Background: Addiction to illicit drugs is a complex phenomenon characterized by cyclical patterns of relapse, remission, and, for some, a full recovery. People who use drugs (PWUD) and their loved ones form ‘mental models’ of recovery that develop over time through experience and observation. The role of these mental models and how they interact to undermine or support recovery is poorly understood. Therefore, this study asks: 1) What do people who use drugs and their loved ones believe it takes to successfully recover from addiction? and 2) Given these beliefs about recovery and the available evidence on remission, relapse, and recovery, what places to intervene and leverage points would support recovery and prevent relapse?
Methods: Data were collected from in-depth qualitative interviews with 14 people who use drugs (PWUD) and 10 loved ones of PWUD (“loved ones”) in a rural county in Missouri to elicit their mental models of addiction recovery. A grounded theory was developed and translated into mathematical equations to build a system dynamics model. System dynamics is a method to understand systems in terms of their interacting reinforcing and balancing feedback loops. The model was calibrated to replicate a prototypical pattern of addiction relapse, remission, and recovery. The grounded theory and model experiments were used to identify leverage points for sustaining positive change (i.e., recovery).
Results: Participants believed that “you have to want it” to recover from addiction, where “wanting it” means improved social role functioning, seeking support, and abstinence. Insufficient proof of “wanting it” leads some loved ones to withdraw their support, which reinforces the addiction cycle. Model simulations show that expectations for social role functioning are a key driver of addiction and recovery. Changing the model structure so that support is not contingent on proof of “wanting it” has negligible immediate impact on drug use but creates the strongest eventual recovery. Support that is no longer contingent increases expectations for social role functioning, the benefits of which accumulate over time. When these benefits combine with strong balancing feedback loops, the recovery is stronger.
Discussion: Increasing expectations for social role functioning is a key leverage point for recovery from addiction (i.e., for sustaining change). Support can be a critical factor that increases expectations. However, “wanting it” is, in effect, to no longer be addicted, meaning that many PWUD do not get support when they need it most because they have not yet proven to others that they can respond rationally to negative consequences. Thus, expectations must also be increased through means other than support from loved ones, including connecting with others who have similar lived experiences, and sustainable, meaningful changes in social role functioning. This requires social welfare, health, and criminal justice policies and programs that reverse, not merely slow down or even strengthen, the reinforcing loops that drive addiction
