A 2023 study by Reddon and Ivers evaluated the association between levels of hope and rates of relapse following discharge from opioid agonist treatment (OAT) and/or detoxification programmes among those with opioid use disorder (OUD).1 This study adds to the body of evidence on hope levels and recovery, indicating that strategies that cultivate hope and empowerment may be an effective strategy to increase personal recovery capital and decrease relapse rates.

Background

OUD is increasingly recognised as an important public health concern. Global figures estimate that 40.5 million people are dependent on opioids. In the Irish setting, approximately 6.18 per 1,000 population aged 15–64 years are using opioids.2,3 OUD is associated with significant harms, including opioid-related overdose mortality.

Successful recovery from OUD is possible with appropriate treatment. OAT and detoxification programmes have been designed to support those with OUD. However, studies have highlighted the persisting propensity to relapse, with reported relapse rates as high as 30% to 70%.4,5 Methadone and buprenorphine are efficacious forms of OAT, which are widely employed in various healthcare settings.

Opioid cessation and recovery capital

‘Recovery capital’ has been identified as an important indicator of patient-important outcomes, such as relapse during recovery.6 Recovery capital has been defined as the total resources available to a person to support the initiation and maintenance of substance use cessation. This is inclusive of social and community resources, physical resources, and personal resources.

Definition of hope and in practice

Personal hope is an important aspect of personal recovery capital. Hope has been shown to be pivotal in the recovery process and can be a determinant of overall recovery outcomes.6 The term ‘hope’ has been conceptualised as having a positive outlook for the future. It consists of two pathways: pathways thinking and agency thinking. Pathways thinking refers to an individual’s ability to develop routes to goal achievement, whereas agency thinking refers to the level of intention, confidence, and ability to reach the desired outcome. Both these pathways have been linked with improved impulse control among those recovering from OUD.7 However, the evaluation of interventions to improve hope in this cohort are limited.

Methods

Participants were recruited through publicly funded residential drug dependency units in Ireland. All participants had previously received a 4–6 week detoxification treatment programme, which included a 10-day methadone detoxification. Following detoxification, patients followed three distinct recovery pathways, including inpatient, outpatient, and self-selected programmes. Those aged 18–65 years were included in the study. A total of 142 participants met the inclusion criteria and consented to take part in the study.

The study was designed prospectively, with data collection points organised at initial assessment, 3-month, 6-month, and 9-month marks. Participants completed a self-reported questionnaire at each time point that included sociodemographic factors, medical background, and previous engagement with addiction services. A validated measure, the adult Trait Hope Scale8 provided a means to assess ‘hope’. This scale includes 12 items: four items measuring pathways thinking, four items measuring agency thinking, and four distractor items. The primary outcome objective was the first self-reported opioid lapse, which was either a single-event substance use or relapse return to daily use.

Results

Among the 142 study participants, the mean age was 34.5 years, 30.3% were female, and a high proportion were experiencing homelessness (85.9%). Inpatient rehabilitation, outpatient rehabilitation, and no formal care were received in 59.2%, 19.0%, and 21.8% of study participants, respectively. Average years of reported drug use was 14.3 years and over 50% of individuals engaged previously with addiction services.

The study demonstrated that high levels of hope had a protective effect on the rate of relapse during the 9-month window of the study period. For every five-unit increase in the overall hope score, there was a 23% decrease in the likelihood of relapse. The agency–hope domain was strongly associated with a slower relapse rate, while the association between the pathways aspect and lower relapse rate was not significant. This is in line with current literature, which suggests that hope and the agency–hope domain are strongly associated with treatment adherence, initiation, and completion.9,10

Discussion

The task of improving hope in those with OUD remains challenging due to the wider determinants of drug use, such as socioeconomic status stigmatisation. Peer-based recovery and addiction communities are examples of interventions that could increase levels of hope.11 The high failure rate of standalone interventions indicates that a multifaceted approach is needed for long-term recovery adherence. This also demonstrates the need for the long-term implementation of a more integrated approach to recovery, particularly peer-led addiction services and socialisation.

The limitations of this study include the self-reported nature of the assessment, the lack of information on participants’ frequency of opioid use, the non-random sample, and the high occurrence of homelessness among study participants. Nonetheless, the study builds on the literature on hope levels and the addiction recovery process.

Conclusion

Increased measures of hope are associated with slower rates of relapse among those receiving treatment for OUD. Further implementation and examination of interventions that increase hope levels and personal agency will play a key role in addiction recovery.

1    Reddon H and Ivers JH (2023) Increased levels of hope are associated with slower rates of relapse following detoxification among people living with opioid dependence. Addict Res Theory, 31(2): 148–154. Available from: https://www.drugsandalcohol.ie/37292/

2    Degenhardt L, Grebely J, Stone J, et al. (2019) Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet, 394(10208): 1560–1579.

3    Millar S (2018) New estimates of problem opiate use in Ireland. Drugnet Ireland, 64 (Winter): 1–3. Available from: https://www.drugsandalcohol.ie/28566/

4    Ivers JH, Zgaga L, Sweeney B, et al. (2018) A naturalistic longitudinal analysis of post-detoxification outcomes in opioid-dependent patients. Drug Alcohol Rev, 37 (Suppl 1): S339–S347. Available from: https://www.drugsandalcohol.ie/27911/

5    Fishman M, Wenzel K, Vo H, Wildberger J and Burgower R (2021) A pilot randomized controlled trial of assertive treatment including family involvement and home delivery of medication for young adults with opioid use disorder. Addiction, 116(3): 548–557.

6    Cloud W and Granfield R (2008) Conceptualizing recovery capital: expansion of a theoretical construct. Subst Use Misuse, 43(12–13): 1971–1986.

7    Best DW and Lubman DI (2012) The recovery paradigm – a model of hope and change for alcohol and drug addiction. Aust Fam Physician, 41(8): 593–597.

8    Snyder CR (2002) Hope theory: rainbows in the mind. Psychol Inq, 13(4): 249–275.

9    Snyder CR, Sympson SC, Ybasco FC, Borders TF, Babyak MA and Higgins RL (1996) Development and validation of the State Hope Scale. J Pers Soc Psychol, 70(2): 321–335.

10  Bandura A (2001) Social cognitive theory: an agentic perspective. Annu Rev Psychol, 52: 1–26.

11  Bassuk EL, Hanson J, Greene RN, Richard M and Laudet A (2016) Peer-delivered recovery support services for addictions in the United States: a systematic review. J Subst Abuse Treat, 63: 1–9.