like everyone needs to do this, this, and this… They recite the same slogans and adults, it’s all just…brainwashed seeming…it’s like giving up on being yourself… It’s like they lose faith in their mental strength and the power of the human brain, and … they drop the reigns.”

Notably, two participants used the term “recovery cult” to describe the mentality that can surface in 12-step settings, that recovery is a fixed and lifelong pursuit of abstinence. In their rejection of this model of recovery, these two participants stressed their agency and mental strength in creating their own recovery story.

Theme 4: Recovery as a Lifelong Pursuit

Eleven participants described their recovery as a process, an activity and aim that required constant work. They stressed the importance of recovery commitment, and emphasized vigilance and regimented structure, with recovery always having to be top of mind. As Clayton (male, 25) stated,

“I don’t think we necessarily lose our addiction. A lot of people like to say in the rooms [Alcoholics Anonymous and Narcotics Anonymous] … your disease is in the parking lot doing pushups while you’re in this room.’ … If I went and I were to go relapse today… I would pick up right where I left off. I’m no less hurt than I was when I stopped using. Once you put a needle in your arm you don’t go back to your high school days of doing lines and drinking Bud Light. It’s the same way with ... Once you experience anything. You go to war, you come back, people are messed up. A lot of times addiction has a lot of trauma that goes along with it.”

Participants warned of getting complacent in their recovery, endorsing a vision of recovery as a lifelong process that they would have to work on beyond the cessation of their active drug use. Four participants specifically used the phrase “addict for life.” As Celeste (female, 29) stated, “So my recovery… it’s a work in progress. It’s always number one as far as where my life is going. I know my recovery has to remain first in order for anything else to fall into place.”

Ten participants, including Celeste, shared thoughts on whether SUD was a predestined fate, or choice was involved in the initiation and maintenance of substance use. Six participants spoke of their SUD as a “choice,” something that they had agency in choosing whether to engage or not. As Doug (male, 24) said: “I get mad when somebody calls me out on my addiction, but I don’t know. I can’t get too mad because it’s kind of my own fault just because I made the choice to use. I wasn’t held at gunpoint and forced to use. I did that on my own.” The framing of SUD as a choice contrasted with expressions of recovery as a lifelong pursuit. This perspective, that one was able to grow up and out of SUD, was sometimes shared by the same participants who spoke to recovery as a long-term commitment, suggesting the internal conflict that individuals experience when considering the outcome of their early-in-life substance use. Landon (male, 29) commented on the disease model of SUD and his own agency in his use:

“I don’t believe it’s a disease. I believe it’s just a choice... I never knew it was a disease until I went to detox. I knew what I was doing every time I did it. I knew I was being sneaky, I knew I was lying. I knew I was stealing from people I loved. I just decided to do it. And when you go to detox and all these programs, they drill it in your head that it’s a disease and it’s all right to keep relapsing... It’s not… I don’t know, maybe it is a disease. In my head I really don’t feel like it’s a disease… And when they tell us the disease, we tend to use that as an excuse… we start thinking it’s okay.”

Doug and Landon commented that the disease model of SUD was detrimental to taking ownership of the role they played in their SUD and provided them with an excuse for not taking responsibility for their actions.

DISCUSSION

This exploratory study sought to understand how young adults with SUD conceptualize their recovery and priorities. For participants, recovery was a way to achieve developmental milestones shared by other young adults and a way to return to “normalcy.” Recovery was described as multifaceted, with many participants citing the integral role that mental health played in their SUD, and the need to address this in their recovery. Finally, participants stressed that recovery from SUD had to be self-motivated and was a process that required consistent work.

The young adults in this study were hopeful. Those who spoke of recovery as a lifelong pursuit shared an optimism about the future, and the ways in which they saw themselves moving beyond the SUD that had defined their adolescence and into a new phase of their life. The majority of participants endorsed recovery as a lifelong pursuit but eschewed an identity singularly focused on their substance use and being in recovery. This finding is consistent with the development milestone of identity formation and establishing a sense of self in young adulthood.27, 28 It is reasonable that young adults would want to nurture an identity that is distinct from the substance use that has negatively impacted them.28, 29 Participants grappled with the hope of finishing school, developing healthy relationships, and finding a way to give back to others struggling with SUD. Gonzales et al. identified similar themes around individuality and control.8 Similar to the return to “normalcy” theme, their study identified recovery as a “lifestyle improvement” and social development as a way to move past their adolescent phase of substance use. This is consistent with previous qualitative studies considering developmental differences in how young adults think about their mental illness recovery. Young adults in these studies stressed the importance of hope and empowerment in their recovery, the need for personalized treatment regimens, a recovery that was embedded in larger goals related to education and relationships, and for collaborative discussion between providers about goals and expectations.30, 31

Participants’ desire to be defined as more than “in recovery” has implications for SUD treatment for young adults. While MOUD are lifesaving, results from the current study highlight the importance of other indications of treatment success, such as graduating from school, developing a network of non-drug-using peers, or securing independent housing. Models of care that integrate patients’ goals for the future into evidence-based treatment plans and consider how SUD treatment and medication could help in achieving those goals might have better success engaging and retaining young adults in treatment. Future studies could explore intervention development and treatment structures that explicitly address other priorities in a young adult’s life as a way to bolster motivation for continued engagement in medical models of substance use treatment.

A common response from study participants considered the role of their own mental health in the progression of their SUD and the importance of addressing mental health in their SUD treatment.30 The highest risk for development of psychiatric disorders is during young adulthood, with the early onset of substance use related to higher rates of mental illness, with estimates that 80% of people entering SUD treatment experience a co-occurring mental health condition.28, 32 As participants like Clayton described and previous research supports,33, 34 trauma plays an integral role in substance use and should be a particular focus of comprehensive treatment for young adults with use drugs. Including behavioral health and psychosocial treatment options into SUD care directly responds to this need.

While specific themes emerged from interviews, the diversity in how participants considered their recovery is notable. These 20 different construals of recovery emphasize the importance of understanding personal motivations for seeking SUD treatment. Research into SUD and other areas of healthcare shows that professionals’ assessments of treatment needs and health status can differ from their patients’.35, 36 These observations extend into ranking of importance, with doctors and patients disagreeing about the relative importance of specific health outcomes.37 An explicit effort to ensure that expectations are aligned in the provision of care might improve engagement and retention of young adults in SUD treatment. A well-known example of this are anti-smoking campaigns. Studies found that more successful youth-oriented anti-smoking ads included a younger demographic and emphasized sociability and shorter-term consequences of tobacco use, compared to adult-oriented ads that relied on longer-term and health-related consequences of tobacco use.38–40 Although that example highlights adapting public health messaging to resonate with youth, similar lessons could be learned for adapting treatment for this age group.

The current study has certain limitations. Participants were patients already engaged in SUD treatment at an urban New England hospital. While participants matched the demographic breakdown of patients seen in young adult substance use care at the institution, the sample was primarily white and city-dwelling. The themes identified in this study describe the breadth of participant responses; however, this was not a representative sample and results from the small sample are not generalizable. Young adults are not a monolithic group and gender and racial/ethnic variation in conceptualizations of recovery reasonably exist and uniquely affect treatment engagement and outcomes. Further work is necessary to understand how the construct of “recovery” resonates with different groups, and how to ensure it does not perpetuate the history of racist inequities and distrust of medicine among communities of color. Additionally, individuals already engaged in care and along their recovery journeys may think about the construct differently than those still in active SUD.

CONCLUSION

Young adults with substance use disorder are difficult to engage and retain in treatment. Young adults have diverse expectations and multifaceted goals for their recovery from SUD. While young adults consider their recovery journey to be a consistent pursuit, they overwhelmingly seek a normal life not defined by their substance use. Traditional chronic disease models and medical approaches may not resonate with young adults and may affect the ability to engage and retain this difficult-to-reach age group in treatment. Future work should focus on the conception of treatment models that incorporate identity development, mental health treatment addressing trauma, and re-engagement in regular daily activities to meet the unique needs of young adults.