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. Author manuscript; available in PMC: 2022 Jun 1.
Published in final edited form as: Psychol Addict Behav. 2021 Mar 25;35(4):402–414. doi: 10.1037/adb0000689

Reasons to be cheerful: Personal, civic, and economic achievements after resolving an alcohol or drug problem in the United States population

David Eddie 1,*, William L White 2, Corrie L Vilsaint 1, Brandon G Bergman 1, John F Kelly 1
PMCID: PMC8184567  NIHMSID: NIHMS1641978  PMID: 33764087

Abstract

Objective:

Alcohol and other drug (AOD) use disorders impose a prodigious personal and societal burden. While most remit, little is known about the achievements accrued as people accomplish and sustain addiction recovery. Greater knowledge regarding the nature and prevalence of such achievements, when such achievements occur, what factors influence accrual of achievements, and how such achievements relate to other indices of functioning would support treatment and policy planning, and may instill hope for individuals and families seeking AOD problem resolution.

Methods:

Nationally representative, cross-sectional survey of United States (US) population of persons who have overcome an AOD problem (N=2,002), assessing individual factors and achievements in four domains: self-improvement; family engagement; civic, and economic participation. Logistic and linear regression models tested theorized associations among variables.

Results:

Most (80.1%) achieved at least one achievement associated with the four domains. A linear monotonic relationship was observed with greater achievements accruing with greater time in recovery. Accrual of achievements after AOD problem resolution was related to racial minority status, more education, earlier age of substance use initiation, illicit drugs as primary substance used, more years since resolving AOD problem, more psychiatric diagnoses, lower psychological distress, and regular 12-step program attendance. Multiple regression analyses found greater total achievements was independently associated with greater self-esteem, happiness, quality of life, and recovery capital.

Conclusions:

Most individuals achieve an increasing number of achievements with time since AOD problem resolution, and these are associated with gains in measures of well-being that may support ongoing AOD problem remission, and recovery.

Keywords: self-improvement, family engagement, civic participation, economic participation, addiction recovery

Introduction

Alcohol and other drug (AOD) use disorders impose an enormous personal and societal burden. In addition to widely reported psychological (Grant et al., 2015; Kelly et al., 2017), psychophysiological (Bates & Buckman, 2013; Eddie, Bates, et al., In press), and medical problems (Eddie et al., 2019; Whiteford et al., 2013) arising from these disorders, individuals with substance use problems also experience social exclusion, loss of societal standing, loss of access to resources, and general disengagement from civic life (Buchanan, 2004; Hengartner et al., 2013; Marie & Miles, 2008; Vilsaint et al., 2019). Collectively, this gives rise to a massive societal toll of around $520 billion each year in medical expenses, loss of productivity, accidents, and crime (Sacks et al., 2015).

Though clinical scientists and practitioners continue to debate how addiction recovery should be defined, the construct of ‘recovery’ has always included factors extending beyond substance use (Kelly, Abry, et al., 2018; Laudet, 2007; SAMHSA, 2012), and in recent years, researchers have been seeking to measure recovery in ways more consistent with this broad conceptualization. Examples of this work include the ‘Life in Recovery’ surveys in the United States (Kaskutas et al., 2014; Laudet, 2013; Witbrodt et al., 2015), Canada (McQuaid et al., 2017), Australia (Best & Savic, 2015), and the United Kingdom (Best, Albertson, et al., 2015), as well as work by Tucker et al. on discretionary spending in natural recovery (Tucker et al., 2016), and the development of the Substance Use Recovery Evaluator (SURE) by Neale and colleagues (2016).

Taken together, this body of research suggests that individuals who overcome AOD problems often go on to accomplish many personal goals, rebuild familial bonds, and become active participants in civic life and the economy (Best, McKitterick, et al., 2015; Cano et al., 2017; Eddie, Vilsaint, et al., In press; Kurtz & Fisher, 2003). This in turn is thought to lead to improvements in self-esteem, happiness, and quality of life, as well as further accumulation of recovery capital, and reductions in psychological distress (Cano et al., 2017; Eddie, Vilsaint, et al., In press; Laudet & White, 2008). Together, these factors are thought to buffer individuals against return to substance use and related problems (Sahker et al., 2019).

To date however, there has been a dearth of epidemiological research speaking to these observations. That is, nationally representative data on self-improvement, and familial, civic and economic engagement, as well as individual factors that might influence accomplishing these achievements have been missing among those who have overcome an AOD problem. Further, most data on life in recovery to date has been drawn from clinical populations admitted to addiction treatment programs, or mutual-help program members – samples that may not be fully representative of the larger pool of people who have resolved an AOD problem. Greater knowledge regarding the exact nature and prevalence of self-improvement, and familial, civic and economic engagement among those who have resolved an AOD problem, when in the resolution process such achievements are likely to accrue, what factors influence the accrual of achievements, and how such achievements are related to other indices of functioning (e.g., quality of life; self-esteem) would add novel insights for the AOD field and may instill hope for individuals and families in or seeking AOD problem resolution.

As such, using a nationally-representative United States (US) sample of individuals who have resolved an AOD problem (Kelly et al., 2017), the present study sought to characterize the personal, familial, societal, and economic achievements of this population. Achievements covered four broad areas: 1) self-improvement - including returning to school; completing technical school, a college degree, or graduate degree; getting a new job; and getting a promotion in a job; 2) family engagement - including regaining custody of children; and helping financially to support one’s family; 3) civic participation - including helping others who have problems; volunteering to do service in the local community; contributing to charities; and voting; and 4) economic participation - including buying a car; and purchasing a home.

Because these sorts of achievements are thought to give rise to secondary psychosocial benefits that reduce addiction relapse risk, we also explored associations between each category of achievements and factors associated with sustaining addiction recovery such as self-esteem, happiness, enhanced quality of life, and accumulation of recovery capital. More specifically this paper attempted to provide preliminary answers to four significant research questions: 1) How prevalent are different achievements among individuals who have resolved an AOD problem; 2) which demographic, clinical, and recovery related variables are associated with accomplishing such achievements; 3) how do such achievements accrue temporally with time in recovery; and 4) how do achievements relate to addiction recovery related indicators of well-being (e.g., self-esteem, happiness, quality of life, and recovery capital).

Methods

Sample and Procedure

This is a secondary analysis of the National Recovery Study (Kelly et al., 2017), a nationally-representative survey of non-institutionalized individuals in the US aged 18 years and over that answered yes to the screener question: “Did you use to have a problem with drugs or alcohol, but no longer do?” This research was approved by the Mass General Brigham institutional review board. Detailed data collection methods can be found in Kelly et al. (2017).

Data were collected by the survey company GfK, using a probability sampling approach. A representative subset of 39,809 individuals from the GfK KnowledgePanel were sent the screening question via email, to which 25,229 responded (63.4%). This response rate is similar to other nationally representative surveys (Center for Behavioral Health Statistics and Quality, 2016; Centers for Disease Control and Prevention, 2013; Grant et al., 2015). Data were weighted using the method of iterative proportional fitting so as to accurately represent the US civilian population (Battaglia et al., 2009). A total of 2,002 individuals who had resolved an AOD problem were included in the final analyses.

Measures

Demographic characteristics

Demographic characteristics included, 1) age, 2) sex, 3) race/ethnicity (White/non-Hispanic; Black/non-Hispanic; Other/non-Hispanic; Hispanic; 2+ races/non-Hispanic), and 4) level of education (less than high school; high school; some college; bachelor’s degree or higher).

Substance use characteristics

Participants were asked about their substance use history; specifically, which drugs they used ten times or more times in their lifetime, the age at which they started regularly using each of these substances, and which substance they primarily used. Substances included, ‘alcohol’, ‘marijuana’, ‘cocaine (e.g., coke, crack, freebase)’, ‘heroin’, ‘narcotics other than heroin (e.g. codeine, Darvocet, fentanyl, morphine, oxycontin, oxycodone, Percocet, Vicodin, speedball [heroin and cocaine], opium)’, ‘methadone’, ‘Suboxone/Subutex/buprenorphine’, ‘amphetamines (e.g., uppers, speed, ecstasy/MDMA [molly], Adderall, Concerta, Ritalin)’, ‘methamphetamine (crank, meth, crystal)’, ‘benzodiazepines (e.g., Ativan, Klonopin, Librium, Valium, Xanax)’, ‘barbiturates (e.g., phenobarbital, butalbital, Quaaludes)’, ‘hallucinogens (e.g., ketamine [special K], LSD [acid], mescaline [peyote], mushrooms, PCP [angel dust])’, ‘synthetic marijuana/synthetic drugs (e.g., spice, K2, mephedrone, bath salts)’, ‘inhalants (e.g., fumes from gasoline/glue, aerosols, amyl nitrates [poppers, rush], nitrous oxide [whippets]’, ‘steroids’, or ‘other’.

Because of the relatively small number of participants endorsing some less commonly used drugs as their primary substance used, to ensure we retained necessary statistical power for the present analyses, we created four categories of primary substance used: 1) alcohol, 2) cannabis, 3) opioids, and 4) ‘other’ for all other substances.

Number of psychiatric diagnoses

Participants were asked, “Which of the following substance use and/or mental health conditions have you ever been diagnosed with?” Diagnoses included, ‘alcohol use disorder’, ‘other drug use disorder’, ‘agoraphobia’, ‘anorexia’, ‘bipolar disorder (I or II)’, ‘bulimia’, ‘delusional disorder’, ‘dysthymic disorder’, ‘generalized anxiety disorder’, ‘major depressive disorder’, ‘OCD (obsessive-compulsive disorder)’, ‘panic disorder’, ‘personality disorder’, ‘PTSD (post-traumatic stress disorder)’, ‘schizoaffective disorder’, ‘schizophrenia’, ‘social anxiety disorder’, ‘specific phobia’, or ‘other mental health diagnosis’. A measure of number of psychiatric diagnoses was calculated by summing the total of affirmative responses.

Treatment and recovery measures

Participants were asked, “How many times have you been in outpatient addiction treatment?”, and “How many times have you been in inpatient or residential treatment?”. A binary measure of whether participants had received formal treatment was calculated based on responding with either ≥1 for either question (yes), or 0 for both questions (no).

Participants were also asked whether they had ever attended any of the following mutual-help programs regularly: ‘Alcoholics Anonymous’, ‘Narcotics Anonymous’, ‘Marijuana Anonymous’, ‘Cocaine Anonymous’, ‘Crystal Methamphetamine Anonymous’, ‘SMART Recovery’, ‘LifeRing Secular Recovery’, ‘Moderation Management’, ‘Celebrate Recovery’, ‘Women for Sobriety’, or ‘Secular Organizations for Sobriety’. Because very few participants endorsed regularly attending non 12-step based programs including SMART Recovery, LifeRing Secular Recovery, Moderation Management, Celebrate Recovery, Women for Sobriety, and Secular Organizations for Sobriety (n= 89 of 2,002), and these programs are structurally and stylistically quite different from one another, we chose to focus on participation in 12-step programs, which are relatively homogenous, and many participants in our sample endorsed attending regularly (n= 842 of 2,002). Thus, a response of ‘yes’ affirming regular attendance at at least one 12-step mutual-help program was coded as ‘yes’ for regular 12-step attendance. Additional, exploratory analyses are also reported in which we assessed associations with any kind of regular mutual-help program attendance (i.e., a response of ‘yes’ confirming regular attendance at at least one mutual-help program including but not limited to 12-step, was coded as ‘yes’ for regular mutual-help attendance).

Given one and five years are important addiction recovery milestone (Dennis et al., 2007), participants were grouped as having <1 year, 1–5 years, or >5 years since resolving their AOD problem.

Achievements

Achievements were assessed using the following yes/no question developed for this study, “Which of the following have you achieved since you stopped having a problem with alcohol/drugs?” Items included, 1) Promotion in my old job, 2) A new job, 3) Returned to school, 4) Completed technical school, college degree, or graduate degree, 5) Bought a new car, 6) Purchased a home, 7) Helped financially support my family, 8) Regained custody of my children, 9) Voted, 10) Contributed to charities, 11) Helped others who were having problems, 12) Did volunteer service in my local community, 13) None. To facilitate analyses and interpretation of the results, findings are presented in the following conceptual clusters: 1) self-improvement (i.e., returning to school, completing technical school, a college degree, or graduate degree, getting a job, and getting a promotion in a job); 2) family engagement (i.e., regaining custody of children and helping financially to support one’s family); 3) civic participation (i.e., helping others who have problems, volunteering to do service in the local community, contributing to charities, and voting); and 4) economic participation (i.e., buying a car, and purchasing a home).

Psychological distress

Psychological distress was measured using the six-item Kessler 6 (Kessler et al., 2002). Item responses are on a Likert scale from 1=all of the time to 5=none of the time (e.g., “During the past 30 days, about how often did you feel… nervous; hopeless; restless or fidgety; so depressed that nothing could cheer you up; that everything was an effort; worthless?’). The Kessler 6 is psychometrically sound with very good very good discriminative validity and excellent internal consistency (α=.89).

Self-esteem and happiness

Participants rated the extent to which they felt the statement “I have high self-esteem” is true on a Likert scale from 1=not very true to 5=very true (Robins et al., 2001). They also rated their happiness from 1=completely unhappy to 5=completely happy (Meyers & Smith, 1995). The traditional 10-point scales for these items were modified to 5-point scale.

Quality of life

Quality of life was assessed using the European Health Interview Survey – Quality of Life (EUROHIS-QOL) (Schmidt et al., 2005), an eight-item measure adapted from the World Health Organization Quality of Life - Brief Version. Item responses are from 1 to 5 (e.g., “How satisfied are you with your personal relationships?” 1=very dissatisfied to 5=very satisfied) with a possible range of 8–40. The European Health Interview Survey – Quality of Life (EUROHIS-QOL) is psychometrically sound with good to excellent predictive validity. Its internal consistency in the current sample was excellent (α=.90).

Recovery capital

Recovery capital was measured using the 10-item Brief Assessment of Recovery Capital (BARC-10; Vilsaint et al., 2017). Item responses are on a Likert scale from 1 to 6 (e.g., “My living space has helped to drive my recovery journey” 1=strongly disagree to 6=strongly agree). The measure has strong psychometric properties, including acceptable predictive validity, and excellent internal consistency (α=.90).

Analyses

Survey weights were used throughout the analyses to statistically account for any under-representation in the KnowledgePanel sample, as well as differential responding to the National Recovery Study screening question. We describe below the four research questions and how we addressed each analytically:

1. How prevalent are different achievements among individuals who have resolved an AOD problem? Sample prevalence of achievements were explored descriptively using the SURVEYFREQ procedure in SAS 9.4 (SAS Institute, 2013).

2. Which demographic, clinical, and addiction recovery related variables are associated with accomplishing such achievements? In order to identify demographic, clinical, and recovery related variables associated with achievement accrual, we conducted univariate screening using a more liberal statistical type I criterion of p< .10. Variables with significant associations with achievement measures were then entered into simultaneous regression models to understand the relative and independent associations between these variables and achievement categories. Based on the results of the univariate screening, independent variables included in these models were sex, race/ethnicity, level of education, average age of onset of regular substance use, time since resolving a problem with AOD, number of psychiatric diagnoses, psychological distress, whether formal treatment was ever received (yes/no), whether 12-step programs were ever regularly attended (yes/no).

Univariate screening indicated age was also associated with achievement accrual, however, inclusion of age in subsequent logistic regression models caused the beta coefficients for ‘Total years since resolving AOD problem’ to erroneously flip (Simpson's parardox; Blyth, 1972). In other words, models showed a negative association, when in fact the associations were positive. We therefore excluded age from our regression models.

We created a binary, yes/no variable for each of the four achievement categories (i.e., self-improvement, family engagement, civic participation, economic participation) indicating if a participant endorsed at least one achievement within each of these categories. Four separate logistic regression models were then tested using the SURVEYLOGISITC procedure in SAS 9.4 (SAS Institute, 2018), with endorsement of an achievement in each achievement category as the dependent variable (achieved= 1; not achieved= 0). We also ran a linear regression model using the SURVEYREG procedure in SAS 9.4 (SAS Institute, 2016) with total number of achievements endorsed as the dependent variable (i.e., the sum of yes responses to the 12 individual achievement questions).

3. How do such achievements accrue temporally with time in recovery? Temporal effects of achievement accrual were explored descriptively using the SURVEYFREQ procedure in SAS 9.4 (SAS Institute, 2013). We examined frequency counts of endorsement of each type of achievement and examined this in relation to length of time in recovery.

4. How do achievements relate to addiction recovery related indicators of well-being (i.e., self-esteem, happiness, quality of life, and recovery capital)? Associations between total number of achievements and indicators of well-being associated with sustaining remission from an AOD problem were explored using the SURVEYREG procedure in SAS 9.4 (SAS Institute, 2016), with self-esteem, happiness, quality of life, and recovery capital as dependent variables. The independent variable for each of these four models was total number of achievements endorsed, with sex, race/ethnicity, level of education, age of onset of regular substance use, time since resolving an AOD problem, number of psychiatric diagnoses, psychological distress, whether treatment was ever received (yes/no), and whether 12-step programs were ever regularly attended (yes/no) as covariates.

For logistic regression models, effect sizes are reported as McFadden R-squared values, which are akin to the percent-of-variance-accounted-for metric captured by R-squared values in linear regression models (Allison, 2014; Shtatland et al., 2002). McFadden’s R-squared values were calculated with covariates excluded from the models in order to reflect the actual variance accounted for by each independent variables/covariate. For the linear regression models standard R-squared values are reported, also excluding covariates.

Results

The sample’s age characteristics are as follows: 7.1% 18–24yrs (emerging adulthood); 45.2% 25–49yrs (young adults); 34.7% 50–64yrs (mid-life stage adults); and 13.0% 65+yrs (older adults). The sample is 40% female and 60% male, 61.5% White/non-Hispanic, 13.8% Black/non-Hispanic, 5.8% Other/non-Hispanic, 17.3% Hispanic, and 1.7% 2+ races/non-Hispanic. In terms of time since resolving their AOD problem, 11.1% of the sample endorsed having <1 year, 21.5% endorsed 1–5 years, and 67.4% endorsed >5 years. As previously reported, just over half the sample (51.4%) were abstinent from all AODs at the time of survey, with 48.6% endorsing current use of at least one substance (Kelly et al., 2017). Of those using one or more substances, 76.4% of those who considered themselves to be ‘in recovery’ were abstinent from all substances that were problematic for them, while 70.4% of those who used to be, or never considered themselves to be ‘in recovery’, were abstinent from all substances that were problematic for them (Kelly, Greene, et al., 2018).

1. How prevalent are different achievements among individuals who have resolved an alcohol or other drug (AOD) problem?

Prevalence of achievements are displayed in Figure 1. Weighted frequencies showed that of the total sample of 2,002 participants (weighted N= 1,980), since resolving an AOD problem, 332 (16.8%) had returned to school; 263 (13.3%) had completed technical school, a college degree, or a graduate degree; 714 (36.0%) had gotten a new job; 306 (15.5%) had received a promotion in their old job; 64 (3.2%) had regained custody of their children; 667 (33.7%) had helped financially support their family; 666 (33.6%) had helped others who were having problems; 415 (20.9%) had done volunteer service in their local community; 512 (25.8%) had contributed to charities; 595 (30.0%) had voted; 724 (36.6%) had bought a new car; and 513 (25.9%) had purchased a home.

Figure 1.

Figure 1.

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Prevalence in the United States population of achievements since resolving a problem with alcohol or other drugs (AOD)

In terms of frequency of number of achievements accrued, 356 (18.0%) participants endorsed 1 achievement; 258 (13.0%) endorsed 2; 232 (11.7%) endorsed 3; 172 (8.7%) endorsed 4; 182 (9.2%) endorsed 5; 125 (6.3%) endorsed 6; 95 (4.8%) endorsed 7; 67 (3.4%) endorsed 8; 39 (2.0%) endorsed 9; 29 (1.5%) endorsed 10; 12 (0.6%) endorsed 11; and 5 (0.2%) endorsed 12. 398 (20.1%) participants endorsed accomplishing none of the surveyed achievements.

2. Which demographic, clinical, and addiction recovery related variables are associated with accomplishing achievements?

Results from logistic regression models exploring associations between achievements, and demographic and psychosocial variables are reported in Table 1.

Table 1.

Achievement categories regressed onto sex, race/ethnicity, education level, average age of substance use initiation, total years since resolving an alcohol and other drug problem (AOD), number of psychiatric diagnoses, psychological distress, formal treatment received (yes/no), regularly attended 12-step programs (yes/no), and showing F-value, percent of variance accounted for represented by R-squared, and unstandardized beta coefficients.

Self-Improvement Family
Engagement		 Civic Participation Economic
Participation		 Total
Achievements
Model (F / R2) 8.42**** 0.06 8.73**** 0.06 15.87**** 0.11 17.16**** 0.12 19.09**** 0.22
Sex (F / R2) 0.10 <0.01 0.38 <0.01 0.05 <0.01 0.94 <0.01 0.27 <0.01
 Female (β) 0.02 0.05 0.02 0.07 0.09
 Male (β) Ref Ref Ref Ref Ref
Race/Ethnicity (F / R2) 1.29 <0.01 3.92** 0.01 1.49 <0.01 2.54* 0.01 3.02* 0.01
 White/non-Hispanic (β) Ref Ref Ref Ref Ref
 Black/non-Hispanic (β) 0.09 0.58** 0.33 −0.23 0.54*
 Other/non-Hispanic (β) −0.28 −0.30 −0.47 −0.64* −0.44
 Hispanic (β) 0.14 0.34 0.19 0.47* 0.57*
 2+ races/non-Hispanic (β) 0.23 −0.44 0.05 0.41 0.08
Education Level (F / R2) 9.15**** 0.01 1.45 <0.01 8.74**** 0.01 6.33*** 0.01 28.32**** 0.05
 Less than high school (β) −0.23 −0.36 −0.39 −0.59** −1.98****
 High school diploma (β) −0.37** 0.08 −0.36** −0.10 −1.63****
 Some college (β) 0.03 0.03 0.20 0.16 −0.93****
 Bachelor’s degree or higher (β) Ref Ref Ref Ref Ref
Average Age of Substance Use Initiation (F / R2) 16.91**** 0.02 0.55 <0.01 0.68 <0.01 2.38 <0.01 8.30** <0.01
−0.05**** −0.01 0.01 −0.02 −0.03**
Primary Substance Used (F / R2) 3.97** 0.01 2.53* 0.01 5.82**** 0.02 4.86*** 0.01 6.93**** 0.02
 Alcohol (β) Ref Ref Ref Ref Ref
 Cannabis (β) 0.03 0.17 −0.02 0.08 0.63*
 Opioids (β) 0.50 0.51 1.09*** −0.03 0.97***
 Other (β) 0.01 0.04 0.15 0.61*** 0.80***
Total Years Since Resolving AOD Problem (F / R2) 8.45** 0.01 26.45**** 0.02 38.82**** 0.03 72.73**** 0.06 110.29**** 0.10
0.02** 0.03**** 0.04**** 0.06**** 0.08****
Psychiatric Diagnoses (F / R2) 2.21 <0.01 9.59** <0.01 8.78** 0.01 0.50 <0.01 5.02* 0.01
−0.07 0.14** 0.16** 0.03 0.18*
Psychological Distress (F / R2) 0.00 <0.01 7.66** 0.01 4.60* <0.01 9.57** 0.02 9.55* 0.02
−0.00 −0.04** −0.04* −0.05** −0.05**
Received Formal Treatment (F / R2) 1.61 <0.01 0.73 <0.01 0.13 <0.01 1.85 <0.01 0.24 0.01
 Yes (β) 0.12 0.08 −0.04 0.13 0.11
 No (β) Ref Ref Ref Ref Ref
Regularly Attended 12-Step Programs (F / R2) 1.68 <0.01 3.21 0.01 19.79**** 0.03 0.67 0.01 12.76*** 0.03
 Yes (β) 0.11 0.15 0.37**** 0.07 0.67***
 No (β) Ref Ref Ref Ref Ref
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Notes. R2= Percent of variance accounted for represented by McFadden’s R-squared for self-improvement, family engagement, civic participation, economic participation models, and standard R-squared for total number of achievements model. β= Unstandardized beta coefficient. Ref = Reference group.

*

p< .05

**

p< .01

***

p< .001

****

p< .0001.

Self-improvement

Self-improvement was associated with level of education; those with a high school diploma (OR= 0.39, 95% CI= 0.27 - 0.56) were less likely to endorse a self-improvement related achievement since resolving an AOD problem compared to those with a bachelor’s degree or higher (reference group). Additionally, self-improvement was associated with earlier substance use initiation (OR= 0.95, 95% CI= 0.92 - 0.97), and greater number of years since resolving an AOD problem (OR= 1.02, 95% CI= 1.01 - 1.03).

Self-improvement was not associated with sex, race/ethnicity, psychiatric diagnoses, psychological distress, receiving formal treatment, or regular 12-step program or any mutual-help program attendance (all p’s> .05).

Family engagement

Individuals identifying as Black/non-Hispanic (OR= 2.14, 95% CI= 1.35 - 3.39) were more likely than those identifying as White/non-Hispanic (reference group) to endorse an achievement related to family engagement since resolving an AOD problem. Additionally, family engagement was associated with greater number of years since resolving an AOD problem (OR= 1.03, 95% CI= 1.02 - 1.05), having psychiatric comorbidity (OR= 1.15, 95% CI= 1.05 - 1.25), and experiencing lower psychological distress (OR= 0.96, 95% CI= 0.93 - 0.99).

Family engagement was not associated with sex, education level, age of initiation of substance use, or receiving formal treatment (all p’s> .05). And although regular attendance at 12-step programs was not associated with achievements related to family engagement (p> .05), there was a significant association (OR= 1.44, 95% CI= 1.03 - 2.01) with regular attendance at any mutual-help program (i.e., 12-step or other).

Civic participation

Civic participation was associated with level of education; those with a high school diploma (OR= 0.40, 95% CI= 0.28 - 0.59) were less likely to endorse a civic participation related achievement since resolving an AOD problem compared to those with a bachelor’s degree or higher (reference group). Additionally, compared to those for whom alcohol was primary, those primarily using opioids (OR= 4.23, 95% CI= 1.92 - 9.31) were more likely to have endorsed a civic participation related achievement since resolving an AOD problem. Civic participation was also associated with greater number of years since resolving an AOD problem (OR= 1.04, 95% CI= 1.03 - 1.06), having psychiatric comorbidity (OR= 1.18, 95% CI= 1.06 - 1.30), experiencing less psychological distress (OR= 0.97, 95% CI= 0.94 - 0.99), and regular attendance at 12-step programs (OR= 2.11, 95% CI= 1.52 - 2.94). Additionally, any regular mutual-help program attendance (i.e., 12-step or other) was also associated with greater civic participation (OR= 2.20, 95% CI= 1.59 - 3.04).

Civic participation was not associated with sex, race/ethnicity, age of substance use initiation, or receiving formal treatment (all p’s> .05).

Economic participation

Economic participation was influenced by race/ethnicity; individuals identifying as Hispanic were more likely (OR= 1.63, 95% CI= 1.05 - 2.52), and those identifying as Other/non-Hispanic were less likely (OR= 0.54, 95% CI= 0.25 - 1.16) to endorse achieving an economic participation related achievement since resolving an AOD problem than those identifying as White/non-Hispanic (reference group). Economic participation was also associated with level of education; those with less than a high school level of education (OR= 0.32, 95% CI= 0.17 - 0.61) were less likely to endorse an economic participation related achievement compared to those with a bachelor’s degree or higher (reference group). Additionally, compared to those for whom alcohol was primary, those in the primary ‘other’ substance use category (OR= 1.84, 95% CI= 1.28 - 2.66) were more likely to have endorsed an economic participation related achievement. Economic participation was also associated with greater number of years since resolving an AOD problem (OR= 1.06, 95% CI= 1.05 - 1.08), and experiencing lower psychological distress (OR= 0.96, 95% CI= 0.93 - 0.98).

Economic participation was not associated with sex, age of substance use initiation, psychiatric diagnoses, receiving formal treatment, regular attendance at 12-step programs, or regular attendance at any mutual-help programs (all p’s> .05).

Total achievements

Individuals identifying as Black/non-Hispanic (β= 0.54, SE= 0.26, p= .04), and Hispanic (β= 0.57, SE= 0.23, p= .01), accomplished a greater number of achievements since resolving an AOD problem than those identifying as White/non-Hispanic (reference group). Total achievements was also associated with level of education, such that those with less than a high school level of education (β= −1.98, SE= 0.29, p< .0001), a high school diploma (β= −1.63, SE= 0.20, p< .0001), and some college (β= −0.93, SE= 0.18, p< .0001) all endorsed accruing fewer achievements compared to those with a bachelor’s degree or higher (reference group). Additionally, lower age of initiation of substance use was associated with greater number of achievements endorsed (β= −0.03, SE= 0.01, p= .004). Compared to those for whom alcohol was primary, those primarily using cannabis (β= 0.63, SE= 0.31, p= .04), opioids (β= 0.97, SE= 0.29, p= .0008), and ‘other’ (β= 0.80, SE= 0.21, p= .0001) accomplished more achievements since resolving an AOD problem (Figure 2). Greater number of achievements was also associated with greater number of years since resolving an AOD problem (β= 0.08, SE= 0.01, p< .0001), greater psychiatric comorbidity (β= 0.17, SE= 0.78, p= .02), and less psychological distress (β= −0.05, SE= 0.02, p= .002). In addition, participants who regularly attended a 12-step program accrued more achievements than those who did not (β= 0.67, SE= 0.19, p= .0004). Additional analysis showed that any regular mutual-help program attendance (i.e., 12-step or other) was also positively associated with total number of achievements (β= 0.70, SE= 0.18, p= .0001).

Figure 2.

Figure 2.

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Prevalence in the United States population of average number of achievements since resolving a problem with alcohol or other drugs (AOD) by primary substance used. Weighted number of participants in each bin are in parentheses.

Notes. * p< .05, *** p< .001.

Total number of achievements was not associated with sex, or having received formal treatment (p’s> .05).

3. How do achievements accrue temporally with time in recovery?

Accrual of achievements across time is displayed in Figures 3 and 4. Figure 3 shows a general trend of increasing achievement accrual across five-year increments of years since resolving an AOD problem. Figure 4 displays mean total number of achievements per participant across 10-year increments by primary substance used, and shows a steady accrual of achievements across years since AOD problem resolution.

Figure 3.

Figure 3.

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Bar graph showing average number of achievements achieved by five-year epochs of time in recovery. Weighted number of participants in each bin are in parentheses.

Figure 4.

Figure 4.

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Line graph showing average number of achievements accomplished by ten-year epochs of time since AOD problem resolution, and primary substance used. Weighted number of participants in each bin are in parentheses.

4. How do achievements relate to addiction recovery related indicators of well-being?

Results from linear regression models exploring associations between total number of achievements, and indicators of well-being associated with sustaining remission from an AOD problem are reported in Table 2.

Table 2.

Self-esteem, happiness, quality of life, and recovery capital regressed onto total number of achievements, sex, race/ethnicity, education level, average age of substance use initiation, total years since resolving an alcohol and other drug problem (AOD), number of psychiatric diagnoses, psychological distress, formal treatment received (yes/no), regularly attended 12-step programs (yes/no), and showing F-value, percent of variance accounted for represented by R-squared, and unstandardized beta coefficients.

Self-Esteem Happiness Quality of Life Recovery Capital
Model (F / R2) 20.02**** 0.32 20.60**** 0.31 34.10**** 0.42 24.32**** 0.30
Total Achievements (F / R2) 16.16**** 0.03 20.16**** 0.03 30.17**** 0.05 48.56**** 0.09
0.05**** 0.05**** 0.36**** 0.82****
Sex (F / R2) 2.25 0.01 2.36 <0.01 1.14 0.14 <0.01
 Female (β) −0.10 0.09 −0.39 0.22
 Male (β) Ref Ref Ref Ref
Race/Ethnicity (F / R2) 5.51*** 0.03 0.75 0.01 1.16 0.02 1.50 0.03
 White/non-Hispanic (β) Ref Ref Ref Ref
 Black/non-Hispanic (β) 0.46*** 0.05 0.03 1.79
 Other/non-Hispanic (β) 0.10 −0.04 −1.09 −1.98
 Hispanic (β) 0.05 −0.04 −0.04 −0.58
 2+ races/non-Hispanic (β) 0.39** −0.29 −1.75* 0.98
Education Level (F / R2) 3.33* 0.02 1.36 <0.01 6.98*** 0.04 0.38 <0.01
 Less than high school (β) −0.22 0.09 −3.21**** −0.97
 High school diploma (β) −0.20* −0.06 −1.24** −0.45
 Some college (β) −0.17** −0.09 −1.12** −0.57
 Bachelor’s degree or higher (β) Ref Ref Ref Ref
Average Age of Substance Use Initiation (F / R2) 0.95 <0.01 0.27 <0.01 0.03 <0.01 0.07 <0.01
−0.00 0.00 −0.00 −0.01
Primary Substance Used (F / R2) 0.98 0.03 0.67 0.01 1.63 <0.01 1.22 0.01
 Alcohol (β) Ref Ref Ref Ref
 Cannabis (β) −0.18 0.08 0.40 2.04*
 Opioids (β) −0.09 −0.04 0.74 −0.55
 Other (β) −0.00 0.09 1.91 −0.12
Total Years Since Resolving AOD Problem (F / R2) 2.17 0.05 0.79 0.05 0.01 0.05 0.60 0.05
0.00 0.00 −0.00 −0.02
Psychiatric Diagnoses (F / R2) 7.08** 0.07 1.09 0.06 2.28 0.07 0.13 0.03
−0.06** −0.02 −0.16 −0.06
Psychological Distress (F / R2) 125.24**** 0.27 195.40**** 0.28 246.36**** 0.37 106.84**** 0.23
−0.10**** −0.09**** −0.67**** −0.75****
Received Formal Treatment (F / R2) 4.76* 0.01 2.62 <0.01 0.86 <0.01 3.11 <0.01
 Yes (β) −0.19* −0.11 −0.44 −1.32
 No (β) Ref Ref Ref Ref
Regularly Attended 12-Step Programs (F / R2) 0.19 <0.01 0.17 <0.01 0.36 <0.01 1.61 <0.01
 Yes (β) 0.03 0.03 0.24 0.84
 No (β) Ref Ref Ref Ref
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Notes. R2= Percent of variance accounted for represented by standard R-squared. β= Unstandardized beta coefficient. Ref = Reference group.

*

p< .05

**

p< .01

***

p< .001

****

p< .0001.

After controlling for sex, race/ethnicity, level of education, average age of onset of regular substance use, time since resolving a problem with AOD, number of psychiatric diagnoses, psychological distress, whether formal treatment was ever received, and whether 12-step programs were ever regularly attended, greater total number of achievements was associated with greater self-esteem (β= 0.05, SE= 0.01, p< .0001), greater happiness (β= 0.05, SE= 0.01, p< .0001), greater quality of life (β= 0.35, SE= 0.06, p< .0001), and greater recovery capital (β= 0.80, SE= 0.11, p< .0001).

Discussion

It often takes individuals many attempts to overcome an AOD problem (Kelly et al., 2019), yet recovery is not only possible, it is common (Dawson et al., 2005; Kelly et al., 2017; White, 2012). Also, in spite of much stigmatization of addiction and numerous societal barriers to recovery (Vilsaint et al., 2020), it is widely appreciated that many individuals who have a resolved an AOD problem make significant self-improvements and valuable contributions to society. In turn, it is thought that this self-improvement and societal participation gives rise to improvements in self-image, and increased positive affect.

The present study is the first to report on the accrual of achievements among people who have resolved an AOD problem using a nationally representative sample, and to explore how achievement accrual differs by sub-groups, as well as the relationship between achievements and measures of well-being including self-esteem, happiness, quality of life, and recovery capital.

The national US prevalence of individuals who have overcome an AOD problem estimated from the National Recovery Study was 9.1%. This is comparable to non-probability based estimates of addiction recovery in the US, which have ranged from 5 to 15%, with prior estimates influenced by differences in remission/recovery definitions and other inclusion criteria (Office of the Surgeon General, 2016; White, 2012). Of individuals who have overcome an AOD problem, about half were found to be abstinent from all AODs, half endorsed current use of at least one substance, and around three quarters were abstinent from all substances that were problematic for them. Thus, the accomplishment of achievements is common among US individuals who have overcome and AOD problem, regardless of whether they are totally abstinent from AOD or using a substance/s in a non-problematic way. Further, achievement accrual was related to a number of demographic, clinical, and recovery variables, and was also associated with indices of well-being. Though on the whole effect sizes representing the observed associations were largely fairly small, this is to be expected given the complex and numerous factors contributing to achieving the kinds of achievements studied here, and their influence on self-esteem, happiness, quality of life, and recovery capital.

Prevalence of different achievements

Accomplishment of achievements was very common, with findings indicating that the majority of individuals in AOD problem recovery in the US (80.1%) have achieved at least one of the surveyed achievements, and over half have achieved two or more (61.4%). Further, the accrual of achievements follows a generally linear trend across years following AOD problem resolution (Figure 3), suggesting individuals gradually accumulate achievements with greater time since successfully resolving their AOD problem. From a behavioral economic standpoint (Tucker et al., 2016), a greater amount of discretionary spending that is being redirected from AOD to other goods and services could be contributing to several of these material gains. The fact that 20% of the sample endorsed no achievements was noteworthy, but this may be in part attributable to participants in early AOD recovery having had less time to achieve the surveyed achievements. It is well appreciated that, for many, early recovery involves clearing away the debris of AOD problem-related consequences, and building the foundation upon which later achievements can be constructed. Post hoc, exploratory analysis suggests this was the case. Those endorsing no achievements reported significantly less time since resolving their AOD problem than those with one or more achievements (t= −3.53, p= .0004).

Demographic, clinical, and recovery related correlates of achievements

With regards to race and ethnicity, individuals identifying as Black/non-Hispanic and Hispanic ethnicity endorsed accomplishing a greater total number of achievements since resolving an AOD problem compared to those identifying at White/non-Hispanic. For individuals identifying as Black/non-Hispanic this effect appears to be driven by family engagement. Termination of parental rights and risk of foster care placement is marked by glaring race and class disparities that pervasively disrupt poor black communities (Roberts, 2012). While African American children represent about 14% of the nation’s children (Annie E. Casey Foundation, 2020), they account for 23% of the foster care population (Department of Health and Human Services Children's Bureau, 2019) despite equivalent child maltreatment rates as White children at the same level of poverty (Kim & Drake, 2018). Financial support may be another important part of family engagement given nonmarital births occur more frequently among individuals who identify as Black (69%) compared to White (28%)(Martin et al., 2019). Financial support may also reflect parental and sibling support. Thus, engagement or re-engagement with the family is likely occurring more frequently after resolving an AOD problem for those identifying as Black/non-Hispanic because these individuals experience more familial disruption and financial disadvantage, before and in the context of an AOD problem.

For individuals identifying as Hispanic compared to White, the effect of greater number of achievements in recovery appears to stem from economic participation in terms of home or car purchases. People of color have long faced higher hurdles in purchasing homes because of governmental and corporate policies like redlining, which led to higher rates of credit and loan denial (Jo et al., 2020) and greater loan refinancing fees (Bartlett et al., 2019), even at the same income, loan amount, debt, and neighborhood as White counterparts (Martinez & Glantz, 2018). This has manifested alarming race differences in inherited wealth, and today, for every US$1 in White child households, Hispanic families have 8¢, and Black families have 1¢ (Percheski & Gibson-Davis, 2020). Additionally, car purchases cost an average of $2,662 more for individuals who identify as Black or Hispanic even with superior credit than their White counterparts (Rice & Schwartz, 2018). Because of these discriminatory practices, on top of the significant financial burden of having a problem with AOD, it is highly probable that individuals identifying as Hispanic were less likely to have accomplished these financial achievements before resolving an AOD problem, and had a greater chance of achieving them after resolving their AOD problem.

There was a positive linear relationship between level of education and total number of achievements since resolving an AOD problem, suggesting education may support accrual of achievements in this population. This is consistent with previous findings that speak to protective effects of education among individuals in AOD problem recovery (Eddie et al., 2019; Eddie, Vilsaint, et al., In press), and general associations in society between education and the kinds of achievements studied here. At the same time, education is highly correlated with factors like socio-economic status; thus, while being a marker for achievement accrual, education effects in this study could be accounted for by education’s ability to facilitate greater income, which in turn can facilitate other purchases and abilities. Regardless, the association between education and achievements observed here speaks to the potential of educational enhancement (e.g., collegiate recovery programs; Laudet et al., 2014) as an aid to increased stability and quality of life in long-term AOD problem recovery.

Regarding primary substance used and achievement since entering recovery, Figure 2 shows individuals for whom ‘cannabis’, ‘opioids’, or ‘other’ are primary, accrue more of the surveyed achievements than those for whom ‘alcohol’ is primary, although as highlighted in Figure 4, rate of accrual over time is similar regardless of primary substance. It is possible that because alcohol is legal and socially sanctioned, its use does not drive people underground in the same way illicit substance use does, and conversely, because illicit substance use is more marginalized, use of these substances may lead to barriers to mainstream pathways of societal participation. As such, those for whom illicit substances are primary may be less likely to accomplish the kinds of achievements surveyed in this study prior to AOD problem resolution, compared to those for whom alcohol is primary. It is also possible that individuals for whom illicit substances are primary initiate regular substance use earlier, and as a result accumulate less of the surveyed achievements prior to developing an AOD problem, and are thus more likely to accomplish these achievements after resolving an AOD problem. Post hoc analysis suggests this may be true for those for whom cannabis is primary; this sub-group was significantly younger when initiating regular AOD use compared to those for whom alcohol was primary (t= −3.05, p= .002). However, those for whom opioids or ‘other’ were primary, were not significantly younger when initiating regular AOD use (p> .05).

Greater number of lifetime psychiatric diagnoses and lower psychological distress were also associated with greater number of achievements since resolving an AOD problem. While it is not surprising that lower current psychological distress is associated with a greater number of total achievements, the finding for psychiatric diagnoses is less intuitive. It is possible that given the psychological burden of mental disorders, this result was influenced by those with more psychiatric diagnoses being less likely to have achieved the surveyed achievements prior to having resolved a problem with AOD, versus after, when such burden—if still present—may become more manageable, thus facilitating enhanced functioning and the accrual of more achievements. It is also possible, however, that having a greater number of psychiatric diagnoses is partially an artefact of greater access to healthcare, given the measure ‘number of psychiatric diagnoses’ was derived from a survey question that stated, “Which of the following substance use and/or mental health conditions have you ever been diagnosed with?” Greater access to healthcare could be a marker of greater resources, which in turn could have led to greater accrual of achievements.

Those who regularly attended 12-step mutual-help organizations programs endorsed greater total number of achievements compared to those that did not. This effect appears to be in large part driven by greater civic participation related achievements among those who regularly attended 12-step programs. This finding makes sense given the emphasis in 12-step programs on helping others (Pagano et al., 2009; Zemore & Pagano, 2008), and builds on a large literature showing the value of 12-step approaches (Bøg et al., 2017; Humphreys et al., 2020; Kaskutas, 2009; Kelly, Humphreys, et al., 2020). Similarly, those with any regular mutual-help program attendance (i.e., 12-step or other) also endorsed more civic-related and total number of achievements versus those not endorsing any mutual-help program attendance. In addition, those who endorsed any regular mutual-help program attendance also endorsed more family engagement related achievements. Though we were not powered to test the effects of non-12-step based mutual-help organization participation in this study alone, this finding is encouraging and we hope will stimulate further work in this area that can build on previous work showing the benefits of non-12-step based mutual-help programs (Zemore et al., 2018).

Relations between achievements and indices of current well-being

Total number of achievements accomplished since resolving an AOD problem was positively associated with measures of current well-being, with total achievements explaining 3% of the variance in self-esteem, 3% of the variance in happiness, 5% of the variance in quality of life, and 9% of the variance in accumulation of recovery capital (Table 2). These findings build on previous work speaking to the benefits of participation in civic and economic life among individuals in AOD problem recovery in terms of these positive factors (Best, McKitterick, et al., 2015; Cano et al., 2017; Eddie, Vilsaint, et al., In press; Laudet & White, 2008). Moreover, such findings suggest that supporting individuals in education and employment efforts beyond acute care stabilization and clinical management of substance-related symptoms and sequalae, may result in subsequent enhancements in indices associated with better functioning and quality of life. This may be one reason why recovery community centers recently have emerged and grown so quickly around the US, and are showing similar benefits (Kelly, Stout, et al., 2020).

Limitations

A number of limitations should be considered when interpreting these results. 1) These data are cross-sectional, limiting our capacity to draw conclusions about direction of effects and causality. 2) We were forced to omit age from our regression models due to observed Simpson’s paradox (Blyth, 1972) in which the sign of the beta coefficients for the variable ‘Total years since resolving AOD problem’ reversed direction when age was included in the models. At the same time, because ‘Total years since resolving AOD problem’ and ‘Age’ were highly correlated (r= .57), a large portion of the variance that would have been accounted for by age was accounted for by total number of years since resolving an AOD problem. 3) Though data were weighted to reflect the general population, it is not known if there were demographic/psychosocial differences between those who endorsed having resolved a problem with AOD, and those who said they had not in the initial survey screening question. 4) We do not have data on the accrual of achievements prior to resolving an AOD problem. It is likely that many participants had already achieved some of the surveyed achievements prior to resolving their AOD problem, which may have influenced the results in unknown ways. 5) We also do not have data marking the time to first achievement subsequent to resolving an AOD problem. Although accrual of achievements appears to show an increasing monotonic linear function over time, we do not know from these data how long it takes to begin accomplishing such achievements. 6) Felony disenfranchisement laws may have influenced the ability to vote among some participants with criminal records, and we were not able to control for this is our analyses. 7) Although results showed achievement attainment was associated with greater self-esteem, quality of life, and happiness, we did not measure perceived sense of accomplishment or benefit associated with achievements measured in this study. It is possible attaining certain achievements did not actually benefit some participants. 8) This study explored accrual of achievements generally desirable to mainstream society. It does not consider how important these achievements are to those with lived experience of AOD problems, who may prioritize or attach greater value to achievements not measured here (Lancaster, 2017).

Conclusions and Implications

This study utilized rigorous survey methods to collect nationally representative data, and reports for the first time what many healthcare providers and individuals with lived experience of AOD problem recovery have long appreciated: that in spite of major stigmatization and discrimination against individuals with AOD problem histories (Kulesza et al., 2016), most recovering individuals accomplish several achievements associated with self-improvement, family engagement, and civic and economic participation. Further, these achievements are independently associated with measures of well-being including greater self-esteem, happiness, quality of life, and recovery capital. Though effect sizes representing the observed associations were generally fairly small, this is to be expected given the complex and myriad factors that contribute to achieving the kinds of achievements investigated here, and their effects on well-being.

Future longitudinal studies would help clarify the nature and sequencing of the accrual of various achievements over time in AOD recovery, and deepen understanding about the predictors and facilitators of such achievements and their subsequent effect on other indices of functioning, psychological well-being, and quality of life. Future epidemiological studies should also characterize achievements outside of the domains studied in the present paper, including health-related achievements like addressing/managing medical problems, and social achievements like reestablishing friendships and building pro-recovery social supports, while also considering input about variable selection from individuals with lived experience of AOD problem resolution (Neale et al., 2016). Additionally, inclusion of measures like the Substance Use Recovery Evaluator (SURE; Neale et al., 2016) and the Brief Assessment of Recovery Capital (BARC-10; Vilsaint et al., 2017) that capture broader aspects of psychosocial functioning and recovery capital gains could play a larger role in treatment planning and addiction recovery research.

Recovery initiation from AOD problems is often portrayed as a product of push factors; i.e., the accumulation of AOD-related consequences that enhance motivation for behavioral change (e.g., the experience of ‘hitting bottom’). The present findings, however, speak to the importance of pull factors; i.e., recovery initiation triggered by hope for what could be accomplished through the recovery experience. As the present findings suggest, resolving an AOD problem is far more than the removal of alcohol and other drugs from an otherwise unchanged life. Rather, for the majority, it involves the accumulation of achievements, not necessarily in spite of addiction recovery, but because of the transformations in lifestyle and behavior that are integral to the recovery process (White & Kurtz, 2006).

Public Health Significance Statement: The majority of people in the United States who have overcome an alcohol and other drug problem report achievements related to self-improvement, family engagement, and civic and economic participation since resolving their substance use issue. These achievements accumulate with time in recovery, and are associated with greater self-esteem, happiness, quality of life, and recovery capital.

Acknowledgements:

The National Recovery Study was funded by the Massachusetts General Hospital Recovery Research Institute. The authors of this publication were supported by NIAAA awards L30AA026135, F32AA025251, F32AA025823, K23AA027577-01A1, 1K23AA025707-01A1, and K24AA022136.

Footnotes

Prior dissemination of data and narrative interpretations: Data for this paper came from the National Recovery Study conducted by the Recovery Research Institute at Massachusetts General Hospital. The analyses and results of this paper have not been previously reported.

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