(113) Rock Bottom Is Not a Motivator: From Opioid Addiction to Human Flourishing

Background &

Introduction: Individuals seeking support for addiction report stigmatizing attitudes and a lack of compassion from healthcare providers, both of which have been associated with adverse health outcomes. Understanding the experiences of people with opioid use disorder and developing effective strategies to treat opioid addiction are critically important as opioid-related deaths continue to rise, with 81,806 deaths from opioid overdose in 2022 alone. “Rock bottom” is a prevailing idea pertaining to addiction and recovery, referring to the lowest point in one’s addiction. Recovery programs such as 12-Step programs often imply that of “hitting bottom” is necessary for recovery. However, this assumption of rock bottom’s necessity has been called “dangerous”, as it can lead to unnecessarily delayed addiction treatment. There exists a gap in the research regarding the extent to which rock bottoms motivate recovery and what characterizes rock bottom. This study aims to: 1) explore individuals’ decisions and motivators to seeking recovery from opioid use, 2) characterize rock bottom, and 3) identify resources critical to lasting recovery.

Methods: We invited individuals self-reporting being in recovery from opioid addiction via flyers posted at Charm City Care Connection (a harm reduction clinic in Baltimore, Maryland) to participate in a research study approved by the Johns Hopkins Medicine Institutional Review Board. We conducted semi-structured, one-on-one interviews with all participants in-person at Charm City Care Connection. These interviews consisted of each participant recounting their experiences with addiction and recovery in chronological order and answering open-ended questions about the concept of rock bottom, its relevance to their decision to seek recovery, and other factors involved in this decision. We then transcribed the interviews, which 2 researchers independently coded using standard thematic analysis.

Results: Study participants (N = 20) ranged in age from 32-66 years, and reported being in opioid addiction recovery for < 1 month–15 years. Participants were majority male [18/20 (90%) male and 2/20 (10%) female]. Thirteen (65%) participants were black and 7 (35%) were Caucasian. Fourteen participants (70%) reported having experienced a rock bottom, but only 2 of these 14 participants [14% (10% of all participants)] reported that rock bottom was what motivated them towards recovery. Qualitative analysis of the descriptions of rock bottom revealed the following themes: 1) loss of relationships/social support, 2) character erosion, 3) loss of resources and 4) no will to live. Seventeen participants (85%) reported that their motivation towards recovery was a “turning point” – a motivating event that was distinct from rock bottom. Qualitative analysis of the descriptions of turning points revealed the following themes: 1) having a child, 2) incarceration and 3) overdosing/almost dying. Qualitative analysis also identified longitudinal themes related to participants’ experiences with addiction and recovery. These included “social connectedness” – relating how addiction is associated with a loss of social connection/support [15/20 (75%)]. Rock bottom was defined as an acute loss of important social connections, such as through conflict or death, and was described as an intensely isolating period [9/20 (45%)]. Rebuilding these social connections was critical to lasting recovery, and resources that fostered this by providing durable social support networks were most impactful – through recovery groups such as Narcotics Anonymous, or volunteering at harm reduction clinics, for instance. “Character erosion and growth” also emerged as a longitudinal theme. Here, addiction was characterized by participants as a time when they acted in ways misaligned with their “true” character [13/20 (65%)]. Rock bottom in particular, emerged as a time of immense character erosion, and often involved enduring degrading and dehumanizing life circumstances such as homelessness [8/20 (40%)]. Character growth – “wanting to be a better person” – emerged as the most common motivator through recovery [9/20 (45%)]. Avenues to foster this character growth and introspection were impactful for many – including faith-based/spiritual practices and therapy. Perspectives on the utility of rock bottom as a concept were mixed. Some participants [12/20 (60%)] described how rock bottom could potentially serve as a “wake-up call”, though it often did not serve this purpose in their own experiences. Only 4/20 (20%) participants reported rock bottom being necessary for one to experience before seeking recovery.

Conclusion &

Discussion: Our study found that rock bottom was not a motivator to recovery for the majority of participants. Turning points, distinct from rock bottoms, were the primary motivators towards recovery. Rock bottoms were primarily characterized by loss of social support and character erosion. These findings can be situated within the broader landscape of human flourishing research, exploring this aspirational state in which all areas in one’s life are going well. Consistent with VanderWeele’s model of human flourishing, rock bottoms were characterized by losses primarily across ‘close social relations’ and ‘character and virtue’ flourishing domains. Turning points were interpreted as: 1) having a child: gain of ‘family’ flourishing pathway’; 2) overdosing/almost dying: gain of ‘meaning and purpose’ flourishing domain, as participants often attributed immense meaning to surviving; and 3) incarceration: an extreme loss of ‘close social relations’ flourishing domain. This study underscores the impact of social connections and character growth in promoting human flourishing, beyond solely achieving recovery from opioid addiction. Addiction treatment should assess social support, and promote resources that facilitate social connectedness – such as recovery groups, or community service – as well as those that promote character growth – such as faith-based/spiritual practices and therapy.

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