LOOKING BEYOND DRUGS: A SCOPING REVIEW OF RECOVERY IN THE CONTEXT OF ILLICIT SUBSTANCE USE AMONG ADOLESCENTS AND YOUNG ADULTS

Abstract

Background

Despite extensive literature exploring the harms associated with illicit substance use among young people who use drugs (YPWUD), the concept of “recovery” among this population has received significantly less attention. Addressing this literature gap can inform efforts to better support YPWUD as they pursue their goals.

Objective

To examine the qualitative literature on how young people (< 30 years of age) understand and navigate substance use recovery and healing in the context of illicit substance use, including how interventions and caregivers are implicated in these processes.

Methods

The design for this scoping review was guided by Arksey and O’Malley’s framework and informed by Levac et al. refinements. We surveyed five bibliographic databases for English, peer-reviewed, empirical studies published between 1999 and 2023. Studies were independently reviewed by two reviewers. We charted, synthesized, and assessed studies for common themes.

Findings

A total of 28 articles met the inclusion criteria for this scoping review. Studies show varied definitions and enactments of recovery as part of a continuum of substance use care, frequently extending beyond the notion of recovery as abstinence. Caregivers providing emotional, material, and social support are crucial to recovery; however, the challenges of supporting a young person’s recovery are manifold, including misaligned expectations about recovery definitions and processes.

Conclusion

Findings underscore the need for recovery-oriented care that aligns with young people’s diverse and shifting needs, goals, and contexts. Recovery programs must range from harm reduction to abstinence-based approaches across institutional and non-institutional settings and actively engage YPWUD and caregivers.

INTRODUCTION

Improving the health and well-being of adolescents and young adults (hereafter “young people”) who use illicit drugs remains an urgent public health concern worldwide (United Nations Office on Drugs & Crime, 2020; World Health Organization, 2014). Substance use generally begins during the formative years of adolescence and young adulthood, with international recognition of young people as a priority population at risk for substance use disorder (SUD) and related health and social harms (Substance Abuse & Mental Health Services Administration, 2014; United Nations Office on Drugs & Crime, 2020; World Health Organization, 2014). Indeed, it is during this developmental period – a time marked by complex social transitions as individuals navigate growing independence, new kinds of interpersonal relationships, and heightened responsibilities related to school and work, for example – that the clinical onset of SUD generally peaks (Centers for Disease Control & Prevention, 2018; Clark et al., 2008; Hser et al., 2007; World Health Organization, 2014). Research focused on young people diagnosed with SUD reveals they often face significant structural vulnerabilities (Bourgois et al., 2017) shaped by race, class, gender, sexuality, and disability. They also often face constrained access to determinants of health such as safe and stable housing and concurrent mental health challenges, often interrelated with experiences of homelessness and discrimination (Chang et al., 2018; European Monitoring Centre for Drugs & Drug Addiction, 2008; Kidd, 2013; Köck et al., 2022; Uhlmann et al., 2014). Structural vulnerabilities and the health and social inequities that they produce must be accounted for in efforts to redress the high burden of risks and harms among young people who use drugs (YPWUD) (Alegria et al., 2011; Daniels et al., 2021; Hagle et al., 2021; Jongbloed et al., 2017; Tao et al., 2023; Urbanoski, 2017).

Ongoing efforts by researchers, policymakers, and clinicians to address the risks, harms, and inequities affecting YPWUD focus heavily on identifying and implementing effective interventions to more fulsomely support this priority population (Das et al., 2016; Krausz et al., 2022; World Health Organization, 2014). In settings across North America, including our Canadian setting, there is increasing emphasis on implementing a continuum of care for those using illicit substances– ranging from harm reduction services, to evidence-based substance use treatment, to community-based recovery programs – similar to continuums of substance use care that exist in parts of the United Kingdom and Australia (British Columbia Centre on Substance Use, 2018; Krausz et al., 2022; Public Health England, 2017; Ritter & Stoove, 2016; United Nations Office on Drugs & Crime, 2020). This approach aligns with the widely accepted notion of SUD as “chronic and relapsing” and is rooted in the disease model of addiction (Volkow et al., 2016, National Institute on Drug Abuse, 2014). It should be noted that this model has faced increasing criticism, particularly in the context of SUD treatment and recovery, because of its potential to overemphasize biological determinism, reinforce stigma, and overlook critical social structural dynamics that powerfully shape treatment engagement, recovery, and healing (Hall et al., 2015; Hart, 2017; Heather et al., 2018). Nevertheless, the notion that individuals often need to repeatedly access multiple components of the substance use care continuum as they move in and out of periods of substance use cessation, resumption, and reductions and increases in use underscores the urgent need for a range of programs that align with diverse and shifting needs, goals, and contexts (Bagot & Kaminer, 2018; Buchholz et al., 2023; Bryant, 2018; Kelly et al., 2018; McLellan, 2017; Meyers, 2013; Volkow et al., 2016). In this scoping review, we examine recovery as one key component of the continuum of care for YPWUD, recognizing that young people’s recovery experiences will often span this continuum.

Compared to substance use treatment, conceptualizations of recovery often extend beyond a move away from substance use and associated risks and harms, instead focusing on broader, longer-term health, wellness, and social goals related to the pursuit of a meaningful and fulfilling life (Anthony, 1993; Ashford et al., 2019; Betty Ford Institute Consensus Panel 2007, Davidson et al., 2021; Laudet, 2007, Substance Abuse and Mental Health Administration, 2012; U.S. Department of Health & Human Services, 2016). Despite broader conceptualizations, recovery nevertheless often continues to be largely defined – whether explicitly or implicitly – as abstinence from substance use (Finch et al., 2020; Kougiali et al., 2017). It is partly for this reason that the term recovery continues to be debated and contested. It has been argued that it can reinforce stigma by framing drug use in narrow, problem-focused terms, positioning people who use drugs as “patients” needing correction and management (Lancaster et al., 2015). This framing tends to overlook the constantly shifting and highly contextual nature of drug use, as well as alternative understandings of healing. In response, some have called for a shift to the language of “living well” in an attempt to better capture the complexities of substance use and desires for overall health and well-being (Bryant et al., 2022; Maclean et al., 2012). Regardless of terminology, to date, there has been relatively little investigation of how young people perceive and pursue recovery in the context of illicit substance use. One exception is an integrative review by Finch et al. (2020), which provided a summary of the recovery literature among adolescents under the age of 18. This review considered a total of 39 articles, exploring (i) recovery as an outcome of substance use treatment; (ii) considerations for supporting recovery among priority populations, such as those with co-occurring substance use and mental health disorders; (iii) the emergence and value of recovery-oriented systems of care that build senses of community (e.g., peer recovery support groups); (iv) the role of family involvement in adolescent recovery; and (v) nonabstinence-based approaches to recovery programming. In this review, we join Finch et al. (2020) in calling for the adoption of more expansive definitions of recovery beyond abstinence from substance use. Specifically, we define recovery as a move towards individually defined health, healing, and well-being in the context of substance use, which is often but not always supported by substance use treatment. We further agree with Finch et al. (2020, p. 13) that additional prospective, longitudinal, and life-course research is needed in order to “fully appreciate the complex and cascading nature of recovery across the life span” among adolescents and young adults.

Calls for increased focus on recovery trajectories dovetail with the recent focus on a continuum of substance use care and alert us to the important, and at times complex, relationship between treatment and recovery along this continuum. Indeed, a growing body of literature is exploring the intersection of recovery and substance use treatment among young people (Christie et al., 2020; Finch et al., 2020; Monico et al., 2022; Schoenberger et al., 2022). This work underscores that a variety of treatment programs, including cognitive-behavioral and family-based therapy, motivational interviewing, and contingency management, can all play crucial roles in recovery processes across time and place (Hadland et al., 2021; Haughwout et al., 2016; Hser et al., 2007; Lu et al., 2023, Marks & Leukefeld, 2018, National Institute on Drug Abuse, 2014; Wu et al., 2011a; Xuan et al., 2021). Pharmacotherapies such as opioid agonist therapy (OAT; e.g., methadone, buprenorphine/naloxone) are also often highlighted in this literature, particularly in North American settings where opioid use disorders among young people are prevalent (Donroe et al., 2018; The Lancet Regional Health, 2023). OAT can significantly influence the recovery experiences of adolescents and young adults in these settings but will perhaps have less impact in settings of low opioid use among young people (Pilarinos et al., 2022a, Pilarinos et al., 2022b; Vasilev et al., 2016). In general, access to effective substance use and mental health treatment remains a challenge globally (Degenhardt et al., 2017; Salwan & Katz, 2014; Sterling et al., 2010). Barriers to treatment for adolescents and young adults include stigma, discrimination based on race (Alegria et al., 2011; Cummings et al., 2011, Wu et al., 2011b), gender (Lu et al., 2023; Porche et al., 2022), sexuality, and class (Acevedo et al., 2020), as well as long program wait times (Castro-Ramirez et al., 2021).

Recovery-oriented care and systems of care arose largely in response to the limitations of acute models of substance use treatment that are primarily focused on responding to and managing moments of substance use crisis (Davidson et al., 2021; Finch et al., 2020). Building on the work of others, we define recovery-oriented systems of care as assemblages of community-based programs that primarily seek to engender senses of social connectedness, community, and belonging in relation to health, wellness, and social goals among those who are seeking to move away from intensive illicit substance use (Davidson et al., 2021, Substance Abuse and Mental Health Administration, 2009). While recovery-oriented systems of care can encompass the continuum of substance use care described above, they most often include Twelve-Step mutual support programs, Self-Management and Recovery Training (SMART) programs, therapeutic communities, peer support groups, education and vocational training programs (e.g., recovery high schools), and other life-skill development programs (Marks & Leukefeld, 2018, Xuan et al., 2021, Substance Abuse and Mental Health Administration, 2009). Recovery-oriented systems of care often encompass a range of institutional (e.g., recovery high schools) and non-institutional (e.g., peer support groups) settings, increasingly including various online and virtual spaces that have emerged largely in response to global challenges posed by COVID-19 (Calihan & Levy, 2022; Langabeer et al., 2021; Lundahl & Cannoy, 2021).

Early work framed recovery as an outcome of “successful” treatment, where success is defined as completing a treatment program and maintaining abstinence for a period of time – a framing that has been largely critiqued (Anderson et al., 2007; Bagot & Kaminer, 2018; Christie et al., 2020; Scott et al., 2005; Smith et al., 2023). In more recent work, there has been a shift toward understanding recovery as a dynamic process (Ashford et al., 2019; Buchholz et al., 2023; Finch et al., 2020; Kougiali et al., 2017; Meyers, 2013, Raikhel & Garriott, 2013). For example, the concept of recovery careers has been used to better understand unfolding recovery trajectories (Best et al., 2010). Recovery careers can be characterized as individual trajectories marked by changes in substance use patterns, multiple treatment engagements, and key moments of overcoming challenges and opportunities for personal and social growth (Best et al., 2010; Best & Hennessy, 2022). Alongside recovery careers, the concept of recovchen et ery capital has been used to describe the array of resources that one can mobilize in order to initiate and maintain recovery across time and place, including among young people (Best & Hennessy, 2022; Cloud & Granfield, 2008; Hennessy et al., 2019). Literature in this area generally focuses on factors that facilitate recovery (often termed positive recovery capital), as well as factors that have the potential to impede recovery (known as negative recovery capital) (Best & Hennessy, 2022; Cloud & Granfield, 2008; Hennessy et al., 2019). This research demonstrates that young people’s social networks are essential sources of recovery capital and paramount to consider in designing effective programs (Bryant, 2018; Hogue et al., 2021; Mawson et al., 2015; Tambling et al., 2021). In particular, studies demonstrate that family members, especially parents, guardians, or other adult caregivers, can be but are not always a key source of positive recovery capital and social support for YPWUD (Hennessy et al., 2019).

A focus on recovery careers and capital represents an important move toward understanding recovery as a dynamic process of change. The goal of this scoping review is to further examine how YPWUD (<30 years of age) perceive and pursue recovery and healing across time and place in the context of past or current illicit substance use, including how various interventions, as well as caregivers (e.g., biological, adoptive, and chosen family members), are implicated in these processes. While the literature demonstrates that SUD diagnoses are often implicated in recovery processes among YPWUD, we did not limit our focus to studies that focused on SUD and recovery among YPWUD. We argue that defining recovery as precipitated by a formal SUD diagnosis may overlook the needs, goals, and desires of young people, who often have shorter histories of substance use and may want to address their substance use prior to diagnoses. This review excludes the perspectives of young people using exclusively alcohol or cannabis. We defined exclusive alcohol and cannabis use as beyond the scope of the current review due to the unique legal and sociocultural dynamics surrounding these substances, particularly in regions such as North America where recent changes in legality have significantly altered public perceptions and patterns of use (Hanson, 2013; Heilig & Spanagel, 2015; Sudhinaraset et al., 2016). There is evidence that the distinct historical, legal, and sociocultural contexts of cannabis and alcohol have led to the emergence of substance-specific understandings of recovery that differ from those associated with opioid and stimulant use. More focused reviews on cannabis and alcohol use recovery among young people are needed to adequately address these nuances (Bartram, Eliott, & Crabb, 2017, Hagman, Falk, Litten, & Koob, 2022). By synthesizing diverse perspectives on and lived realities of recovery in the context of illicit substance use – primarily psychedelic, opioid, amphetamine, and other stimulant use – we aim to guide future research and inform policy and program development so that these better align with the needs, priorities, and desires of YPWUD pursuing recovery and healing, broadly defined.

MATERIALS AND METHODS

Design

The scoping review was guided by Arksey and O’Malley’s five-stage framework and informed by refinements outlined by Levac et al. (2010).

Stage 1: We developed the research question

The purpose of this scoping review is to understand how recovery, broadly defined, features in the lived experiences of YPWUD. While reductionist definitions of recovery have major limitations (e.g., recovery defined as abstinence from substance use), we use this term throughout the review as a means of organizing existing literature and young people’s diverse experiences of substance use recovery and healing (which, in some cases, did not include abstinence). Our research question, “How do YPWUD under the age of 30 and their caregivers perceive and pursue recovery and healing in the context of past or current illicit substance use?”, was developed by author CRE after an initial survey of the qualitative literature. Given the different age ranges used to classify young people and define eligibility criteria in the included studies, this review focuses on individuals under 30 years of age. The impetus for this review was largely pragmatic in that we sought to inform the work of our interdisciplinary team (including those with backgrounds in population and public health, nursing, library and information science, and anthropology) and other research, policy, and practice stakeholders who are championing efforts to improve the continuum of care, including recovery programs, for YPWUD.

Stage 2: We identified relevant studies

We searched MEDLINE (Ovid), CINAHL (Ovid), PsycINFO (Ovid), Embase (Ovid), and PubMed. The search strategy was developed in consultation with a library and information science professional (co-author CM) to include a wide set of terms and synonyms in an attempt to capture the concepts of youth, recovery, healing, substance use, and qualitative approaches. We opted to focus on qualitative research because of its potential to delineate subjective, contextualized perspectives on recovery based on the lived experiences of YPWUD and their caregivers. The searches were restricted to peer-reviewed, English-language articles published between January 1, 1999, and October 11, 2023. The decision to focus on more recent articles was for feasibility reasons but also aligns with our aim to synthesize literature that is likely to be most relevant to contemporary youth substance use continuums of care (Davidson et al., 2021). Citations retrieved from these databases were imported into an EndNote citation manager and de-duplicated. See Appendix A for the MEDLINE search strategy.

Stage 3: We selected studies

All citations were uploaded to Covidence (Veritas Health Innovation, Melbourne, Australia, available at www.covidence.org) and de-duplicated once more prior to beginning a two-stage study selection process using PICO and study design criteria (Table 1). First, authors CRE and MS independently reviewed the title and abstract of each retrieved citation. A second stage of screening involved reviewing all full-text articles deemed by both reviewers as relevant or possibly relevant (categorized as ‘yes’ or ‘maybe’) based on the initial title and abstract review. Disagreements between reviewers were settled through discussion between CRE, MS, and CM. The determination of relevant articles was made by authors CRE, MS, CM, and DF during planning sessions, with specific attention paid to longitudinal studies focused on recovery processes and trajectories, as well as specific outcomes implicated in these processes and trajectories (Table 1). Outcomes of interest were identified by drawing on prior literature (Finch et al., 2020) and informed by the senior authors’ extensive experience conducting longitudinal qualitative and ethnographic research with YPWUD pursuing recovery and healing across institutional and non-institutional settings (Fast, 2024).

Table 1.

PICO and study design criteria guiding a scoping review on recovery among young people who use(d) drugs, 1999–2023.

Population	(1a) Participants were young people under 30 years of age.
	(1b) Participants reported current or past illicit substance use (excluding the use of only alcohol or cannabis) as part of study participation, including illicit use and prescribed medication misuse.
	(1c) Participants were engaged in, or actively reflecting on, recovery, healing, or other restorative pursuits in the context of substance use. OR,
	(2a) Caregivers (broadly defined) supporting young people with current or past illicit substance use who were engaged in recovery and healing, excluding care providers in institutionalized settings (e.g., clinicians, counselors).
Intervention	This review included studies which documented experiences with any action, treatment, assessment, or intervention for substance use and related issues (e.g., mental health) in institutional (e.g., acute care), community-based (e.g., group counseling), and private (e.g., self-managed) settings. Studies focused on evaluating a specific intervention were not included unless they included substantial qualitative findings relevant to how recovery and healing were perceived and pursued among youth and caregivers.
Comparisons	None
Outcomes	This review included studies which described unfolding recovery processes, trajectories, and outcomes. These include, but are not limited to:
	(a) abstinence,
	(b) changes in the severity of substance use,
	(c) changes in social functioning,
	(d) changes in employment,
	(e) changes in community engagement and citizenship,
	(f) changes in mental health,
	(g) changes in self-concept,
	(h) accrual of recovery capital, and
	(i) changes to quality of life and well-being.
Study Design	(a) qualitative studies (articles employing mixed methodologies were considered only if they presented substantial qualitative findings that were pertinent to the research question guiding the current review)
	(b) published in English

Stage 4: We charted the data

Data were extracted from the 28 articles by authors CRE and MS. The identification of data extraction points was informed by prior work (Arksey & O’Malley, 2005; Levac et al., 2010) and our initial reading of the retrieved articles. Data on the year of publication, location of the study, and topic-specific study details (e.g., relevant findings, salient policy, and programmatic recommendations) were extracted from each article and managed using Microsoft Word. After multiple readings of the articles, author CRE developed thematic categories to organize the information captured. CRE collected representative quotes from the articles that supported, challenged, and contextualized these themes. All articles were then re-scanned in order to nuance the findings related to these themes.

Stage 5: We organized, summarized and reported the findings

Analysis of the collected data was performed by authors CRE and MS. Following Levac et al. (2010) guidelines for reporting scoping review findings, the analysis involved both a descriptive summary of the data and a qualitative content analysis guided by Stemler’s (2001) articulation of emergent coding. CRE and MS reviewed and analyzed the articles independently to identify emergent data content categories and codes. Subsequently, CRE coded the complete dataset, iteratively grouping findings according to reoccurring ideas, concepts, and contexts. CRE regularly met with co-authors MS, CM, and DF throughout the analysis to determine the best approach for organizing the data in relation to emerging interpretations. This iterative process enabled the team to offer feedback on potential gaps and areas for future inquiry.

RESULTS

Search summary

The search strategy led to the identification of 755 potentially eligible records. Following de-duplication and screening of titles, abstracts, and full texts, a total of 28 articles met the inclusion criteria. Appendix B presents the article collection process in the form of a PRISMA Flow Diagram.

Study characteristics

The 28 articles included in this scoping review were published between January 1999 and November 2023, with 19 (68%) articles published since 2017. Most studies originated from the United States (n = 17), and Canada (n = 5), including studies conducted in Vancouver (n = 3), Baltimore (n = 2), and Boston (n = 2), among others. There were an additional six studies from Israel, Denmark, India, Zimbabwe, Norway, Azerbaijan, and Germany. All included studies employed either a qualitative (n = 26) or mixed-methods (n = 2) study design. Approximately 80% of the included studies focused on individuals aged 12 to 26 years, with the most common age range being 12 to 24 years. The studies primarily featured white participants (72%), and over half (57%) involved predominantly young men. Around 36% of the studies included individuals actively engaged in residential substance use treatment. Data collection approaches included in-depth interviews, focus groups, and ethnographic fieldwork. Table 2 provides additional detail about the included articles, including study characteristics and key findings.

Table 2.

Characteristics of studies (N = 28) included in a scoping review on recovery among young people who use(d) drugs, 1999–2023.

Author(s) (year)	Study aim(s)1	Population & demographics	Study approach	Relevant findings about recovery processes	Salient policy and programmatic recommendations
Acri et al. (2012)	Investigate the types of support youth need after leaving residential treatment.	87 total participants (28 adolescents, 30 parents or primary caretakers, and 29 staff).	Qualitative; semi-structured interviews.	Adolescents, parents, and staff largely agreed on key factors for youths’ recovery post-discharge: aftercare, relationships, and drug-free activities. This aligns with existing research which has indicated strong support for these aspects.	It is crucial to prioritize support, structured substance-free activities, and aftercare services for adolescents transitioning from residential treatment. Further research should explore whether adolescent beliefs align with recovery facilitators post-care.
Boyd et al. (2017)	Explore the social, structural, and environmental factors influencing periods of injection cessation among youth and young adults.	22 street-involved young people who use drugs.	Ethno-epidemiological study; qualitative interviews.	Addressing homelessness, ensuring stable housing, providing robust social support, offering harm reduction services, and facilitating access to opioid agonist therapy are crucial components in enabling periods of injection cessation among young people.	Develop youth-focused services that respect diversity and incorporate youth perspectives. Additionally, it is key to promote non-injection routes of drug administration alongside a shift from sole emphasis on abstinence.
Chen et al., (2012)	Explore parental perspectives on the recovery processes of male adolescents within a therapeutic community.	14 parents of male adolescents who were residents of a Jewish therapeutic community for substance use.	Qualitative semi-structured interviews.	Recovery from SUD involves comprehensive support systems, particularly the active involvement of caregivers, acknowledging the ongoing and diverse challenges posed by chronic stress, to achieve positive and sustainable outcomes for both young people and caregivers.	Practitioners should actively engage caregivers in treatment, viewing them as vital contributors. Temporary separation can enhance support and relationships. Regular assessments, addressing family needs, and equipping them with coping skills are essential.
Earnshaw et al. (2019)	Examine relational processes (e.g., stigma, social support) among young people with SUD and their caregivers.	34 total participants (19 young people with SUD and 15 caregivers).	Qualitative; semi-structured interviews.	Relational processes that young people and their caregivers engage in may act as barriers to, or facilitators of, recovery. Addressing these processes may support recovery efforts.	Addressing relational processes and encouraging patient-centered disclosure discussions between young people with SUD and their caregivers in treatment settings can alleviate conflict, reduce distress, and frustrations felt by young people and their caregivers. Treatment providers should prioritize individual preferences, facilitate open communication, and mitigate stigma to improve social support and access to treatment.
Elswick et al. (2018)	Explore the experiences of young people in recovery from SUD and identify the barriers and facilitators to their recovery.	8 young people with SUD.	Qualitative; semi-structured interviews.	Challenges in physical recovery capital may include financial and residential instability. Spirituality may be a facilitator of human capital for recovery processes. Family cutoff in some cases initiates recovery, yet ongoing family support was viewed as crucial for ongoing maintenance. The presence of recovery role models instilled hope in individuals, indicating their potential for sustained recovery.	Ongoing family support is crucial in providing the necessary guidance and stability for sustained recovery, even after family cutoffs or ultimatums, emphasizing the pivotal, yet complex roles families can play in the recovery processes for young people.
Giang et al. (2020)	Examine perspectives of OAT among young people experiencing unstable housing and their care providers.	53 total participants (40 young people and 13 care providers; including 6 family physicians, 1 nurse practitioner, 1 nurse, 2 drug and alcohol counselors, and 2 social workers).	Qualitative; longitudinal semi-structured interviews.	It is important to understand youths’ hopes and concerns regarding achieving a “full” recovery from past substance use. Sustained adherence to OAT often conflicts with their expectations for both the near and distant future. Providers should be mindful of these perceptions, especially the belief in rapid, complete abstinence, and consider initiating discussions with youth about incorporating harm reduction strategies, such as safer consumption sites and OAT, within the framework of recovery.	Findings suggest that instead of framing discussions with youth about substance use, mental health, and OAT solely within an “addiction as chronic illness” framework, it is more effective to engage in open and empathetic conversations. By understanding the individual logic and motivations behind substance use, providers can collaboratively work with young people to define common short-term goals and long-term visions of recovery, embracing improvisational approaches that acknowledge the complex lived experiences of young individuals.
Gonzales et al. (2013)	Investigate youth attitudes surrounding recovery-related needs and key drug-avoidance behaviors post-treatment.	118 young people (ages 12–24 years) enrolled in outpatient and residential substance use treatment programs.	Qualitative; focus group discussions.	Youth emphasized the significance of recovery programs incorporating developmentally engaging activities, coping skill development for stress management, providing diverse recovery support options beyond abstinence, and maintaining substance use education to effectively support recovery pursuits.	Recovery support programs should integrate coping skills for stress management, enhance self-identities, and provide ongoing education about substance use within recovery-support programs tailored for youth, emphasizing the necessity of aligning programs with youths’ perspectives to enhance recovery outcomes.
Gonzales et al. (2012a)	Investigate how youth engaged in treatment retrospectively interpret the context surrounding substance use relapses.	118 young people (ages 12–24 years) enrolled in outpatient and residential substance use treatment programs.	Qualitative; focus group discussions.	To promote recovery for young people who use drugs, it is essential to address multifaceted challenges, including co-occurring mental health issues, stress management, cognitive factors like motivation and self-efficacy, and the influence of socialization processes and environmental factors on substance use.	Addressing the challenge of sustaining recovery post-treatment for youth with substance use issues requires ongoing interventions, particularly in the transition from structured institutional care settings to less structured settings, emphasizing the need for continuing care models that comprehensively tackle the complex, interrelated issues they face.
Gonzales et al. (2012b)	Understand youth perceptions around substance use behaviors, relapse, and recovery.	118 young people (ages 12–24 years) enrolled in outpatient and residential substance use treatment programs.	Qualitative; focus group discussions.	Youth perceptions of substance use problems primarily revolve around lifestyle choices and personal control, highlighting the need for personalized and empowering approaches in treatment and recovery programs.	There is a need for age-appropriate recovery support models for youth. Programs should avoid prematurely applying conventional recovery rhetoric such as abstinence and 12-step participation. Providers should emphasize personalized recovery support after treatment without conveying the impression that it must be lifelong, recognizing the importance of behavioral improvement as a top priority and exploring suitable forms of social support tailored to the unique needs of youth in recovery.
Hennessy et al. (2022)	Explore parents’ perspectives on their children’s recovery processes and components of social recovery capital that supported their children.	10 caregivers (5 mothers and 5 fathers) of youth who attended an alternative peer group for SUD recovery.	Qualitative; longitudinal ethnographic study.	Parents often play a crucial role in their child’s recovery, recognizing harms, taking action, and creating a supportive environment while balancing the responsibility for decision-making between themselves and their child. This work emphasizes the need for parents to learn and grow alongside their children for successful recovery.	There is a need to systematize alternative peer group activities to build youth social recovery capital. The study proposes a model to guide future examinations of recovery capital development through alternative peer groups or similar adolescent recovery-oriented services engaging families.
Herold and Søgaard (2019)	Investigate how young people who use drugs, as part of their recovery processes, negotiate their relationships with still-using friends through complex performances of recovering identities.	15 young people enrolled in outpatient substance use treatment.	Qualitative; semi-structured and participant-driven narrative interviews.	Young people pursuing recovery grapple with complex dilemmas and ambivalences related to their drug-related social relationships, challenging the notion that ending all such relationships is imperative and underscoring the importance of personalized approaches to reconfiguring these connections.	Employ individualized approaches in substance use prevention and treatment for young people; treatment programs should respect youths’ diverse perspectives on friendships and substance use. Rather than enforcing total abstinence and discontinuing relationships with peers, programs could adopt graduated goals, which must involve youth in defining their needs and desires regarding substance use and friendships to provide personalized and effective support.
Jenkins et al. (2017)	Examine how young people interact with informal harm reduction approaches in the context of peer groups and their broader communities.	83 young people attending high school.	Qualitative; semi-structured interviews.	This study does not address recovery directly; however, it highlights the regional variation in youth substance use patterns, with distinct norms and strategies for substance use management in different contexts.	To effectively resonate with young people, programs must recognize diverse substance use patterns and informal harm minimization strategies employed by youth. A context-specific, normalized harm reduction framework can enhance resilience and minimize potential harms associated with youth substance use.
Jurinsky et al. (2023)	Investigate youth substance use recovery and recovery capital development by examining their self-reported experiences with changes in their social networks during recovery processes.	10 young people (ages 17 to 19 years).	Qualitative; social identity maps and semi-structured interviews.	Change plays a pivotal role in young people’s recovery journeys, encompassing shifts in personal perspectives, social networks, and recovery actions. Improved family relationships and efforts to expand their supportive networks reflected their evolving identities, highlighting the intricate dynamics of recovery, social networks, and personal growth.	Programs should focus on supporting positive changes in social networks, recognizing the influence of family and peers. Additionally, addressing substance use within the context of social relationships is crucial, requiring tailored interventions and strategies to facilitate successful recovery experiences for youth.
Krüsi et al., (2010)	Explore the social and structural barriers faced by young people who use drugs experiencing street-entrenchment.	38 young people (ages 16 to 26 years old).	Qualitative; semi-structured interviews.	This study does not address recovery directly. It does highlight the myriad of social and structural challenges, including the lack of formal support in accessing safe housing, overregulated government-sponsored shelters, and discrimination and financial constraints making it difficult to secure apartments, leaving many feeling unsupported.	There is a need to increase resources to establish safe, low-threshold housing options, centered on harm reduction strategies, and aimed at supporting youth experiencing street-entrenchment and dealing with substance use challenges.
Long and Vaughn (1999)	Examining how young people become and remain abstinent from substance use.	7 young people (ages 15–18 years old).	Qualitative; phenomenological longitudinal interviews.	Social stress can have a significant impact on recovery, while positive environmental conditions and resilient responses, even in the face of diminishing external support, enabled some young people to maintain abstinence, emphasizing the importance of internalized resiliency and spiritual connections throughout recovery processes.	Not explicitly stated.
Ludwig et al. (2021)	Investigate and contextualize factors shaping the resources caregivers provided their children following residential substance use treatment.	31 caregivers of youth (28 women and 3 men).	Qualitative; semi-structured interviews.	Caregivers have varied understandings of relapse and recovery, highlighting the impact of unrealistic expectations, and emphasizes the crucial role of caregiver engagement in outpatient care following residential treatment to support youth recovery during the vulnerable post-discharge period.	Discharge planning for caregivers of young people with opioid use disorders should emphasize stepwise and gradual options, providing skills, and resources for adaptive decision-making, while also highlighting the potential benefits of support groups to reduce feelings of isolation and uncertainty. Additionally, healthcare policy should address resource allocation challenges and financial burdens on families, emphasizing the need for long-term support in the context of opioid use disorders.
Madill et al. (2023)	Understand the pathways to recovery for youth with SUD in Assam, India.	15 participants (11 young men and 4 young women; ages 19–24 years).	Qualitative; photo-led interviews.	Detailing a unique recovery model for youth substance misuse in Assam, the study uncovers three phases—recreational use, addiction, and supported recovery—enabling targeted intervention strategies tailored to each phase’s challenges and opportunities.	Interventions are needed to encourage youth to accept support for substance use cessation, advocating for long-term psychosocial support alongside medical treatment, investing in women’s rehabilitation, and supporting family/community education and peer-to-peer programs as effective strategies for preventing and enabling rehabilitation for youth SUDs in Assam.
Monico et al. (2022)	Investigate the preferences of youth with opioid use disorders regarding outpatient substance use treatment options following discharge from residential substance use treatment.	35 young people (22 young women and 13 young men; ages 15–21 years).	Qualitative; longitudinal semi-structured interviews.	Accountability, particularly in the form of structured programs like intensive outpatient treatment (IOP), is crucial for some youth in establishing daily habits and routines, while positive support, such as same-age peers and sponsor relationships, also plays a significant role in supporting recovery, highlighting the importance of individualized outpatient care plans tailored to the preferences of young people.	Therapeutic relationships are significant in the recovery processes for some youth, thus there should be a greater emphasis on increasing access to age-specific recovery groups for young people, as well as ensuring sustained insurance coverage for substance use treatment.
Nash et al. (2015)	Examine the experiences of recovery from SUD among young people who previously attended an alternative peer group.	14 young people (11 young men and 3 young women; ages 15–30 years) who previously attended an alternative peer group.	Qualitative; ethnography interviews.	Recovery from SUD, as defined by young people in this study is a holistic and transformative process involving the gradual evolution of identity, beliefs, and values, leading to comprehensive improvements in health, behavior, relationships, cognitive function, and overall quality of life.	To enhance adolescent SUD treatment outcomes, policy recommendations should extend treatment durations beyond traditional models, acknowledging the developmental processes of adolescents and recognizing the vital role of recovery support in both treatment engagement and sustained recovery; the implementation of peer-led recovery support projects and the incorporation of tailored programs like alternative peer groups and recovery high schools are crucial components within a coordinated system of care.
Nyashanu et al., (2023)	Investigate treatment barriers and the abstinence paradigm among young people who use crystal methamphetamine in Harare, Zimbabwe.	30 young people (ages 18–30 years) with methamphetamine use disorders.	Qualitative; semi-structured interviews.	Promoting well-being among young people necessitates fostering open dialogue and training, urging reflection on the delicate balance between personal freedom and responsible citizenship to with respect to ethical considerations and community responsibilities.	Enhancing drug awareness and treatment efficacy requires equipping professionals with modern tools and training, alongside a comprehensive strategy involving increased training of health personnel at various levels to ensure adequate staffing and qualified support for individuals with drug-related issues across all health facilities.
Schoenberger et al., (2022)	Examine the perspectives of recovery among young people with SUDs.	20 young people [12 men, 7 women; 1 non-binary; ages 21–29 years) who visited an urban safety net hospital.	Qualitative; semi-structured interviews.	Young people with SUDs hold diverse perspectives on recovery, emphasizing the multifaceted nature of recovery, the integral role of mental health, and the importance of control, choice, and self-motivation.	Treatment programs should prioritize incorporating young adults’ broader life goals, such as education, building non-drug-using social networks, and securing housing, into evidence-based SUD treatment plans, recognizing that addressing these priorities may enhance engagement and success beyond medication-assisted treatment alone.
Semb et al. (2019)	Investigate the challenges faced by young people with co-occurring substance use and mental health issues in relation to belonging to their local communities.	7 young people (five men and two women; ages 18–30 years) who received substance use and mental health services.	Qualitative; semi-structured interviews.	A process of ‘communal invalidation’ operates, socially defining young people in the community as inadequate, serving as a significant barrier to their recovery, a phenomenon similarly noted by others managing mental health and substance use problems in their progress towards leading meaningful lives in the community.	This study does not propose policy or program recommendations directly. However, this study argues that beyond the influence of social and mental health work initiatives, there is a societal and communal imperative to broaden the frameworks defining valid or legitimate lives, reflecting a need for more inclusive perspectives, and understanding.
Smith et al. (2020)	Obtain a comprehensive understanding of adolescents’ perspectives on the benefits and drawbacks of alternative peer groups in supporting SUD recovery.	12 young people (9 males and 3 females; ages 14–19 years) who had experience in an alternative peer group.	Qualitative; semi-structured interviews.	The process of adolescent recovery within an alternative peer group involves initial ambivalence, often intensified by peer group influence, with a sense of belonging and structured alternative peer group activities eventually transforming perceived disadvantages, such as time commitment and the “work of recovery,” into advantages, aligning with previous research on alternative peer groups and adolescent recovery.	Understanding the crucial elements in adolescent SUD recovery, such as recovery role models, structured activities, and a positive social climate, can inform the development of effective recovery service models, essential for preventing the personal and social costs associated with chronic SUD in adolescents.
Sultan and Duff (2021)	Investigate the nature of recovery contexts, seeking to unveil underlying dynamics and contribute to critical inquiries into the experiences of recovery.	20 young people (ages 16–21 years) who had engaged in treatment for their substance use.	Qualitative; narrative interviews.	Recovery is conceptualized as a dynamic and unfolding process shaped by the entangled relationships between spaces, practices, and embodied subjectivity, challenging the traditional focus on treatment arrangements and emphasizing the diverse and unpredictable nature of individual experiences of recovery.	Policy reforms should prioritize the development of culturally diverse understandings of recovery, informed by comparative analyses of Western and non-Western settings, to enhance the experiences of youth in formal treatment and promote a holistic pursuit of recovery, health, and wellness.
Turuba et al. (2022)	Explore the perceptions and experiences of substance use services among youth in British Columbia, Canada.	30 young people (ages 12–24 years) who had lived or living experience with substance use.	Qualitative; participatory action research methods; semi-structured focus groups.	Some youth perceive conventional, abstinence-based recovery as intimidating, emphasizing the need for a more inclusive and diverse approach; participants express the value of service providers assisting in building recovery capital by addressing basic needs, recommending educational and employment programs, and fostering healthy habits, suggesting a comprehensive framework that extends beyond substance use-specific interventions to support recovery.	Policy efforts should prioritize substance use prevention and early interventions for young people, involving diverse youth and peers with lived or living experience in the design and evaluation of services, with an emphasis on intentional and sustained investment to optimize health outcomes and experiences across British Columbia.
Vandermause et al. (2018)	Explore the dimensions and qualities of relational health in adolescent girls undergoing substance use treatment, aiming to provide insights into their relationships.	30 young women (ages 16–17 years) attending a residential substance use treatment program.	Mixed-method; survey questions; qualitative interviews.	Participants consistently expressed plans for self-care as part of their envisioned path to recovery, often using the concept of “drama” as a perceptual pivot point that could be transformed into a positive aspect of their recovery journey.	The study emphasizes the need for tailored policy and program recommendations informed by the nuanced understanding of relational complexities and the distinctive challenges presented by relationships among adolescents who use drugs to address the intricacies of their substance use and treatment.
Whitt et al. (2022)	Characterize the factors associated with relapse among adolescents attending a recovery high school.	200 adolescents attending a recovery high school (200 node maps were assessed, however, some node maps may have been from the same person).	Qualitative; node map approach.	Navigating adolescent recovery requires addressing common triggers like using with others, being away from home, and coping with negative emotions, emphasizing the need to understand and address these challenges for effective substance use intervention.	Node maps can serve as a valuable addition to current treatment approaches and programs, providing a user-friendly means for young people to actively and collaboratively explore effective ways to bolster and sustain their personal recovery pursuits.
Wisdom and Gogel (2010)	Exploring perspectives of treatment success among adolescents attending residential substance use treatment, their parents, and treatment staff.	87 total participants (28 adolescents, 30 parents, 29 staff) at three residential treatment programs.	Qualitative; semi-structured interviews.	Findings suggest there is no universal definition of recovery among young people, parents, and staff. Recovery from substance use is best supported through the partnership of all stakeholders; however, there was not a universal understanding of what treatment goals were.	Programs for substance use should outline more clearly and consistently what the goals of treatment are to improve treatment efficacy and facilitate collaboration between young people, their caregivers, and staff.

FINDINGS

Overview

The included studies examine how YPWUD perceive and pursue health and well-being in the context of recovery from past or current illicit substance use. They document a diversity of definitions and enactments of recovery as part of a continuum of substance use care, which frequently extend beyond the notion of recovery as abstinence from substance use. Caregivers and other sources of social support can be particularly pivotal to processes of recovery among young people; however, the challenges of supporting a young person’s recovery are manifold. This review organizes the literature into three interconnected themes: (i) defining recovery; (ii) the relationship between treatment and recovery; and (iii) supporting recovery: the role of caregivers.

Defining recovery

Abstinence and chronicity

The included articles shed light on the different ways that recovery was characterized among YPWUD across various settings and contexts. Across several studies, recovery was described by young people as an unfolding process that spanned institutional (e.g., residential treatment) and non-institutional (e.g., family home) settings, marked by shifts in substance use, health, social functioning, and overall well-being (Gonzales et al., 2012a, Gonzales et al., 2012b, Gonzales et al., 2013 Jurinsky et al., 2023; Madill et al., 2023; Nash et al., 2015; Schoenberger et al., 2022; Sultan & Duff, 2021; Wisdom & Gogel, 2010). For some young people, recovery was strongly associated with sustained abstinence from substance use, including through the use of OAT (Hennessy et al., 2022; Long & Vaughn, 1999; Nash et al., 2015). Several studies explored barriers to sustaining abstinence, noting that young people’s unique developmental tasks might increase the likelihood of substance use “relapses” following treatment (Acri et al., 2012; Elswick et al., 2018; Gonzales et al., 2012; Jurinsky et al., 2023; Nyashanu et al., 2023; Semb et al., 2019). For example, one study conducted with 118 youth aged 12 to 24 years undergoing residential substance use treatment from across Los Angeles County highlighted emotional, cognitive, social, and environmental factors contributing to relapses. Age-specific findings revealed that adolescents (ages 12 to 17) were more likely to note stressors related to parental involvement (e.g., mistrust, conflict), school (e.g., failing classes), and peer pressure (e.g., fitting in), whereas young adults (ages 18 to 24) were more likely to report stress related to establishing and maintaining relationships (e.g., romantic partners), fulfilling financial responsibilities (e.g., debt), and securing housing (Gonzales et al., 2012). The oftentimes nuanced relationship between recovery and abstinence among young people was highlighted by the same group of researchers in a separate study, which found that recovery for many did not include the pursuit of abstinence from all substances, with some young people instead focused on abstaining from their former “drug of choice” while still allowing for the occasional use of other substances such as alcohol (Gonzales et al., 2012b, p. 147).

The majority of articles underscore recovery among young people as multidirectional and frequently marked by periods of remission from and relapses to substance use (Gonzales et al., 2012a, Gonzales et al., 2012b,2013; Ludwig et al., 2021; Madill et al., 2023; Schoenberger et al., 2022; Whitt et al., 2022). This literature often frames SUD as chronic and relapsing and characterizes recovery as a lifelong pursuit (Chen et al., 2012, Nash et al., 2015; Schoenberger et al., 2022; Wisdom & Gogel, 2010). Whether young people’s understandings and experiences of recovery are aligned with this focus on chronicity is explored in a few studies (Giang et al., 2020; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013). For example, one longitudinal study (Giang et al., 2020) explored perspectives on OAT among 40 young people aged 17 to 26 who were experiencing unstable housing and homelessness. In this study, young people challenged the notion of SUD as chronic, relapsing, and lifelong, instead articulating strong desires for “normal” futures free of substance use, including OAT. Across a few studies, imaginings of futures and recovery reflected young people’s desires to exert a newfound sense of “control” over their lives. Desires for “control” often emerged in circumstances marked by heightened parental surveillance and were connected to completion of school, securing meaningful employment and adequate income, reconnecting with family and friends, and finding safe and stable places to live (Giang et al., 2020; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013).

Holistic definitions

Eleven articles explore how young people pursue recovery from SUD through the achievement of broader health, social (including financial), and spiritual goals (Elswick et al., 2018; Giang et al., 2020; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013; Nash et al., 2015; Schoenberger et al., 2022; Turuba et al., 2022). The articles illustrate how recovery extended beyond conventional metrics of treatment “success,” such as completing a treatment program and sustaining a period of abstinence or reduced substance use. Instead, recovery was understood more holistically, encompassing the (re-)establishment of particular values (e.g., accountability and honesty); (re-)discovery of hobbies (e.g., art, music, fitness); (re-)establishment of meaningful relationships and development of supportive social networks; (re-)engagement in cultural and spiritual practices (e.g., visiting places of worship, connecting with a sense of a higher power); (re-)connection with services and service providers; pursuit of education or employment; and restored senses of choice and control (Boyd et al., 2017, Chen et al., 2012; Elswick et al., 2018; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013; Nash et al., 2015; Schoenberger et al., 2022; Whitt et al., 2022). These studies generally conclude that there is a need for recovery programs that are youth-friendly, developmentally appropriate, and that look beyond reducing the harms of substance use to instead support young people’s senses of autonomy, control, and self-determination related to broader pursuits that some young people view as unrelated to substance use. As one participant from a study in Boston exploring the perspectives of young adults aged 21 to 29 on SUD recovery reflected: “I think the conversation isn’t just about… people won’t die [from substance use]… it’s like people will be present for their lives again” (Schoenberger et al., 2022, p. 818).

Recovery capital and careers

A number of articles explore recovery among young people through the interrelated concepts of recovery capital and careers (Elswick et al., 2018; Herold & Søgaard, 2019; Jurinsky et al., 2023; Smith et al., 2020). These articles examine the impacts of both positive and negative recovery capital, assessing how these can support and impede unfolding recovery processes (Elswick et al., 2018; Herold & Søgaard, 2019; Jurinsky et al., 2023; Smith et al., 2020). Studies focused on positive recovery capital underscored the importance of sustained engagement in care (including aftercare following in-patient residential treatment), involvement in education and employment, connections with culture and spirituality, and relationships with like-minded peers to recovery (Elswick et al., 2018; Gonzales et al., 2012b, 2013; Nash et al., 2015). For example, one five-year follow-up study involving 21 young people who had previously engaged in treatment for SUD highlight how recovery capital influenced participants’ abilities to undertake a series of steps towards entering adulthood, such as securing employment, pursuing meaningful education, and fulfilling parental responsibilities (Skogens & von Greiff, 2020). Importantly, the young people in this study underscored a need to strengthen their social connectedness as a crucial form of recovery capital, including in the form of cohabitation with romantic partners and establishing their own families.

Studies considering the influence of negative capital on recovery experiences among YPWUD largely focus on experiences of residential and financial instability and the risks of sustained relationships with peers who have different substance use-related goals, including those who enter treatment involuntarily (e.g., as a result of a court order) and are resistant to treatment (Acri et al., 2012; Elswick et al., 2018; Gonzales et al., 2013; Jurinsky et al., 2023; Long & Vaughn, 1999; Ludwig et al., 2021; Smith et al., 2020). These articles collectively highlight the complexity of peer relationships in this context, which can at times be sources of negative recovery capital and at other times sources of positive recovery capital spanning institutional (e.g., residential treatment programs) and non-institutional (e.g., alternative peer groups) settings. This work highlights the need for programs that attend closely to the housing, financial, and social support needs of young people, particularly during critical transitions such as returns to the community following in-patient care (Acri et al., 2012; Elswick et al., 2018; Gonzales et al., 2013).

The relationship between treatment and recovery

How pivotal is treatment engagement to recovery?

All of the included studies intersect with substance use or mental health treatment, with many studies recruiting from SUD treatment programs (e.g., residential treatment programs, psychosocial programs) or places where SUD treatment is offered (e.g., recovery high schools). Several articles focus explicitly on assessing the impact of treatment interventions (e.g., pharmacotherapies, behavioral therapy) on recovery processes (Acri et al., 2012; Boyd et al., 2017; Giang et al., 2020; Gonzales et al., 2013; Monico et al., 2022; Nash et al., 2015; Nyashanu et al., 2023; Schoenberger et al., 2022; Smith et al., 2020). These articles detail that young people and caregivers often regard engaging in evidence-based substance use treatment as vital to maintaining abstinence, a key indicator of being “in recovery” (Acri et al., 2012; Boyd et al., 2017; Giang et al., 2020; Gonzales et al., 2013; Monico et al., 2022; Nash et al., 2015; Nyashanu et al., 2023; Schoenberger et al., 2022; Smith et al., 2020). Relatedly, participation in various forms of aftercare (e.g., outpatient mutual support groups), particularly during critical transitions such as immediately following in-patient care, is also commonly regarded as crucial to relapse prevention and recovery pursuits (Acri et al., 2012; Boyd et al., 2017; Gonzales et al., 2013; Monico et al., 2022; Nash et al., 2015; Nyashanu et al., 2023; Schoenberger et al., 2022; Smith et al., 2020). For example, one study explores the factors that young people and their caregivers viewed as important for recovery following the completion of a residential treatment program (Acri et al., 2012). Among the 28 young people and 30 caregivers involved in the study, outpatient treatment attendance in the form of regular engagement with either Twelve-Step mutual support programs or outpatient treatment (e.g., family therapy) was most commonly regarded as integral to relapse prevention and ongoing recovery success (Acri et al., 2012). In contrast, another study of over 100 treatment-involved young people between the ages of 12 and 24 found that participants prioritized “lifestyle improvements” – described as “keeping on track with life goals,” “general wellness and wellbeing,” and “being happy again” – over continued engagement in treatment (Gonzales et al., 2012a, Gonzales et al., 2012b, 2013). Taken together, these studies underscore a need to collaborate with young people enrolled in treatment programs on defining and actualizing diverse goals that range from abstinence to treatment adherence and meeting attendance to broader “lifestyle improvements” (Acri et al., 2012; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013).

What shapes senses of treatment and recovery success?

Eleven articles point to factors implicated in experiences of treatment and recovery success among young people. Being actively involved in treatment decision-making (Giang et al., 2020; Madill et al., 2023; Smith et al., 2020; Whitt et al., 2022), feelings of being “ready to change” (Acri et al., 2012; Gonzales et al., 2012a, Gonzales et al., 2012b; Turuba et al., 2022) and a sense of “commitment” to treatment and recovery more generally (Acri et al., 2012; Long & Vaughn, 1999; Madill et al., 2023; Schoenberger et al., 2022; Whitt et al., 2022) are identified in several studies as facilitators of treatment, and by extension recovery, success. Several studies highlight that managing withdrawal symptoms by receiving the “right” medications, including OAT, can be a key component of treatment and recovery success (Giang et al., 2020; Gonzales et al., 2012a; Sultan & Duff, 2021, p. 4). One study by Wisdom and Gogel (2010) examines how 28 young people aged 15 to 21 who were engaged in a residential treatment program, as well as their caregivers, defined treatment success and readiness to “transition into” recovery. Young people’s responses indicated that changes such as “not thinking about using drugs,” being able to talk about goals and successes, and a perceived ability to “stay out of trouble” were all indicators of successful treatment and readiness for recovery (Wisdom & Gogel, 2010). Relatedly, Nash and colleagues (2015) explore what young people aged 15 to 30 viewed as important for facilitating treatment and recovery success. Maintaining a sense of belonging and hope, engaging in youth-friendly and “fun” activities, and fostering positive social networks consisting of peers with similar substance use-related goals were all considered critical. In contrast, navigating unstable housing and inadequate income were identified as significant barriers to treatment and recovery success in one study of young people aged 18 to 25 who identified as “in recovery” (Elswick et al., 2018).

Navigating recovery beyond treatment

Some articles shed light on the specific challenges young people experience when pursuing recovery via engagement with substance use treatment programs, which include long program wait times, discrimination based on age, gender, sexuality, race, and socioeconomic status, and fears of “aging out” of programs where they have had success previously (Boyd et al., 2017; Jenkins et al., 2017; Madill et al., 2023; Vandermause et al., 2018). Some young people found that treatment programs did not adequately attend to their needs, priorities, and goals, particularly when they were not focused on achieving abstinence or avoiding peers who continued to use drugs; as one participant put it, “they should stop pushing us into feeling guilty if we do not pick the total abstinence path” (Boyd et al., 2017; Gonzales et al., 2013, p. 300; Jenkins et al., 2017; Madill et al., 2023). Other barriers to treatment engagement included strict rules and punitive policies (e.g., being kicked out of a program due to attendance issues) and a lack of attentiveness to cultural safety (i.e., a lack of programming rooted in Indigenous customs, values, and beliefs) and gender inclusivity (Boyd et al., 2017; Krusi et al., 2010; Monico et al., 2022). Challenges and barriers prompted some young people to undertake a range of self-management strategies in pursuit of recovery. For example, a few articles describe how young people may engage in various harm reduction strategies in pursuit of greater well-being, including transitions between substance use consumption practices (e.g., from injecting to smoking), or gradually reducing or eliminating the use of a particular substance by substituting one substance for another considered to be less harmful (e.g., substituting opioid use with cannabis use) (Boyd et al., 2017; Giang et al., 2020; Jenkins et al., 2017). While the young people in these studies did not necessarily define themselves as “in recovery,” they did talk in great detail about pursuing well-being in the context of shifting substance use patterns. For example, a study involving 20 young people aged 21 to 29 years recruited from an outpatient substance use program in Boston demonstrates that for some, ongoing substance use was a way to mediate un- or under-managed mental health issues. These young people emphasized a need to acquire additional skills to manage their mental health in order to sustain recovery over the long term (Schoenberger et al., 2022).

Supporting recovery: the role of caregivers

The role that caregivers and their associated social capital play in young people’s recovery processes, as well as their experiences providing support, is examined in several articles (Chen et al., 2012, Hennessy et al., 2022 Ludwig et al., 2021; Nash et al., 2015; Vandermause et al., 2018). Studies illuminate the benefits and burdens of active caregiver involvement across young people’s treatment and recovery trajectories. They demonstrate that ongoing caregiver involvement and support are often viewed by both young people and caregivers as integral to recovery, particularly during and after in-patient residential treatment (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021; Nash et al., 2015).

Some young people viewed residential treatment settings as crucial sites for working towards (re-)building relationships with caregivers and others. Across studies, caregiver involvement within these institutional settings had the potential to improve communication, trust, and relationships with young people (Chen et al., 2012, Hennessy et al., 2022; Nash et al., 2015; Vandermause et al., 2018). Support could take the form of regularly attending group meetings or forming connections with other parents. This work emphasizes the significance of involving caregivers in recovery processes through family-based programming, such as alternative peer groups. These groups work to integrate peer role models and other supportive social networks into residential treatment, fostering social connectedness and also helping to harmonize expectations among youth and caregivers (Hennessy et al., 2022; Jurinsky et al., 2023; Nash et al., 2015; Smith et al., 2020). In residential treatment settings, programming can be focused on working with young people and caregivers one-on-one or group-based (i.e., aimed at working with young people and caregivers together), in both cases seeking to address relationship dynamics within families and provide counseling to caregivers (Chen et al., 2012).

Some articles explore caregiver experiences supporting young people in the context of recovery, documenting the tremendous financial and emotional tolls of this support and the reduced capacity to provide support to other children and aging family members at the same time (Chen et al., 2012, Ludwig et al., 2021). Caregiving often extends beyond material, emotional, and social support, to also include changes to caregivers’ lifestyles, such as making changes in substance use behaviours (e.g., abstaining from alcohol use) to create home environments that are more conducive to young people’s recovery and overall growth and development (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021; Nash et al., 2015; Vandermause et al., 2018). Supporting young people’s recovery is a source of exhaustion and frustration for many caregivers, particularly when young people are repeatedly engaging and disengaging with treatment programs across time (Hennessy et al., 2022; Ludwig et al., 2021). Misalignment of expectations between young people and caregivers surrounding treatment and recovery goals also contributes to fatigue and frustration among caregivers. For example, the common expectation among caregivers that a young person will maintain abstinence following treatment does not always align with young people’s own goals or lived realities. Over time, unmet expectations and repeated cycles of engagement and disengagement from treatment can limit caregivers’ capacity to offer long-term support, and lead them to feel “mentally and physically drained” (Hennessy et al., 2022; Ludwig et al., 2021, p. 993).

In some studies, caregivers questioned the point at which their support could become counterproductive to young people’s recovery (Hennessy et al., 2022; Ludwig et al., 2021). For example, in a qualitative study with 28 caregivers (defined as parents, guardians, and other adult family members) supporting a young person enrolled in residential treatment in the Northeastern United States, caregivers described concerns with providing material support post-treatment, such as money, or access to a vehicle, fearing that this kind of support could potentially enable returns to substance use (Ludwig et al., 2021). Caregivers also worried that their trust in young people had been irreparably damaged as a result of experiences of being lied to and stolen from, making it challenging to rebuild relationships and support post-treatment recovery efforts (Ludwig et al., 2021). However, one study with 14 parents of adolescent boys aged 14 to 18 who were part of a therapeutic community in Israel found that, even in the context of caregiver concerns regarding post-treatment challenges, there was generally a strong desire and level of motivation to build supportive and accepting relationships with sons in recovery (Chen et al., 2012).

Collectively, these articles suggest that engaging caregivers in young peoples’ treatment and recovery trajectories, while vital, is highly challenging and requires programs that attend to the needs, priorities, and desires of both young people and caregivers, as well as how these intersect (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021; Nash et al., 2015; Vandermause et al., 2018). With many young people engaging in treatment due to pressure from concerned caregivers (Gonzales et al., 2012b), important questions remain regarding whether, when, and how to best involve caregivers in different circumstances. Regardless of whether, when, and how caregivers are engaged, several articles identify the need for programs to better support and foster self-care among caregivers in the context of supporting young people’s recovery (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021; Nash et al., 2015; Vandermause et al., 2018).

DISCUSSION

This study synthesizes the available qualitative evidence regarding how YPWUD perceive and pursue substance use recovery and healing in the context of past and ongoing illicit substance use, including how interventions and caregivers are implicated in these processes across time and place. Despite numerous previous attempts to define and operationalize recovery, critical gaps remain regarding perspectives on and lived realities of recovery among young people (Kougali et al., 2017; Finch et al., 2020). This review extends Finch and colleagues (2020) review of the recovery literature focused on adolescents aged 12 to 18, providing the first summary of qualitative research examining how young people under the age of 30 understand, experience, and navigate recovery and healing in the context of illicit substance use. Findings underscore a diversity of definitions and enactments of recovery as part of a continuum of substance use care, which frequently extends beyond the notion of recovery as abstinence from substance use. Caregivers and other sources of social support can be pivotal to processes of recovery among young people; however, the challenges of supporting a young person’s recovery are manifold and can include misaligned expectations and difficulties establishing and maintaining trust.

These review findings suggest young peoples’ perspectives often contradicted reductionist views of recovery as abstinence from substance use (Betty Ford Institute Consensus Panel, 2007), which continue to be pervasive despite more recent work conceptualizing recovery as an unfolding, non-linear process or trajectory shaped by individual, social, structural, and environmental factors (Ashford et al., 2019, Brophy et al., 2023; Finch et al., 2020; Hser et al., 2007). Our findings alert us to the important yet complex relationship between recovery and abstinence, positioning abstinence as one possible recovery goal rather than a requirement (Ashford et al., 2019; Boyd et al., 2017, Chen et al., 2012; Finch et al., 2020; Gonzales et al., 2013; Hennessy et al., 2017; Nash et al., 2015; Paquette et al., 2022; Schoenberger et al., 2022; Whitt et al., 2022). More holistic pursuits of well-being linked to broader health, social (including financial), material, and spiritual goals often regarded by young people as unrelated to substance use can also be positioned as central to recovery (Elswick et al., 2018; Giang et al., 2020; Gonzales et al., 2012a, Gonzales et al., 2012b, 2013; Hennessy et al., 2017; Nash et al., 2015; Schoenberger et al., 2022; Turuba et al., 2022; Inanlou et al., 2020). This is consistent with a recent systematized review by Inanlou et al. (2020) that focuses on recovery among adults, which characterizes recovery as holistic and multiaxial, requiring attention to biological, psychological, social, and spiritual dimensions (Inanlou et al., 2020). Our work and that of others signifies the need for a critical shift in recovery programming towards conceptualizing and supporting recovery as an unfolding process within unique, youth-specific developmental and social contexts, encompassing diverse goals ranging from abstinence (Acri et al., 2012; Gonzales et al., 2012b; Long & Vaughn, 1999; Madill et al., 2023; Nash et al., 2015; Whitt et al., 2022), to (re-)establishing meaningful relationships and supportive social networks (Acri et al., 2012; Boyd et al., 2017, Chen et al., 2012; Gonzales et al., 2013; Hennessy et al., 2022; Monico et al., 2022; Nash et al., 2015; Vandermause et al., 2018; Wisdom & Gogel, 2010), to (re-)discovering hobbies (Acri et al., 2012; Gonzales et al., 2013) and (re-)engaging in cultural and spiritual practices (Elswick et al., 2018; Long & Vaughn, 1999), to pursuing education and employment (Boyd et al., 2017; Gonzales et al., 2012b, 2013).

Relatedly, our findings underscore the importance of adopting a trajectory or life-course perspective in research examining unfolding recovery experiences among young people and others, as well as how caregivers are implicated in these processes. Trajectory or life-course perspectives acknowledge that biological, psychological, social, structural, and environmental determinants of substance use and recovery unfold along distinct timescales (Finch et al., 2020; Hser et al., 2007). Recovery is best conceptualized and researched as a dynamic process often characterized by the evolving pursuit of holistic senses of health and well-being and emancipatory change occurring across multiple institutional and non-institutional settings, life stages, and social relationships (Brown & Ashford, 2019). Research and clinical practice must seek to identify the full spectrum of health, wellness, social, housing, and caregiver programs that can support recovery among young people as they navigate critical social and developmental transitions. Programs should regularly assess for diverse substance-use-related goals (such as maintaining abstinence or reduced or safer use) and support the pursuit of broader aspirations, recognizing that goals and aspirations are likely to change across time and place.

This scoping review identifies the importance of situating recovery as part of a broader continuum of care that includes substance use treatment. Young people and caregivers across numerous studies stressed the importance of treatment engagement to recovery processes, including by highlighting the role of pharmacotherapies such as OAT in alleviating painful withdrawal symptoms (Acri et al., 2012; Boyd et al., 2017; Giang et al., 2020; Gonzales et al., 2013; Monico et al., 2022; Nash et al., 2015; Nyashanu et al., 2023; Schoenberger et al., 2022; Smith et al., 2020; Sultan & Duff, 2021). Staying engaged in treatment during critical periods of transition, such as the period immediately following in-patient hospital or residential treatment, or in the context of ongoing experiences of unstable housing and homelessness, may be particularly pivotal (Acri et al., 2012; Boyd et al., 2017; Giang et al., 2020; Gonzales et al., 2013; Krausz et al., 2022; Monico et al., 2022; Nash et al., 2015; Nyashanu et al., 2023; Schoenberger et al., 2022; Smith et al., 2020; Xuan et al., 2021). Alternatively, it is well established that pursuits of abstinence, healing, and recovery can occur independent of treatment engagement (Hser et al., 2007, Marks & Leukefeld, 2018). Critical to consider here is how young people engage in a variety of self-management and harm minimization strategies in pursuit of recovery and healing in the context of ongoing illicit substance use, including transitioning consumption practices, or substituting one substance with another considered to be less harmful or risky (Boyd et al., 2017; Giang et al., 2020; Jenkins et al., 2017; Madill et al., 2023; Vandermause et al., 2018). These practices are largely undertaken outside of institutional settings, and often give young people a highly valued sense of control and independence in relation to their substance use, recovery, and healing goals (Boyd et al., 2017; Brown et al., 2011; Fast et al., 2014; Jenkins et al., 2017; Madill et al., 2023; Paul et al., 2020; Thulien et al., 2022). Qualitative research outside of treatment environments is essential to fully examine the experiences of young people pursuing abstinence, healing, and recovery independent of treatment engagement. Additionally, there may be opportunities to design treatment and recovery programs that better support these self-management and harm reduction strategies and these senses of control and independence, such as contingency management programs and other psychosocial interventions that can better attend to these kinds of goals.

This review prompts recognition that recovery processes among young people are inevitably influenced by broader social and structural determinants of health, for which upstream action is urgently needed (Bryant et al., 2022; Boyd et al., 2017; Giang et al., 2020; Purtle et al., 2022). Prior studies demonstrate that individuals experiencing structural vulnerability, particularly those experiencing low socioeconomic status, may require additional recovery capital to achieve and maintain recovery (Skogens and von Greiff, 2020, von Greiff and Skogens, 2017)). Recovery presents unique challenges in the context of street-based homelessness and other forms of residential instability among young people, as documented in the current review and elsewhere (Abramovich et al., 2013; Collins et al., 2018; Elswick et al., 2018; Henwood et al., 2012). Results from a study examining how 38 adults with experiences of street-based homelessness understood recovery found that maintaining safe and stable housing (a critical form of positive recovery capital) was viewed as a tremendous motivator for recovery (Henwood et al., 2012). Additionally, in North America and elsewhere, structurally embedded white supremacy, colonialism and cis-heteropatriarchy impact individuals experiencing marginalization along axes of race, gender, and sexuality as they pursue recovery (Antonio & Chung-Do, 2015; Boyd et al., 2017; Pearce et al., 2015). More research is needed to understand how recovery among young people is shaped by these intersections of race, gender, sexuality, and class. Moreover, the perspectives of young people experiencing structural vulnerabilities have alerted us to how illicit substance use may have several valuable roles in their lives, at times opening up social, spatial, economic, and affective possibilities (Boys et al., 2001; Fast, 2024; Lojszczyk et al., 2023). For example, a small qualitative study involving 12 youth experiencing homelessness found that crystal methamphetamine was used as a means of enhancing social interactions, staying awake to protect belongings, and coping with negative emotions (Bungay et al., 2006). For these priority populations, reducing recovery to abstinence may not only be unproductive but harmful. Recovery programming must be attentive to contexts and prioritize cultural safety, anti-racism, and gender inclusivity. For structurally vulnerable young people, recovery programs must be linked with housing and income support, two fundamental sources of positive recovery capital.

Our review underscores that caregivers are influential in shaping young people’s understandings and pursuits of recovery, although the impacts on caregivers are substantial and not always positive (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021; Nash et al., 2015, Tyo and McCurry, 2020; Vandermause et al., 2018). The emotional fatigue and the burden associated with caring for youth noted by several articles (Chen et al., 2012, Hennessy et al., 2022; Ludwig et al., 2021) are substantiated in both the broader quantitative and qualitative literature. For example, a recent descriptive, cross-sectional study by Sharma et al. (2019) documents substantial objective and subjective burden among family members of individuals experiencing SUD, particularly among those experiencing low incomes. As described by Marchand et al. (2022), caregivers of young people navigating SUD can feel as though they must become “case managers,” requiring various tools and resources. In British Columbia, Canada, this led to the co-creation of a “Parents Like Us” handbook with 12 caregivers of young people experiencing SUD (Foundry BC, 2021; Marchand et al., 2022). The findings of this review and the broader literature provide strong support for innovative family-centered recovery programs and the provision of robust support with navigating youth-caregiver relationships, as offered in some alternative peer groups, as part of recovery programs. Alternative peer groups can engender social connectedness and provide a sense of community, understanding, and shared experiences, with the potential to positively influence young people’s recovery and healing as well as outcomes for caregivers (Hennessy et al., 2022; Jurinsky et al., 2023; Nash et al., 2015; Smith et al., 2020). It is crucial that recovery programs cater to the needs of both young people and caregivers and account for structural drivers of harm such as homelessness and poverty (Chen et al., 2012, Das et al., 2016; Hennessy et al., 2022; Liddle et al., 2018; Ludwig et al., 2021; Nash et al., 2015; Tambling et al., 2021; Russell et al., 2022, Vandermause et al., 2018). Indeed, family and relationship-centered programs align with international consensus regarding how to manage high-risk substance use among young people; researchers and clinicians have argued strongly for investing in family-centered interventions while also recognizing that the absence of family or other caregiver support should not be a barrier to the delivery of effective treatment and recovery programs for youth (Krausz et al., 2022).

Limitations

This scoping review study employed a robust search strategy across five bibliographic databases, screened articles with two independent reviewers, and provides a comprehensive overview of how recovery and healing are perceived and pursued in the context of past or ongoing illicit substance use among young people and their caregivers. There are also important limitations to this work. First, most of the articles reviewed originated from large urban centers in the United States and Canada, limiting the transferability of study findings beyond these settings. This limitation may be partly due to our primary focus on health and medical databases, which were chosen to prioritize empirical research at the intersection of substance use, treatment, recovery and healing. Additional future reviews that seek to comprehensively explore social science databases are needed to more fulsomely capture these perspectives on recovery, as well as a fuller breadth of international literature on this topic. Second, it is possible that relevant peer-reviewed articles were missed, including articles that did not fully meet our inclusion and exclusion criteria, such as evaluation studies and those that included youth as part of a broader population. Third, while the study explored recovery among young people spanning a wide age range, additional studies are encouraged to analyze the impact of more specific developmental stages on recovery experiences, such as early adolescence, late adolescence, and emerging adulthood. Refining the inquiry in this way may introduce distinct age-related recovery challenges and opportunities. Finally, there remain opportunities for robust intersectional and context-sensitive analyses of recovery among diverse YPWUD, including Black, Brown, Indigenous, and Two-Spirit/LGBTQ+ young people and those experiencing psychiatric co-morbidities.

CONCLUSIONS

High rates of SUD and associated health and social harms among young people demand research delineating how YPWUD perceive and pursue recovery and healing in this context. Findings from this scoping review highlight diverse lived realities of recovery among young people across institutional and non-institutional settings, underscoring recovery as a dynamic and unfolding process shaped by individual, social, structural, and environmental contexts. Recovery programs must align with and encompass young people’s diverse needs, goals, and desires and work to actively engage and collaborate with YPWUD and their caregivers.

HIGHLIGHTS.

• Synthesizes the literature on substance use recovery and healing among young people.

• Young people have diverse understandings of substance use recovery and healing.

• Young people challenge the relationship between abstinence and recovery and healing.

• Social supports can be pivotal to recovery and healing among young people.

Appendix A. MEDLINE search strategy for a scoping review on “recovery” among young people who use(d) drugs

Medline Search Strategy

Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily

<1946 to October 11, 2023>

Search Strategy:

1. (young adj1 people).tw. (36,949)

2. (young adj1 adult*).tw. (121,935)

3. (young adj1 person*).tw. (4096)

4. youth.tw. (88,091)

5. adolescen*.tw. (352,594)

6. minors.tw. (5704)

7. teen*.tw. (35,472)

8. 1 or 2 or 3 or 4 or 5 or 6 or 7 (545,006)

9. substance use*.tw. (50,710)

10. substance abuse.tw. (26,700)

11. substance misuse.tw. (3160)

12. substance dependen*.tw. (3133)

13. drug use*.tw. (72,411)

14. drug misuse.tw. (1699)

15. drug abuse.tw. (18,207)

16. drug dependen*.tw. (6527)

17. addiction.tw. (54,184)

18. substance-related problem*.tw. (272)

19. substance-related disorder*.tw. (652)

20. substance-related issue*.tw. (21)

21. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 (199,516)

22. recover*.tw. (816,356)

23. sobriety.tw. (1228)

24. abstinen*.tw. (30,112)

25. healing.tw. (223,535)

26. wellness.tw. (14,272)

27. wellbeing.tw. (29,804)

28. 22 or 23 or 24 or 25 or 26 or 27 (1,099,216)

29. qualitative.tw. (323,424)

30. focus group*.tw. (65,188)

31. narrative analysis.tw. (1750)

32. ethnograph*.tw. (13,901)

33. interview.tw. (170,502)

34. observation.tw. (355,760)

35. 29 or 30 or 31 or 32 or 33 or 34 (851,860)

36. 8 and 21 and 28 and 35 (155)

37. young drug users.tw. (99)

38. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 37 (545,060)

39. 21 and 28 and 35 and 38 (156)

Appendix B. PRISMA-ScR flow diagram for a scoping review on “recovery” among young people who use(d) drugs, 1999–2023