Insights from individuals successfully recovered from cannabis use disorder: natural versus treatment-assisted recoveries and abstinent versus moderation outcomes

Rates of cannabis use and cannabis use disorder (CUD) are rising in North America, and CUD is a common presenting issue in addiction treatment [20, 32]. However, treatment-seeking rates are low relative to the numbers of people with the disorder [17] and rates of natural recovery are significant [3, 8]. Increasing our understanding of the pathways and processes of recovery may help in designing effective and attractive interventions to promote recovery.

A growing body of literature supports the efficacy of a variety of interventions for CUD [14]. However, only a few empirical studies of the recovery process from CUDs have been reported. Cunningham et al. [9] interviewed former frequent cannabis users about their reasons for stopping. The most common explanations included emotional maturation and taking on new roles and responsibilities. Boyd et al. [4] interviewed cannabis users who had quit using at least once in the past about change strategies. Participants described changing their environment to be the most helpful strategy and help from professionals as the least helpful strategy. Ellingstad interviewed a more defined group of former daily cannabis users who had quit for at least 1 year without the assistance of treatment [11]. The major reasons described for resolving their problem were increasingly viewing cannabis as negative, experiencing more negative effects, and change being related to a broader lifestyle shift. Strategies cited as helpful in quitting included involvement in activities unrelated to cannabis use, avoidance of triggers to use, and lifestyle changes. Finally, in the only prospective study, Swift et al. [30] followed a group of 200 long-term cannabis users for a 1-year period during which time nearly two-thirds attempted to reduce or stop using. The top reasons for these change attempts were physical or psychological health effects, boredom with using, concerns they were using too much, lack of money, and lifestyle circumstances.

One limitation of the existing research is that samples generally include individuals with relatively brief periods of reduction or cessation of use, and therefore, the results may not be relevant for understanding the longer-term recovery process, which typically occurs after multiple change attempts. The only study that focused on stable recoveries, specifically, is the Ellingstad study [11] of abstinent individuals who had naturally recovered (i.e., did not attend treatment). We extended this research by comparing the experiences of individuals who had recovered with and without the assistance of treatment, either though abstinence from any use or moderation of use [29]. The treatment-assisted and abstinence groups exhibited higher levels of lifetime severity of cannabis problems than the natural and moderation groups. This association between severity of problem and recovery pathways has been found for other addictive behaviours including alcohol, heroin, and gambling [3]. Interestingly, however, despite the different pathways to recovery, the motivators and processes of recovery were mostly similar for the different groups. Regardless of whether they sought treatment or not, or whether they become abstinent or moderated their use, recovered individuals most frequently described their motivations for tackling recovery as a conscious choice that was related to their cannabis use becoming incompatible with their self-image and lifestyle, and related to their use causing negative psychological concerns. They described relying most frequently on cognitive strategies such as thinking about the negative consequences of their use or the benefits of less use as well as a variety of behavioural strategies (decreasing time spent with other users, avoidance of cues to use, involvement in incompatible activities).

These descriptions of pathways and processes of recovery are potentially helpful in the development of treatment approaches and treatment system policies. For example, the association between severity and treatment pathway is consistent with the tenets of stepped care models that offer increasingly intense treatment for increasingly severe problems. However, given that the treatment processes appear similar in the different pathways, it is important to delve deeper into individual experiences for a more complete understanding of the recovery process. In the present report we describe further insights from individuals who have successfully recovered from cannabis use disorder, contrasting treatment-assisted and natural pathways, and abstinent and moderation outcomes. Comparing these groups potentially provides the broad perspective necessary to conceptualize treatment systems. Specifically, we summarize individual perceptions of why they developed the problem, why they were successful in recovering, and the advice they would offer to individuals with similar problems. The perspective of people with lived experience is increasingly recognized as central to planning interventions that are both effective and attractive [24].

Understanding the perceptions of people with lived experience about the development and resolution of a CUD is instructive in conceptualizing and promoting the process of recovery. Individuals with stable recoveries are one important informant group, but it is important that different experiences be represented, including different pathways and both abstinent and moderation outcomes. In this study, recovered individuals described their problems as having developed for multiple reasons, but in particular due to the use of cannabis to cope, because of environmental and social influences, and enjoyment of the positive effects. These perceptions align with research into the etiology of CUD insofar as coping motives for cannabis use have been found to be associated with the development of cannabis use disorders [6, 13]; environmental and social influences such as low parental monitoring, high peer group deviance, and cannabis availability have been found to predict cannabis initiation [15]; and perceived risk of harm has been found to be inversely associated with frequency of cannabis use [10, 12, 19]. Interestingly, we previously reported the responses of this sample to the Marijuana Motives Measure (MMM, [27]), which indicated that participants most often used cannabis for enhancement motives during their lifetime, followed by social, coping, expansion, and conformity motives [29]. This suggests that while participants believed that coping motives were the strongest contributor to the development of their cannabis problem, they more often used cannabis for other purposes (i.e., enhancement and social reasons), which highlights the pervasiveness of cannabis use during their lifetime.

Treatment-assisted participants were more likely to endorse genetics/predisposition compared to naturally recovered participants, whereas the latter group was more likely to endorse the reason of enjoyment/boredom/positive perceptions of cannabis. The fact that treatment-assisted participants more readily identified genetics/predisposition as an etiological category might reflect that they were taught this addiction model in treatment, but it is also possible that their CUDs were relatively and genuinely more influenced by genetic factors in light of their more frequent reports of family addiction problems [28]. There is indeed solid evidence that cannabis use and cannabis use disorders have heritable components [1, 33].

Participants were also asked to explain their understanding of why they were able to overcome their cannabis problem. The content analysis revealed that the top cited reasons were focusing on reasons for change, goal commitment to change, and conquering denial/self-deception. While there were no differences with respect to the recovery use status, treatment-assisted participants were more likely to perceive that they overcame their cannabis problem due to reasons of treatment/self-help and conquered underlying issues, whereas naturally recovered participants were more likely to cite the categories of focused on reasons for change, will power, and lost enjoyment/lifestyle change. These results suggest that participants attributed their recovery success to cognitive and motivational factors, which is consistent with our previous analyses demonstrating that cognitive strategies were the most helpful actions taken and maintenance factors involved in recovery [29]. These results support CBT-MET approaches to the treatment of CUDs [7, 14], and might suggest that an increased cognitive and motivational focus might be one way to improve psychosocial treatments [29].

Finally, participants were asked to provide advice and recommendations to help another hypothetical person with a cannabis problem. The top cited advice categories were to seek help/social support, reflect on reasons for change, and engage in hobbies/distracting activities. Interestingly, no differences emerged between the abstinence- and moderation-oriented participants. Whereas treatment-assisted participants were more likely to endorse the category of seek help/social support naturally recovered participants were more likely to endorse the categories of reflect on reasons for change, engage in hobbies/distracting activities, and stimulus control/avoidance/change social environment. These results differ from the advice provided by a sample of recovered gamblers participating in a treatment outcome study [31], whereby it was mostly indicated that there was nothing that could be done to aid in the decision to cease or reduce gambling, with a smaller proportion suggesting awareness-raising strategies (e.g., pointing out the negative consequences of problem gambling and arousing cognitive dissonance).

The majority of participants reported that they would recommend treatment and self-help materials to a hypothetical person with a cannabis problem. However, treatment-assisted participants were more likely to recommend self-help materials compared to naturally recovered participants, whereas the latter group was more likely to recommend natural recovery (i.e., try to resolve the cannabis problem without professional assistance), albeit only among those who were abstinent. Interestingly, moderation status participants who were treatment-assisted were more likely to recommend natural recovery than other participants, which might reflect a perceived lack of fit between their goals and the goals of the treatment program they attended. It is unclear to what extent these recommendations might be influenced in the future if moderation-focused treatments for cannabis use disorders become widely available. Additionally, the majority of participants reported that they would recommend abstinence to a hypothetical person with a cannabis problem, and not surprisingly, moderation status participants were more likely to recommend moderation compared to abstinent status participants.

These findings are limited in that the results are based on self-reports of volunteer participants. Use of open-ended questions with probing by interviews, and qualitative analysis is helpful given how little is known about the recovery process. However, it is impossible to know how representative these individuals are of the general recovery population, and how able individuals are at identifying recovery influences. In addition, although the cannabis use histories were corroborated by family and friend interviews [18], the findings are based upon participant retrospective attributions of events occurring a number of years ago. Assessing similar issues earlier in recovery may elicit somewhat different information.

It is timely and important that we attend to how to best promote recovery from CUD. With the recent trend towards cannabis decriminalization and legalization, it remains unclear to what extent these legal changes might impact the incidence of cannabis use disorders. While the majority of individuals who use cannabis will not develop a problem, a substantial minority of individuals who will develop a problem deserve greater access to non-stigmatizing and improved treatment options. With a view towards informing evidence-based clinical practice, the present study explored the recovery process from cannabis use disorders in the context of multiple recovery pathways, the findings of which hold a number of implications for policy and practice. These insights from people with lived experience further support previous research that treatment-assisted and natural recoveries are for the most part similar with respect to the recovery process, which is consistent with Klingemann’s contention that there exists a shrinking gap between the natural recovery and treatment outcome literature [23]. The frequent attribution of the use of cannabis for coping with negative emotions reinforces the inclusion of emotional regulation training in treatment protocols and prevention efforts. The results for cannabis are also consistent with those for other substances, which supports the growing attention to transdiagnostic etiological and treatment models focusing on common elements [16, 22, 26].

However, participants, whether or not they had had treatment involvement, recommended the use of treatment and self-help materials to sharpen their focus on the reasons to change and to enhance their commitment to change. At the same time, they saw value in the efforts of individuals to recovery without help. As we have previously argued, these findings support the development of stepped care models that offer varying levels of support according to client wishes and needs [29]. Such models can include the provision of quality self-help materials by primary care providers and public health initiatives that promote self-directed efforts that are similar to treatment processes. The acknowledgement of moderation recovery outcomes within these models and self-help materials provides a more accurate and nuanced depiction of the recovery process, which might serve to de-stigmatize the non-isomorphic link between cannabis use and cannabis use disorder.