In the last decade ‘recovery’ has emerged as a priority in several national drug strategies. It is also included in the EU drug strategy and action plan, and is the subject of a recent UN resolution, Supporting recovery from substance use disorders.1 This article explores how recovery has been incorporated in the national drug strategies of the USA, England/Wales and Scotland, and in particular how it relates to the goals and objectives of the strategies, how it is integrated with other policy measures, and how it is proposed to support recovery. It is clear that understanding of the concept and its operationalisation varies considerably across the three jurisdictions. 

While the benefits of ‘recovery’ may be self-evident at practice level, at policy level, where recovery is placed alongside competing policy options and approaches, in what Duke calls ‘nested contexts’,2 the concept is more open to interpretation. In 2012 the journal Drugs: education, prevention and policy published a special issue on Recovery. The editors included articles on the origins and development of the concept in the United Kingdom, and explored some of the policy debates.3 In the strategies described below some of the same debates are still being worked through, for example the relationship between recovery and harm reduction (abstinence versus maintenance), between criminal justice and public health responses, and the role of sanctions. 

United States – expanding support for recovery 

In July 2014 the White House released its 2014 National drug control strategy (NDCS).4 It has two short-term goals: (1) to curtail illicit drug consumption in America, and (2) to improve the public health and public safety of the American people by reducing the consequences of drug abuse. The strategy contains a balance of supply and demand reduction measures. Recovery is linked with treatment in a chapter entitled ‘Integrate treatment for substance use disorders into health care and expand support for recovery’. 

Citing research showing that ‘addiction is a disease from which people can recover… [and that] success rates for treating addictive disorders are roughly on a par with recovery rates for other chronic diseases such as diabetes, asthma, and hypertension’, the NDCS pledges to substantially increase the number of Americans who can access high-quality treatment for their substance disorder. Under the Affordable Care Act 2010 insurance companies will be required to cover treatment for addiction just as they cover any other chronic disease, and ‘health homes’, set up under the same Act, will be required to provide integrated and coordinated care for those presenting with chronic conditions including substance use disorders. The NDCS also emphasises harm reduction, including drug overdose and the transmission of HIV/AIDS, hepatitis C and other infectious diseases. The strategy pledges support for the development of new medications for addiction, including naloxone and vaccines against substance use disorders, and promote the use of public health information systems that support the implementation of needle exchange programmes, which protect the public, reduce infections, and encourage involvement in substance use disorder treatment.

Regarding recovery, it is acknowledged that those who successfully make the journey from addiction to recovery too often face barriers to maintaining their sobriety, including a lack of access to housing, employment, or even failing to get a driver's licence or student loan. The NDCS commits to reviewing laws and regulations that impede recovery from addiction and to fostering the expansion of community-based recovery support programmes, including recovery schools, peer-led programmes, mutual aid groups, and recovery community organisations (RCOs). The Office of National Drug Control Policy has established a Recovery Branch to support Americans in recovery and to help lift the stigma associated with addiction. 

Special provision is made in the NDCS for the creations of supportive communities to sustain the recovery of the ‘reentry population’, i.e. offenders leaving prison. Measures include transitional recovery programmes, access to safe, stable and affordable housing, assistance in competing for appropriate work opportunities, and provision of work-related training. The Federal Interagency Reentry Council is helping reentering offenders compete for appropriate work opportunities. 

Acknowledging that the war on drugs has been ‘counter-productive, inefficient and costly’, this new NDCS emphasises prevention over incarceration. It promises to expand national and community-based prevention programmes and early intervention programmes, particularly the Screening, Brief Intervention and Referral to Treatment (SBIRT) programme, to identify and treat problematic drug use before it becomes a chronic substance use disorder. In the law enforcement area the NCDS signals a shift from a ‘tough on crime’ to a ‘smart on crime’ approach. It calls for lower incarceration rates and reduced recidivism while also protecting public safety through measures such as expanding the range and use of specialised courts that divert non-violent drug offenders into treatment instead of prison, and reducing the use of mandatory minimum sentencing. 

While welcoming the adoption of harm reduction policies in the NDCS, the Drug Policy Alliance (a US-based non-profit organisation which advocates for ‘drug policies grounded in science, compassion, health and human rights’) has challenged the assertion in the NDCS that drug use is a health issue: ‘Until the Drug Czar says it is time to stop arresting people for drug use, he is not treating drug use as a health issue no matter what he says. I know of no other health issue in which people are thrown in jail if they don’t get better.’5 

England and Wales – building recovery into communities  

The current national drugs strategy for England and Wales was launched in 2010.6 It has two overarching aims: (1) to reduce illicit and other harmful drug use, including alcohol and prescription and over-the-counter drugs, through reducing demand and restricting supply, and (2) to increase the numbers recovering from their dependence. In her foreword to the strategy, the Home Secretary expressed reservations about the harm reduction approach: ‘…we are determined to break the cycle of dependence on drugs and alcohol and the wasted opportunities that result. Individuals do not take drugs in isolation from what is happening in the rest of their lives. The causes and drivers of drug and alcohol dependence are complex and personal. The solutions need to be holistic and centred around each individual, with the expectation that full recovery is possible and desirable.’ 

Following chapters on reducing demand and restricting supply, the final chapter of the strategy focuses on ‘building recovery into communities’. Drug treatment is dealt with in a single paragraph in the introduction to this chapter, where it is stated that the treatment system now has sufficient capacity to enable people ‘to access treatment for a sufficient period of time to bring about substantial health gains’. The only additional step needed is ‘to make the same progress in treating those with more severe alcohol dependence’. The thrust of the new strategy is to take treatment to a higher level of ambition: ‘We will create a recovery system that focuses not only on getting people into treatment and meeting process-driven targets, but getting them into full recovery and off drugs and alcohol for good. It is only through this permanent change that individuals will cease offending, stop harming themselves and their communities and successfully contribute to society.’ 

The strategy sets out the steps to ‘full recovery’: 

• Recovery is an individual, person-centred journey, based on three over-arching principles – well-being, citizenship and freedom from dependence;
• built on the recovery capital available to individuals, i.e. social, physical, human and cultural;

• in a system that is locally led and locally owned, and in which local accountability is key;

• where all services are outcome-focused, with outcomes determined locally and central government’s role is restricted to researching and publishing the evidence base as to ‘what works’;

• delivered using a ‘whole systems’ approach, including education, training, employment, housing, family support services, wider health services, and where relevant, probation and youth justice services;

• by an inspirational recovery orientated workforce;

• supported by recovery networks comprising ‘recovery champions’; and

• keeping children safe and rebuilding families.

As well as spelling out how to support people in recovering from the symptoms and causes of dependence, the strategy addresses the question of how to enable people to successfully reintegrate into their communities. This involves tackling housing needs and helping people to find sustained employment. The strategy outlines two specific methods of incentivising the take-up of initiatives to help meet accommodation and employment needs: 

• Payment by results (PBR) is an approach to allocating resources to services that rewards activity or outcomes. Payment depends on what the service does or achieves. The government planned six pilots to explore how PBR could work for drugs recovery for adults. This work is ongoing. A recent service providers’ summit on the PBR pilots in the drugs field concluded that while PBR was broadly compatible with a recovery approach, care was needed to contain the costs of transition to a PBR approach and to allay suspicions among service providers as to the ‘real’ intentions behind the scheme.7 
• Benefit conditionality: To ensure the benefit system supports engagement with recovery services, benefit claimants dependent on drugs or alcohol are offered a choice between ‘rigorous enforcement of the normal conditions or sanctions’ where the claimants are not engaged in structured recovery activity, or ‘appropriately tailored conditionality’ for those who are engaged. The strategy goes on to explain: ‘… this means that those not in treatment will neither be specifically targeted with, nor excused from, sanctions by virtue of their dependence, but will be expected to comply with the full requirements of the benefits regime or face the consequences. Where people are taking steps to address their dependence, they will be supported, and the requirements placed upon them will be appropriate to their personal circumstances and will provide them with the necessary time and space to focus on their recovery.’

In a joint submission to a recent review of Jobseeker’s Allowance sanctions in the UK, DrugScope and Homeless Link (both UK-based national membership charities supporting respectively those working in drug and alcohol treatment, drug education and prevention and criminal justice, and those working with homeless people) concluded, with regard to problem drug users: ‘the current sanctions regime is frequently harmful, often perceived as unfair, and may even be counter-productive – moving people further away from the labour market rather than closer to it’. Among their eleven recommendations the authors proposed that conditionality should be appropriate to individuals’ needs and realistically reflect their ability to comply, that a range of sanctions including non-financial sanctions should be considered, and that tailored conditionality should be considered for individuals who are homeless and/or substance dependent. This last provision would allow them to address immediate needs which may act as barriers to employment, e.g. homelessness, insecure accommodation or chaotic substance use.8

Scotland – promoting recovery

The current Scottish drug strategy, launched in 2008,1 is explicitly located within the context of the Scottish government’s ‘overarching purpose, which is to increase sustainable growth’. This overarching purpose is supported by a National Performance Framework, a hierarchy of objectives, outcomes and indicators designed to help realise the ‘overarching purpose’ by 2018. In this framework, ‘Reducing the estimated number of problem drug users in Scotland by 2011’ is one of 45 national indicators developed to measure progress towards 15 national outcomes, which in turn are intended to support achievement of five strategic objectives – to make Scotland wealthier and fairer, smarter, healthier, safer and stronger, and greener. 

The drug strategy adopts a balanced approach to demand and supply reduction. As well as the usual range of prevention measures, the strategy highlights the need to address the underlying factors associated with drug use – poverty, deprivation and inequality – and to promote inclusion. As well as reducing supply and targeting dealers, law enforcement agencies are explicitly required to promote recovery, providing opportunities at all stages of the criminal justice system for people ‘to access treatment to promote recovery from drug addiction’, for example through arrest referral schemes, mandatory drug testing, drug courts, and drug treatment and testing orders. 

The drug strategy states emphatically that harm reduction and recovery are two sides of the one coin, that maintenance and abstinence both have roles depending on the drug, the drug user and the particular circumstances of each case. The strategy defines recovery as ‘a process through which an individual is enabled to move on from their problem drug use, towards a drug-free life as an active and contributing member of society’. It emphasises that recovery is ‘an aspirational, person-centred process’. It states that recovery as an achievable goal was first pioneered in the field of mental health. It argues that the strength of the recovery principle lies in its capacity to bring about a shift in thinking – a change in attitude both by service providers and by the individual with the drug problem. It sets out the three principles on which drug treatment in Scotland should be delivered:

1. recovery should be the explicit aim of all services providing treatment and rehabilitation for people with problem drug use;
2. a range of appropriate treatment and rehabilitation services should be available at a local level , since different people with different circumstances inevitably need different routes to recovery; and
3. treatment services should integrate effectively with a wider range of generic services to fully address the needs of people with problem drug use, not just their addiction. 

The following ten pages of the strategy spell out how this recovery-based approach to treatment and rehabilitation is to be implemented. In 2012 the Scottish Minister for Community Safety and Legal Affairs, with responsibility for the Scottish drugs strategy, reflected on progress.10 Expressing satisfaction overall, she identified the next big priorities as looking at existing treatment standards and guidelines to ensure that recovery is ‘clearly set front-and-centre as the goal of all that we do to help people with drug problems develop individual strengths to recover’, and maintaining a critical view: 

If we are serious about tackling the stigma of having a drug problem, we will need to continue to listen to those people who have direct experience of the problem. We need to challenge our own perceptions and values and to ensure that we are ensuring fairness and equality for often the most vulnerable people in Scotland. Scotland will be a better country not just by tackling drug problems, but by virtue of the cultural growth and development we will require to undertake to do this well.

1 See Pike B (2013) EU action plan on drugs 2013–2016 adopted. Drugnet Ireland 47: 14–15 www.drugsandalcohol.ie/20735/ , and Pike B (2014) UN body passes drug resolutions. Drugnet Ireland 50: 3–4 www.drugsandalcohol.ie/22297/

2 Duke K (2013) From crime to recovery: the reframing of British drug policy? Journal of Drug Issues 43 (1): 39–55.

3 Drugs: education, prevention and policy (2012) Special Section, The ‘Recovery’ Debate, 19 (4): 275–308. See in the same issue, book review and discussion by S MacGregor of Addiction recovery: a movement for social change and personal growth in the UK by David Best, pp. 351–352.

4 Office of National Drug Control Policy (2014) National drug control strategy 2014. Washington: Executive Office of the President of the United States. www.whitehouse.gov/ondcp/national-drug-control-strategy

5 Drug Policy Alliance (9 July 2014) White House releases 2014 National Drug Control Strategy – steps in right direction but largely kinder, more gentle drug war. Accessed 24 July 2014 at www.drugpolicy.org/news/2014/07/white-house-releases-2014-national-drug-control-strategy-steps-right-direction-largely-

6 Home Office (2010) Drug strategy 2010 reducing demand, restricting supply, building recovery: supporting people to live a drug-free life. London: Her Majesty’s Government. www.gov.uk/government/publications/drug-strategy-2010--2

7 DrugScope and RSA (21 May 2013) Drug and alcohol recovery payment by results (PbR) pilots – National Service Providers Summit. London: DrugScope/RSA. Accessed 24 July 2014 at www.drugscope.org.uk/Resources/Drugscope/Documents/PDF/Policy/RSADrugScopePbRMeetingNote.pdf   See also Roberts M (2011) By their fruits… Applying payment by results to drugs recovery. London: UK Drug Policy Commission. www.drugsandalcohol.ie/15719/

8 DrugScope and Homeless Link (January 2014) Joint submission to independent review of Jobseeker’s Allowance sanctions. 

9 The Scottish Government (2008) The road to recovery: a new approach to tackling Scotland’s drug problem. Edinburgh: The Scottish Government. Accessed on 24 July 2014 at www.scotland.gov.uk/Resource/Doc/224480/0060586.pdf

10 Cunningham R (2012) Recovery in Scotland – playing to strengths. Drugs: education, prevention and policy. 19 (4): 291–293.