Robert David Ashford, Austin Brown, Brenda Curtis, (2019) "Expanding language choices
to reduce stigma: A Delphi study of positive and negative terms in substance use and
Public perception has been found to be influenced by the words used to describe those
with behavioral health disorders, such that using terms like “substance abuser” can
lead to higher levels of stigma. The purpose of this paper is to identify additional
stigmatizing and empowering terms that are commonly used by different stakeholders.
Using digital Delphi groups, the paper identifies positive and negative terms related
to substance use disorder (SUD) from three distinct stakeholder groups: individuals
in recovery, impacted family members and loved ones, and professionals in the treatment
Participants identified 60 different terms that are considered stigmatizing or positive.
Previously identified stigmatizing terms (abuser, addict) were present for all stakeholder
groups, as was the positive term person with a SUD. Additional stigmatizing terms
for all groups included junkie and alcoholic. Additional positive terms for all groups
included long-term recovery.
The results suggest that the continued use of terms like addict, alcoholic, abuser
and junkie can induce stigma in multiple stakeholders. The use of more positive terms
such as person with a SUD or person in recovery is suggested to reduce stigma.
Robert D. Ashford, Austin Brown, Tiffany Brown, Jason Callis, H. Harrington Cleveland,
Emily Eisenhart, Hillary Groover, Nicholas Hayes, Teresa Johnston, Thomas Kimball,
Brigitte Manteuffel, Jessica McDaniel, Lindsay Montgomery, Shane Phillips, Michael
Polacek, Matt Statman & Jason Whitney (2019) Defining and operationalizing the phenomena
of recovery: a working definition from the recovery science research collaborative,
Addiction Research & Theory
A number of definitions exist for the concept of “recovery” in both the substance
use disorder (SUD) and mental health (MH) fields. Previous attempts to define recovery
have not reached consensus among experts within the field. Thus, the definition has
remained diffuse at the expense of attempts to measure and evaluate treatment and
recovery outcomes. The notion of recovery as an organizing principle between SUD and
MH, collectively identified as behavioral health (BH), can be better served by a collaborative
endeavor to define the word and concept of “recovery”. The Recovery Science Research
Collaborative (RSRC), an interdisciplinary bi-annual collaboration among recovery
researchers and professionals from across the country, sought to address the definition
of recovery at the inaugural meeting in December 2017 at Kennesaw State University.
The RSRC undertook this task with the primary goal of defining “recovery” for use
in research – aiming to create a consensus definition that allows recovery to be clearly
operationalized and effectively investigated.
Brown, A., & Ashford, R. (2019). Recovery-informed Theory: Situating the Subjective
in the Science of Substance Use Disorder Recovery. Journal of Recovery Science, 1(3),
As recovery from substance use disorder becomes more than a mere quantifiable outcome,
there exists a need to discuss and propose the underlying theoretical constructs that
ultimately describe and identify the science of recovery. In this abstract undertaking,
we propose an initial formulation of a grand theory of recovery science, built upon
the seminal theories of recovery capital, recovery-oriented systems of care, and socioecological
theory. This grand theory - labeled recovery-informed theory (RIT) - states that successful
long-term recovery is self-evident and is a fundamentally emancipatory set of processes.
This paper will discuss, analyze, and explore this theory as it is situated within
the larger substance use, misuse, and disorder contexts. The uses, implications, and
benefits of RIT as an organizing point of inquiry for recovery science are also discussed.
By promoting the role of subjective recovery experience in the formulation of the
study of recovery, it may be possible to summon new ideas, metrics, and strategies
that can directly address substance use disorders in society. Adopting a recovery-informed
understanding as follows from this grand theory may allow individual recovery and
wellness trajectories to be explored, adapted, and modified to exemplify person-centered
and individualized recovery strategies.
Ashford, R. D., Meeks, M., Curtis, B., & Brown, A. M. (2018). Utilization of peer-based
substance use disorder and recovery interventions in rural emergency departments:
Patient characteristics and exploratory analysis. Journal of Rural Mental Health.
The current opioid crisis has necessitated timely, grassroots social entrepreneurship
from stakeholders involved in the substance-use disorder and recovery fields. One
such innovation involves the use of peer-recovery-support services in acute settings
in which points of contact are made with high-risk substance-using populations. These
programs have emerged organically in emergency departments (EDs) across the country.
The Georgia Council on Substance Abuse, Northeast Georgia Community Connections Program
is a peer-recovery-support service (PRSS) that uses certified addiction-recovery empowerment
specialists (CARES) in rural EDs in Georgia, a Medicaid nonexpansion state. In this
study, we reviewed initial data from the Community Connections Program captured at
rural EDs. Patients (N = 205) met the American Psychiatric Association’s (2013) Diagnostic
and Statistical Manual of Mental Disorders (5th ed.; DSM–5) criteria for substance-use
disorder. This study demonstrated that peer interventions can be beneficial for all
types of drug use, not just for individuals who experience accidental opioid drug
poisoning (i.e., overdose). In addition, results suggest that both clinical and community-based
supports can be used for referrals to appropriate levels of care. These findings also
highlight the utility of innovative and adaptive peer-recovery-support programs in
rural EDs across the United States. (PsycINFO Database Record (c) 2018 APA, all rights
Journal of Rural Mental Health
Editor James L. Werth, PhD
Robert D. Ashford, Brenda Curtis, Austin M. Brown: Peer-delivered harm reduction and
recovery support services: initial evaluation from a hybrid recovery community drop-in
center and syringe exchange program. Harm Reduction Journal 12/2018; 15(1)., DOI:10.1186/s12954-018-0258-2
Recovery from substance use disorder (SUD) is often considered at odds with harm reduction
strategies. More recently, harm reduction has been categorized as both a pathway to
recovery and a series of services to reduce the harmful consequences of substance
use. Peer recovery support services (PRSS) are effective in improving SUD outcomes,
as well as improving the engagement and effectiveness of harm reduction programs.
This study provides an initial evaluation of a hybrid recovery community organization
providing PRSS as well as peer-based harm reduction services via a syringe exchange
program. Administrative data collected during normal operations of the Missouri Network
for Opiate Reform and Recovery were analyzed using Pearson chi-square tests and Monte
Carlo chi-square tests.
Intravenous substance-using participants (N = 417) had an average of 2.14 engagements
(SD = 2.59) with the program. Over the evaluation period, a range of 5345–8995 sterile
syringes were provided, with a range of 600–1530 used syringes collected. Participant
housing status, criminal justice status, and previous health diagnosis were all significantly
related to whether they had multiple engagements.
Results suggest that recovery community organizations are well situated and staffed
to also provide harm reduction services, such as syringe exchange programs. Given
the relationship between engagement and participant housing, criminal justice status,
and previous health diagnosis, recommendations for service delivery include additional
education and outreach for homeless, justice-involved, LatinX, and LGBTQ+ identifying
Brown, A., Ashford, R., Heller, A. T., Whitney, J., & Kimball, T. (2018). Collegiate
Recovery Students and Programs: Literature Review from 1988-2017. Journal of Recovery
Science, 1(1), 1-11.
To present a review of the existing research on college students living in recovery,
including the research on students in recovery participating in collegiate recovery
Studies were included if they: a) were peer-reviewed or archived dissertations, b)
were published between 1988 and 2017, c) directly involved students in recovery on
campus, either with or without involvement in a collegiate recovery program.
From 1988 to 2017, 25 studies met the inclusion criteria. These included 7 studies
on students living in recovery within the general framework of higher education and
18 studies involving students in collegiate recovery programs. Qualitative reports
and quantitative descriptive studies were both included.
Findings identify the gaps in currently available research, and support rationale
for increasing longitudinal and quantitative studies of collegiate recovery programs
and the students they serve.
Ashford, R. D., Brown, A. M., & Curtis, B. (2018) Substance use, recovery, and linguistics:
the impact of word choice on explicit and implicit bias. Drug and alcohol dependence.
The general public, treatment professionals, and healthcare professionals have been
found to exhibit an explicit negative bias towards substance use and individuals with
a substance use disorder (SUD). Terms such as “substance abuser” and “opioid addict”
have shown to elicit greater negative explicit bias. However, other common terms have
yet to be empirically studied.
1,288 participants were recruited from ResearchMatch. Participants were assigned into
one of seven groups with different hypothesized stigmatizing and non-stigmatizing
terms. Participants completed a Go/No Association Task (GNAT) and vignette-based social
distance scale. Repeated-measures ANOVAs were used to analyze the GNAT results, and
one-way ANOVAs were used to analyze vignette results.
The terms “substance abuser”, “addict”, “alcoholic”, and “opioid addict”, were strongly
associated with the negative and significantly different from the positive counterterms.
“Relapse” and “Recurrence of Use” were strongly associated with the negative; however,
the strength of the “recurrence of use” positive association was higher and significantly
different from the “relapse” positive association. “Pharmacotherapy” was strongly
associated with the positive and significantly different than “medication-assisted
treatment”. Both “medication-assisted recovery” and “long-term recovery” were strongly
associated with the positive, and significantly different from the negative association.
Results support calls to cease use of the terms “addict”, “alcoholic”, “opioid addict”,
and “substance abuser”. Additionally, it is suggested that “recurrence of use” and
“pharmacotherapy” be used for their overall positive benefits. Both “medication-assisted
recovery” and “long-term recovery” are positive terms and can be used when applicable
without promoting stigma.
Ashford, Brown, & Curtis (2018)Collegiate Recovery Programs: The Integrated Behavioral
Campus-based recovery programs have been shown to support students in recovery from
substance use disorders, as well as mental health disorders. However, this support
has been historically delivered in isolation. This study highlights preliminary outcomes
from a novel collegiate recovery program, one that uses a model of recovery with integrated
support services for students in recovery from substance use or mental health disorders,
or co-occurring behavioral health disorders. Similar to traditional collegiate recovery
programs, beneficial services of the integrated program were most often related to
peer-based services. Outcomes were also similar, with students in recovery having
higher than average Grade Point Average (M = 3.68, SD = .34) and lengths of recovery
time (M = 3.69, SD = 2.87 [years]).
Ashford, R. D., Brown, A. M., & Curtis, B. (2017). Collegiate Recovery Programs: The
Integrated Behavioral Health Model. Alcoholism Treatment Quarterly, 1-12.
Ashford & Brown (2017) Bridging the gaps: Intergenerational findings from the substance
use disorder and recovery field
The substance use disorder and recovery field has undergone rapid transformation over
the last 40 years. It currently has a workforce that includes three generations—Baby
Boomers, Generation X, and Millennials. The current study sought to identify generational
differences among those involved in the substance-use disorder and recovery profession
using an embedded design and grounded theory approach. Findings suggest that generational
differences do exist across the three generations in regard to ideologies, value of
formal and informal knowledge, training, and education. Results from the current study
provide a further understanding of how we may bridge perceived contentious ideologies
and knowledge gaps between generations to better develop current and future professionals
within the field.
Ashford, R. D., & Brown, A. (2017). Bridging the gaps: Intergenerational findings
from the substance use disorder and recovery field. Journal of Intergenerational Relationships,
Ashford, Brown, Eisenhart, Thompson-Heller, & Curtis (2018) What we know about students
in recovery: meta-synthesis of collegiate recovery programs, 2000-2017
As a relatively new field of practice, collegiate recovery programs (CRP), have used
a practice-informed approach as a means of establishing best practices and pedagogy.
While research on collegiate recovery programs and populations of students in recovery
is growing, much of the qualitative studies have yet to be synthesized into a useful
organizing matrix. This study utilizes meta-synthesis design to explore the leading
qualitative research on student experiences in collegiate recovery. From this synthesis,
researchers identified six metaphors from ten included studies from 2000–2017. The
six metaphors of social connectivity, recovery supports, drop-in recovery centers,
internalized feelings, coping mechanisms, and conflict of recovery/student status,
support much of the preexisting practices and provide a critical framework for future
program design, service delivery, and research.
Addiction, collegiate recovery, meta-synthesis, behavioral health, higher education,
Ashford, Brown, Eisenhart, Thompson-Heller, and Curtis. (2018). What we know about
students in recovery: meta-synthesis of collegiate recovery programs, 2000-2017. Addiction
Research and Theory. Vol. 26 (1), pp. 1-9.
Brown, & Bohler (2018) Achieving a 15% Relapse Rate: A Review of Collegiate Recovery
and Physician Health Programs
Evidence from physician health programs (PHPs) suggest that long-term continuums of
step-down care are effective at achieving at or near a 15% relapse rate. Parallel
to the PHP model, evidence from collegiate recovery programs (CRPs) cite a relapse
rate from year to year of 8%. The CRP and PHP models involve long-term, comprehensive
components of care and ancillary services oriented toward highly transformative abstinence-based
recovery. This article identifies factors between the two models that facilitate recovery
and discusses the implications for future research.
Austin M. Brown, Robert D. Ashford, Naomi Figley, Kayce Courson, Brenda Curtis & Thomas
KimballAlcoholism Treatment Quarterly Vol. 0, Iss. 0, 2018Alumni Characteristics of
Collegiate Recovery Programs: A National Survey
Collegiate recovery programs (CRPs) support students in or seeking recovery from substance
use disorders or mental health disorders while enrolled in college. Collegiate recovery
has been established as a field of study since the 1970s. To date, a number of qualitative
studies have been completed on the programs and students served, along with a single
national descriptive survey. This pilot study is the first undertaken exploring the
status (recovery, professional, and quality of life) of student alumni that engaged
in undergraduate collegiate recovery programs (CRP). Results contain alumni recovery
status, primary recovery supports utilized, relapse rates since graduation, and recovery
capital/quality of life scores. Similar to previously published works, CRP alumni
remain actively in recovery, with relapse rates only slightly higher than the national
average of students currently engaged in CRPs (10.2% vs. 6.8%). Findings are preliminary
evidence that collegiate recovery programs adequately prepare engaged students for
future recovery and professional life.
Ashford, R. D. Wheeler, B. & Brown, A.M. (2018) Collegiate Recovery Programs and Disordered
Eating: exploring sub-clinical behaviors among students in recovery. Alcoholism Treatment
Quarterly. Vol 36.
The co-occurring prevalence of disordered eating (DE) with substance use disorders
is estimated to be high among college students. Collegiate recovery programs (CRPs),
primarily used for the support of students with mental health disorders and substance
use disorders, are well positioned to potentially provide support for students with
DE behaviors. The current study identifies the prevalence of subclinical DE behaviors
among college students currently participating in a collegiate recovery program at
a U.S. institution. 61 recovering students (Age: M = 29 years, SD = 8.35, 59% male)
completed a digital survey inquiring about subclinical DE behaviors using 9 Likert-type
scaled questions. Composite subclinical DE scores were significantly different between
student genders, as well as full-time and part-time students. Female and full-time
students were more likely to experience subclinical DE behaviors than male and part-time
students. As subclinical DE behaviors are present among students engaged in CRPs at
a high rate, and though behaviors are most pronounced among female students, they
are also are present in males. A majority of students engaged in the CRP feel that
the CRP can support mental health and DE recovery in addition to serving those in
recovery from substance use disorders.
Robert D. Ashford, Austin M. Brown & Brenda Curtis (2018) The Language of Substance
Use and Recovery: Novel Use of the Go/No–Go Association Task to Measure Implicit Bias,
Previous research has found initial evidence that word choice impacts the perception
and treatment of those with behavioral health disorders through explicit bias (i.e.,
stigma). A more robust picture of behavioral health disorder stigma should incorporate
both explicit and implicit bias, rather than relying on only one form.
The current study uses the Go/No–Go Association Task to calculate a d′ (sensitivity)
indexed score of automatic attitudes (i.e., implicit associations) to two terms, “addict”
and “person with substance use disorder.”
Participants have significantly more negative automatic attitudes (i.e., implicit
bias) toward the term “addict” in isolation as well as when compared to “person with
a substance use disorder.”
Consistent with previous research on explicit bias, implicit bias does exist for terms
commonly used in the behavioral health field. “Addict” should not be used in professional
or lay settings. Additionally, these results constitute the second pilot study employed
the Go/No–Go Association Task in this manner, suggesting it is a viable option for
continued linguistic stigma related research.
Robert D. Ashford. Austin M. Brown & Brenda Curtis (2018) Systemic Barriers in substance
use disorder treatment: A prospective qualitative study of professionals in the field.
Drug and Alcohol Dependence.
The US is in the midst of one of the largest public health crises in recent history
with over 63,000 drug poisoning deaths in 2016 and a projected annual economic cost
of over $420 billion. With the rise of deaths and economic burden related to substance
use, it is paramount that systemic barriers within the treatment industry be identified
Data were collected from US substance use treatment professionals (N = 182) in the
fall of 2016. Thematic analysis with axial coding was used on anonymized responses
to an online open-ended survey. Additional ad hoc testing for variance (education,
generation, regional location, and employment) was completed using Monte Carlo chi-square
7 major themes emerged: 1) additional training, education, and use of evidence-based
practices, 2) expansion of treatment services, 3) increased resources, 4) stigma reduction,
5) increased collaboration and leadership, 6) reductions in regulations, requirements,
and incentives, and 7) expansion of recovery support services. Participant response
yielded a significant relationship between employment type (p = 0.002) and regional
location (p = 0.046).
Systemic barriers in the treatment field are prevalent from the perspective of professionals
engaged in the field. While previously identified barriers are still present, newly
reported barriers include: 1) lack of treatment services (e.g., capacity), 2) lack
of technological resources (e.g., technological support tools), 3) lack of recovery
support services (e.g., recovery housing), 4) lack of collaboration and leadership
(e.g., communication and partnership), and 5) increasing unethical practices in the
field (e.g., incentive-based patient brokering).
Ashford, R. D., Brown, A. M., & Curtis, B. (2018). “Abusing Addiction”: Our Language
Still Isn’t Good Enough. Alcoholism Treatment Quarterly, 1-16.
Previous research has found initial evidence that word choice affects the perception
and treatment of those with behavioral health disorders. These previous studies have
relied on vignette-based methodologies, however, and a more quantifiable index of
the stigma words can produce is needed. The current study uses the Go/No-Go Association
Task to calculate a d-prime (sensitivity) indexed score of automatic attitudes to
two terms, substance abuser and a person with substance use disorder. Participants
have significantly more negative automatic attitudes toward the term substance abuser,
as compared to a person with a substance use disorder. Consistent with previous research,
implicit bias does exist for terms commonly used in the behavioral health field. Substance
abuser and its derivatives should not be used in professional or lay settings.