Abstract
Knowledge of the association between wellbeing and substance use disorder (SUD) treatment outcomes can guide recovery definitions, measurement strategies, and intervention development. This study recruited individuals in treatment for SUD (N = 81, M=39 years old, 53% female, 26% BIPOC). Wellbeing indicators included positive affect, serenity, flourishing, satisfaction with life, gratitude, quality of life, commitment to sobriety, and confidence staying sober. Outcomes included abstinence during treatment and treatment retention. After adjusting for urges to use, recruitment site, previous treatment episodes, legal issues, and days of sobriety in logistic regression analyses, only happiness with recovery remained significantly associated with either outcome (and was significantly associated with both outcomes: OR = 1.8 and 1.5, respectively, p<.05). Assessed via a single item (“In general, I am happy with my recovery”), this construct shows promise as a novel, simple indicator of wellbeing in recovery and a potential target for intervention.
1.0. Introduction
Contemporary definitions of recovery from substance use problems (e.g., Ashford et al., 2019; Zemore et al., 2023) convey that recovery is a multifaceted phenomenon, defined not only by abstinence or reduced consumption but also by wellbeing. Despite growing recognition of such holistic definitions in addiction research and practice, there is little consensus on which indicators should be used to assess wellbeing in substance use disorder (SUD) recovery (Hagman et al., 2022). Applications of positive psychology to addiction research have addressed multiple domains, including positive affect, satisfaction with life, subjective wellbeing, flourishing, and quality of life (Krentzman, 2013; Krentzman et al., 2022). However, little research to date has examined how these wellbeing domains are associated with standard/foundational SUD outcomes such substance use and treatment completion. Understanding which wellbeing indicators are most strongly associated with these standard/foundational SUD outcomes could help to refine operationalizations of recovery as a holistic construct.
This study aims to address this gap by assessing relationships between several wellbeing indicators and both treatment retention and abstinence for participants enrolled in residential or intensive outpatient treatment. Examinations of the association between wellbeing and recovery outcomes can inform the assessment of recovery and advance the design of interventions to improve outcomes by bolstering specific aspects of wellbeing.
2.0. Methods
2.1. Study Design
This is a longitudinal exploratory study using data originally collected as a randomized controlled pilot designed to determine the impact of a journaling intervention to support recovery from substance use disorder (Krentzman et al., 2024). We sought to determine which wellbeing factors were associated with abstinence and treatment retention in bivariate analyses as well as in multivariate analyses controlling for a robust set of covariates.
2.2. Participants
Investigators of the parent study recruited 81 participants from three treatment centers--one residential and two intensive outpatient--that were branches of the same not-for-profit abstinence-based addiction treatment center in a large urban area in the Midwestern U.S. Eligible participants met the following criteria: age 18 or older; enrolled in the host setting for at least two weeks; approximately two weeks of sobriety; and a scheduled discharge date after the parent study ended. They also met additional criteria related to journaling, such as having sufficient literacy to write short lists. We excluded individuals who reported significant symptoms of a co-morbid mental illness in the past week. Participants were recruited during six cohorts in July, August, October, and November 2020 and January and March 2021 and received up to $160 in gift cards depending on level of participation. For more information about the parent study, see Krentzman et al. (2024). While 81 individuals enrolled in the parent study, in the current study, we could not obtain outcomes for three of these individuals due to agency privacy policies.
2.3. Data Collection Methods
In the parent study, the investigators collected wellbeing indicators and demographic information via a Qualtrics survey during the baseline interview. After study participants were discharged from the host setting, the first author met with administrators to extract outcomes (abstinence and retention) from participants’ health records.
2.3.1. Wellbeing Indicators
Wellbeing indicators aligned with three general categories: affect, thriving, and recovery/abstinence.
2.3.1.1. Affect.
Positive affect is important in recovery research because it can broaden and enhance life circumstances (Fredrickson, 2004) and counter negative affect, which is a robust predictor of substance use recurrence (Sliedrecht et al., 2019). We employed two subscales of the Positive and Negative Affect Schedule to assess present-moment emotion: positive affect (10 items; e.g., enthusiastic, strong) and serenity (3 items; e.g., relaxed, calm); 1 = Very slightly or not at all, 5 = extremely (Watson et al., 1994). αs = .89 and .84, respectively.
2.3.1.2. Thriving.
Flourishing has been defined as “social-psychological prosperity” (Diener et al., 2010, p. 144) which we assessed with the Flourishing Questionnaire (7 items; e.g., “I am engaged and interested in my daily activities”; 1 = strongly disagree, 7 = strongly agree; Diener et al., 2010). α = .89. Overall satisfaction with life has often been construed as core to recovery (Zemore et al., 2023). We assessed this construct with the Satisfaction With Life Scale (5 items; e.g., “In most ways my life is close to my ideal”; 1 = strongly disagree, 7 = strongly agree; Diener et al., 1985). α = .81. Gratitude has been associated with recovery (Krentzman, 2019). We measured this construct with the Gratitude Questionnaire (6 items; e.g., “I am grateful to a wide variety of people”; 1 = strongly disagree, 7 = strongly agree; McCullough et al., 2002). α = .87.
2.3.1.3. Recovery/Abstinence.
Rothman (2000) theorized that successful maintenance of behavior change is predicated on the determination that life is better after making the change than it was before making the change. Therefore, to capture quality of life in recovery versus active addiction, we adapted the EUROHIS-QOL quality of life Index (Schmidt et al., 2006) so that items read, “Think back to your most recent period of active addiction. Compared to that time in your life, how would you rate your life now?” Each item asked about the eight quality-of-life indicators from the original instrument (e.g., health, personal relationships); 1 = much better then, 5 = much better now. α = .86. To obtain an assessment of happiness with recovery specifically, versus satisfaction with life overall, we used a single, novel item we developed for a previous study: “In general, I am happy with my recovery” (0 = strongly disagree, 10 = strongly agree; Krentzman et al., 2022). Commitment to change is a central aspect of overall motivation to change (Kelly & Greene, 2014), which we assessed with the Commitment to Sobriety Scale (5 items; e.g., “I have had enough alcohol and drugs”; 1 = strongly disagree, 6 = strongly agree; Kelly & Greene, 2014). α = .97. Confidence staying sober, or abstinence self-efficacy, is self-confidence in one’s ability to avoid drinking or drug use. We measured this construct with a single item shown to perform well when compared with multi-item measures: “How confident are you that you will be able to stay clean and sober in the next 90 days, or 3 months?”; 0 = Not at all confident to 10 = Very confident (Hoeppner et al., 2011).
2.3.2. Outcome Measures
Abstinence was a dichotomous outcome indicating whether the participant’s treatment record showed no substance use between the study’s baseline assessment and the participant’s departure from the host treatment setting (n = 59, 79%) or substance during in this period (n = 16; 21%). Three participants were excluded from analyses of this outcome because the treatment record did not indicate the date of documented substance use or because the treatment record stated that substance use / abstinence status was unknown.
Treatment retention was a dichotomous outcome indexing whether the participant’s reason for leaving treatment was graduation/leaving on good terms (n = 51, 65%) versus leaving for any other reason (n = 27, 35%); i.e., leaving against staff advice (n = 14), leaving at staff request (n = 3), transferring to another facility (n = 3), or leaving for a more intensive level of care (n = 7).
2.3.4. Covariates
Table 1 shows background variables at baseline and their bivariate associations with study outcomes; findings informed selection of covariates for our multivariate analyses. Age, gender identity, race, education, income, relationship status, primary substance, negative consequences associated with substance use, use of mediation-assisted treatment, trauma history, mutual-aid affiliation, cohort, and parent study arm (journaling or control group) were not significantly associated with either of the two study outcomes and therefore not included as covariates. Recruitment site, length of sobriety, having a current legal issue, number of previous treatment episodes, and urges to use were all significantly associated with at least one study outcome, and therefore were included as covariates.
Table 1.
Baseline Demographic, Clinical, and Study-Related Characteristics of the Sample by Abstinence and Treatment Retention
| Abstinence from Assessment to Treatment Completion (n = 75)a |
Treatment Retention (n = 78) |
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|---|---|---|---|---|---|---|---|
| Baseline Characteristic | Full Sample (N = 81) | Yes (n = 59) | No (n = 16) | p | Yes (n = 51) | No (n = 27) | p |
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| Age in years, M (SD) | 39.0 (11.0) | 37.8 (9.8) | 39.6 (12.5) | .531 | 38.3 (10.0) | 40.0 (12.9) | .544 |
| Gender identity, n (%) | |||||||
| Female | 43 (53.1%) | 35 (59.3%) | 7 (43.8%) | .120 | 29 (56.9%) | 14 (51.9%) | .431 |
| Male | 37 (45.7%) | 24 (40.7%) | 8 (50.0%) | 22 (43.1%) | 12 (44.4%) | ||
| Gender nonconformingb | 1 (1.2%) | 0 (0.0%) | 1 (6.3%) | 0 (0.0%) | 1 (3.7%) | ||
| Race/ethnicity, n (%) | |||||||
| Black or African American | 4 (4.9%) | 2 (3.4%) | 0 (0%) | .902 | 1 (2.0%) | 2 (7.4%) | .707 |
| White | 60 (74.1%) | 42 (71.2%) | 14 (87.5%) | 39 (76.5%) | 19 (70.4%) | ||
| Latine | 2 (2.5%) | 2 (3.4%) | 0 (0%) | 2 (3.9%) | 0 (0%) | ||
| Native American or Alaskan Native | 5 (6.2%) | 5 (8.5%) | 0 (0%) | 3 (5.9%) | 2 (7.4%) | ||
| Asian or Pacific Islander | 1 (1.2%) | 1 (1.7%) | 0 (0%) | 1 (2.0%) | 0 (0%) | ||
| Biracial/Multiracial | 9 (11.1%) | 7 (11.9%) | 2 (12.5%) | 5 (9.8%) | 4 (14.8%) | ||
| Years of education, M (SD) | 13.1 (2.1) | 13.0 (2.0) | 13.8 (2.2) | .203 | 13.3 (2.1) | 12.9 (2.0) | .431 |
| Past year household income ≤ $15,000, n (%) | 51 (63.0%) | 40 (67.8%) | 7 (43.8%) | .078 | 35 (68.6%) | 14 (51.9%) | .145 |
| Relationship status, n (%) | |||||||
| Never married/single | 38 (46.9%) | 28 (47.5%) | 7 (43.8%) | .935 | 26 (51.0%) | 10 (37.0%) | .500 |
| Married, remarried, in a relationship | 21 (25.9%) | 16 (27.1%) | 4 (25.0%) | 12 (23.5%) | 8 (29.6%) | ||
| Separated, divorced, widowed | 22 (27.2%) | 15 (25.4%) | 5 (31.3%) | 13 (25.5%) | 9 (33.3%) | ||
| Substance most addicted to, n (%) | |||||||
| Alcohol | 37 (45.7%) | 28 (47.5%) | 6 (37.5%) | .840 | 22 (43.1%) | 14 (51.9%) | .557 |
| Opiates | 21 (25.9%) | 15 (25.4%) | 5 (31.3%) | 14 (27.5%) | 7 (25.9%) | ||
| Amphetamines | 19 (23.5%) | 13 (22.0%) | 5 (31.3%) | 13 (25.5%) | 5 (18.5%) | ||
| Cannabis | 2 (2.5%) | 1 (1.7%) | 0 (0%) | 0 (0.0%) | 1 (3.7%) | ||
| Cocaine/crack | 2 (2.5%) | 2 (3.4%) | 0 (0%) | 2 (3.9%) | 0 (0%) | ||
| Length of sobriety in days, M (SD) | 139.9 (187.8) | 165.9 (213.7) | 69.5 (38.8) | .002 | 179.9 (225.7) | 71.8 (45.8) | .002 |
| # previous treatment episodes, M (SD) | 6.0 (3.4) | 5.4 (3.2) | 7.3 (3.5) | .048 | 5.6 (3.2) | 6.5 (3.6) | .295 |
| Negative consequences of SUD, M (SD) c | 15.6 (11.4) | 14.9 (12.0) | 18.1 (8.6) | .239 | 14.6 (12.2) | 17.3 (9.5) | .273 |
| Strength of urge for drugs or alcohol, M (SD) | 3.5 (2.7) | 3.2 (2.6) | 4.9 (2.5) | .021 | 3.4 (2.7) | 3.7 (2.7) | .631 |
| Receiving medication-assisted treatment, n (%) | 33 (40.7%) | 26 (44.1%) | 5 (31.3%) | .356 | 23 (45.1%) | 10 (37.0%) | .631 |
| Legal issue, n (%) | 35 (43.2%) | 31 (52.5%) | 3 (18.8%) | .023 | 28 (54.9%) | 6 (22.2%) | .006 |
| History of trauma, n (%) | 77 (95.1%) | 57 (96.6%) | 15 (93.8%) | .519 | 49 (96.1%) | 26 (96.3%) | 1.000 |
| Mutual Aid Affiliation, M (SD)d | 4.9 (2.3) | 4.7 (2.4) | 5.2 (2.0) | .498 | 4.7 (2.3) | 5.2 (2.3) | .295 |
| Cohort, n (%) | |||||||
| July 2020 | 10 (12.3%) | 9 (15.3%) | 1 (6.3%) | .515 | 9 (17.6%) | 1 (3.7%) | .288 |
| August 2020 | 12 (14.8%) | 10 (16.9%) | 1 (6.3%) | 9 (17.6%) | 2 (7.4%) | ||
| October 2020 | 16 (19.8%) | 11 (18.6%) | 5 (31.3%) | 9 (17.6%) | 7 (25.9%) | ||
| November 2020 | 15 (18.5%) | 10 (16.9%) | 3 (18.8%) | 7 (13.7%) | 7 (25.9%) | ||
| January 2021 | 13 (16.0%) | 9 (15.3%) | 1 (6.3%) | 8 (15.7%) | 4 (14.8%) | ||
| March 2021 | 15 (18.5%) | 10 (16.9%) | 5 (31.3%) | 9 (17.6%) | 6 (22.2%) | ||
| Recruitment site, n (%) | |||||||
| Site 1 | 28 (34.6%) | 15 (25.4%) | 10 (62.5%) | .033 | 15 (29.4%) | 13 (48.1%) | .201 |
| Site 2 | 39 (48.1%) | 32 (54.2%) | 4 (25.0%) | 27 (52.9%) | 9 (33.3%) | ||
| Site 3 | 14 (17.3%) | 12 (20.3%) | 2 (12.5%) | 9 (17.6%) | 5 (18.5%) | ||
| Parent study arm, n (%) | |||||||
| Treatment | 42 (51.9%) | 31 (52.5%) | 7 (43.8%) | .533 | 27 (52.9%) | 13 (48.1%) | .687 |
| Control | 39 (48.1%) | 28 (47.5%) | 9 (56.3%) | 24 (47.1%) | 14 (51.9%) | ||
Note. Continuous variables were compared using t tests; categorical variables were compared using Pearson Chi-Square or Fisher’s Exact Test if cell sizes were < 5.
Three participants were excluded from this analysis because the treatment record either did not indicate the date of documented substance use or indicated that abstinence status was unknown.
Expressed in participant’s own words.
To assess for the negative impact of SUDs, investigators of the parent study employed the Short Inventory of Problems–Alcohol and Drugs Scale (10 times, “I have been unhappy because of my drinking or drug use” 0 = never, 3 = daily or almost daily; Hagman et al., 2009) α = .97.
To assess the strength of the participant’s affiliation with their primary mutual aid recovery group, we modified the Alcoholics Anonymous Affiliation Scale so that it referenced the participant’s chosen recovery group (9 items, “In the past 12 months, have you read [primary mutual-aid group] literature?” yes/no, Humphreys et al., 1998) α = .80.
2.4. Statistical Methods
We conducted point-biserial correlations relating each outcome to each wellbeing predictor. Wellbeing indicators significantly associated with either outcome (positive affect, serenity, flourishing, confidence staying sober, and happiness with recovery) were included in separate, two-step, logistic regression models for each outcome-wellbeing pair. In the first step, we regressed outcomes on the wellbeing predictor only. In the second step, we added the covariates selected in preliminary analyses (see above). All analyses were conducted using SPSS v. 28.
2.5. Ethical Approval
The University of Minnesota’s Institutional Review Board provided its first approval for this study on 10/22/2018 (#00004619). All participants provided written informed consent. The authors report there are not competing interests to declare.
3.0. Results
The sample was M = 39.0 (SD = 11) years of age, 53.1% female, 25.9% BIPOC, and had M = 13.1 (SD = 2.1) years of education. Nearly half (45.7%) named alcohol as the substance to which they were most addicted.
Table 2 displays correlations among wellbeing indicators and study outcomes. Happiness with recovery was positively and significantly associated with abstinence (r = .39, p < .001), retention (r = .35, p = .002), positive affect (r = .42, p < .001), flourishing (r = .66, p < .001), satisfaction with life (r = .36, p = .001), gratitude (r = .26, p = .021), quality of life in recovery (r = .26, p = .020), and confidence staying sober (r = .61, p < .001).
Table 2.
Correlations: Outcomes and Wellbeing Factors
| Variable | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 |
|---|---|---|---|---|---|---|---|---|---|---|
| 1. Abstinence | -- | |||||||||
| 2. Retention | .62 | -- | ||||||||
| <0.001 | ||||||||||
| 3. Positive affect | .31 | .29 | -- | |||||||
| 0.007 | 0.009 | |||||||||
| 4. Serenity | .37 | .27 | .49 | -- | ||||||
| 0.001 | 0.017 | <0.001 | ||||||||
| 5. Flourishing | .33 | .30 | .66 | .41 | -- | |||||
| 0.004 | 0.007 | <0.001 | <0.001 | |||||||
| 6. Satisfaction with life | .22 | .17 | .50 | 0.43 | .64 | -- | ||||
| 0.062 | 0.127 | <0.001 | <0.001 | <0.001 | ||||||
| 7. Gratitude | −0.02 | −.03 | .34 | −.01 | .46 | .22 | -- | |||
| 0.848 | 0.771 | 0.002 | 0.959 | <0.001 | 0.047 | |||||
| 8. Quality of life in recovery | −0.07 | −.04 | .33 | 0.15 | .38 | .22 | .29 | -- | ||
| 0.548 | 0.723 | 0.002 | 0.181 | <0.001 | 0.046 | 0.010 | ||||
| 9. Happy with recovery | 0.39 | 0.35 | 0.42 | 0.21 | 0.66 | 0.36 | 0.26 | .26 | -- | |
| <0.001 | 0.002 | <0.001 | 0.057 | <0.001 | 0.001 | 0.021 | 0.020 | |||
| 10. Commitment to sobriety | −0.08 | −.13 | .13 | −.19 | .19 | −.11 | .49 | .20 | 0.13 | -- |
| 0.478 | 0.242 | 0.233 | 0.090 | 0.091 | 0.321 | <0.001 | 0.072 | 0.236 | ||
| 11. Confidence staying sober | .25 | 0.19 | .27 | 0.07 | .45 | .28 | .28 | .10 | 0.61 | 0.06 |
| 0.028 | 0.097 | 0.014 | 0.544 | <0.001 | 0.011 | 0.012 | 0.385 | <0.001 | 0.583 |
Table 3 displays the logistic regression models. After adjusting for covariates, only happiness with recovery remained significantly associated with either abstinence or retention, and it was significantly associated with both outcomes (OR = 1.83 [p = .019] and 1.54 [p = .019], respectively). In other words, for every one unit increase in happiness with recovery, while adjusting for covariates in the model, participants were 82.7% more likely to be abstinent and 54.4% more likely to complete treatment successfully. See Figures 1 and 2 for graphic depictions of these associations. After adjusting for covariates, positive affect and flourishing were marginally associated with retention (OR = 1.11 [p = .068] and 1.10 [p = .062], respectively).
Table 3.
Logistic Regression: Wellbeing Indicators, Covariates, and Treatment Outcomes
| Model 1: Wellbeing Only | Model 2: Wellbeing and Covariates | |||||
|---|---|---|---|---|---|---|
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| Variable | Odds Ratio | 95% CI | p | Odds Ratio | 95% CI | p |
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| Outcome: Abstinence during Treatment | ||||||
| Positive Affect | 1.152 | [1.038, 1.278] | .008 | 1.055 | [.933, 1.192] | .394 |
| Days Sober | 1.023 | [1.002, 1.045] | .029 | |||
| # Previous Txs | .869 | [.663, 1.140] | .312 | |||
| Urges | .768 | [.579, 1.018] | .066 | |||
| Legal Issue | 6.435 | [1.046, 39.589] | .045 | |||
| Site | 8.049 | [1.020, 63.515] | .048 | |||
| Model Evaluation | ||||||
| Model X2 and p | 8.695, p = .003 | 31.684, p < .001 | ||||
| Cox & Snell R2 | .112 | .352 | ||||
| Nagelkerke R2 | .176 | .552 | ||||
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| Serenity | 1.456 | [1.115, 1.901] | .006 | 1.268 | [.905, 1.776] | .168 |
| Days Sober | 1.025 | [1.003, 1.047] | .027 | |||
| # Previous Txs | .885 | [.672, 1.165] | .383 | |||
| Urges | .771 | [.581, 1.022] | .071 | |||
| Legal Issue | 6.693 | [1.050, 42.657] | .044 | |||
| Site | 7.941 | [.976, 64.586] | .053 | |||
| Model Evaluation | ||||||
| Model X2 and p | 9.431, p = .002 | 32.946, p < .001 | ||||
| Cox & Snell R2 | .121 | .363 | ||||
| Nagelkerke R2 | .190 | .569 | ||||
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| Flourishing | 1.145 | [1.042, 1.258] | .005 | 1.084 | [.947, 1.241] | .244 |
| Days Sober | 1.024 | [1.003, 1.045] | .028 | |||
| # Previous Txs | .913 | [.684, 1.219] | .538 | |||
| Urges | .767 | [.580, 1.016] | .064 | |||
| Legal Issue | 5.513 | [.856, 35.491] | .072 | |||
| Site | 9.582 | [1.106, 83.008] | .040 | |||
| Model Evaluation | ||||||
| Model X2 and p | 9.124, p = .003 | 32.426, p < .001 | ||||
| Cox & Snell R2 | .117 | .359 | ||||
| Nagelkerke R2 | .184 | .562 | ||||
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| Happiness with Recovery | 1.873 | [1.292, 2.716] | <.001 | 1.827 | [1.105, 3.020] | .019 |
| Days Sober | 1.028 | [1.002, 1.054] | .033 | |||
| # Previous Txs | .908 | [.684, 1.204] | .502 | |||
| Urges | .759 | [.555, 1.038] | .084 | |||
| Legal Issue | 7.019 | [.982, 50.172] | .052 | |||
| Site | 10.909 | [.940, 126.572] | .056 | |||
| Model Evaluation | ||||||
| Model X2 and p | 13.920, p <.001 | 34.621, p < .001 | ||||
| Cox & Snell R2 | .176 | .382 | ||||
| Nagelkerke R2 | .281 | .609 | ||||
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| Confidence | 1.651 | [1.063, 2.564] | .026 | 1.289 | [.673, 2.469] | .443 |
| Days Sober | 1.024 | [1.003, 1.046] | .028 | |||
| # Previous Txs | .875 | [.663, 1.155] | .345 | |||
| Urges | .775 | [.581, 1.034] | .084 | |||
| Legal Issue | 6.170 | [1.005, 37.865] | .049 | |||
| Site | 9.732 | [1.198, 79.072] | .033 | |||
| Model Evaluation | ||||||
| Model X2 and p | 5.376, p = .020 | 31.523, p < .001 | ||||
| Cox & Snell R2 | .071 | .351 | ||||
| Nagelkerke R2 | .111 | .550 | ||||
| Outcome: Treatment Retention | ||||||
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| Positive Affect | 1.117 | [1.028, 1.214] | .009 | 1.108 | [.993, 1.237] | .068 |
| Days Sober | 1.015 | [1.003, 1.026] | .012 | |||
| # Previous Txs | 1.011 | [.830, 1.230] | .915 | |||
| Urges | 1.071 | [.851, 1.347] | .559 | |||
| Legal Issue | 4.606 | [1.363, 15.556] | .014 | |||
| Site | 1.849 | [.477, 7.163] | .374 | |||
| Model Evaluation | ||||||
| Model X2 and p | 7.984, p = .005 | 28.749, p < .001 | ||||
| Cox & Snell R2 | .100 | .315 | ||||
| Nagelkerke R2 | .137 | .433 | ||||
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| Serenity | 1.259 | [1.033, 1.534] | .023 | 1.210 | [.929, 1.575] | .158 |
| Days Sober | 1.014 | [1.003, 1.025] | .014 | |||
| # Previous Txs | .999 | [.823, 1.212] | .992 | |||
| Urges | 1.037 | [.836, 1.287] | .742 | |||
| Legal Issue | 4.919 | [1.495, 16.181] | .009 | |||
| Site | 1.811 | [.460, 7.134] | .396 | |||
| Model Evaluation | ||||||
| Model X2 and p | 5.705, p = .017 | 27.072, p < .001 | ||||
| Cox & Snell R2 | .072 | .300 | ||||
| Nagelkerke R2 | .099 | .412 | ||||
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| Flourishing | 1.112 | [1.026, 1.205] | .010 | 1.103 | [.995, 1.222] | .062 |
| Days Sober | 1.014 | [1.003, 1.026] | .014 | |||
| # Previous Txs | 1.024 | [.841, 1.246] | .815 | |||
| Urges | 1.053 | [.844, 1.313] | .650 | |||
| Legal Issue | 4.501 | [1.326, 15.274] | .016 | |||
| Site | 2.070 | [.521, 8.219] | .301 | |||
| Model Evaluation | ||||||
| Model X2 and p | 7.574, p = .006 | 28.703, p < .001 | ||||
| Cox & Snell R2 | .095 | .315 | ||||
| Nagelkerke R2 | .130 | .432 | ||||
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| Happiness with Recovery | 1.562 | [1.168, 2.090] | .003 | 1.544 | [1.073, 2.221] | .019 |
| Days Sober | 1.013 | [1.002, 1.024] | .025 | |||
| # Previous Txs | 1.020 | [.839, 1.241] | .841 | |||
| Urges | 1.070 | [.850, 1.346] | .567 | |||
| Legal Issue | 5.782 | [1.629, 20.526] | .007 | |||
| Site | 1.485 | [.344, 6.409] | .596 | |||
| Model Evaluation | ||||||
| Model X2 and p | 10.420, p = .001 | 29.329 p < .001 | ||||
| Cox & Snell R2 | .130 | .324 | ||||
| Nagelkerke R2 | .179 | .446 | ||||
Figure 1.
Relationship between Happiness with Recovery and Abstinence
Note. No participants endorsed 0, 1, or 2 in response to the prompt, “In general, I am happy with my recovery.” Percentages appearing above the bars in the figure = number of abstinent individuals ÷ total number of individuals who endorsed each response option as follows: response option 3 = 0/1; 4 = 1/2; 5 = 2/4; 6 = 2/4; 7 = 9/13; 8 = 8/9; 9 = 9/10; 10 = 28/31.
Figure 2.
Relationship between Happiness with Recovery and Retention
Note. No participants endorsed 0, 1, or 2 in response to the prompt, “In general, I am happy with my recovery.” Percentages appearing above the bars in the figure = number of retained individuals ÷ total number of individuals who endorsed each response option as follows: response option 3 = 0/1; 4 = 1/2; 5 = 2/5; 6 = 2/5; 7 = 7/14; 8 = 7/9; 9 = 6/10; 10 = 26/31.
4.0. Discussion
We found that positive affect, serenity, flourishing, confidence staying sober, and happiness with recovery were associated with treatment retention and/or abstinence in bivariate analyses. After adjusting for covariates, only happiness with recovery remained significantly associated with either one of the two outcomes--and it remained significantly associated with both of them. It is notable that indicators of general quality of life (i.e, satisfaction with life, flourishing) were nonsignificant in multivariate analyses because overall quality of life is often emphasized in recovery definitions (Zemore et al., 2023).
These findings can inform future research on wellbeing and recovery. Although we encourage researchers to continue investigating a range of wellbeing indicators, findings for happiness with recovery in our investigation suggest that this simple, single-item measure is a meaningful predictor that should be prioritized in studies of recovery outcomes. Further, happiness with recovery may be a malleable intervention target. Interventions such as journaling using prompts informed by positive psychology are associated with increased happiness with recovery, as well as other wellbeing indicators (Krentzman et al., 2022, 2024).
We acknowledge several limitations. The sample size was modest and drawn from people currently in treatment; thus, results may not generalize to all subpopulations of people in recovery (e.g., people recovering outside of treatment settings). While the treatment program emphasized that return-to-substance-use events would have very high priority for documentation in clients’ health records, some participants classified as abstinent may have engaged in substance use that the treatment team was not aware of. Future studies could build from this work by examining relationships between wellbeing indicators and recovery outcomes in large and heterogenous populations, ideally using multiple means of assessing abstinence and other outcomes (e.g., treatment records, self-report, and biological testing).
As definitions of recovery continue to evolve, clarifying the role of wellbeing in recovery is paramount. Our findings suggest that self-reported happiness with recovery is a particularly salient aspect of wellbeing that warrants further attention in both research and intervention development.
Primary funding:
This research was supported by the National Center for Advancing Translational Sciences at the National Institutes of Health under Grant UL1TR002494; the Hatch Project of the National Institute of Food and Agriculture at the United States Department of Agriculture under Projects MN-55-078, MN-55-072, and MN-55-056; and the Research & Innovation Office of the University of Minnesota. Dr. Zemore’s effort was partially supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R01AA027920 to Dr. Zemore). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the US Department of Agriculture, or the University of Minnesota.
Footnotes
Disclosure of interest: The authors report there are not competing interests to declare.
Clinical trial registration details: The parent study was registered on clinicaltrials.gov (NCT04458181) on July 7, 2020.
Data Availability Statement:
Data are not available for this small sample to preserve anonymity of participants.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are not available for this small sample to preserve anonymity of participants.