An exploration of desired abstinent and non-abstinent recovery outcomes among people who use methamphetamine

Abstract

Background

In the United States, complete abstinence persists as the standard for demonstrating recovery success from substance use disorders (SUDs), apart from alcohol use disorder (AUD). Although the FDA has recently indicated openness for non-abstinence outcomes as treatment targets, the traditional benchmark of complete abstinence for new medications to treat SUDs remains a hurdle and overshadows other non-abstinent outcomes desired by people with SUDs (e.g., improved sleep, employment, family reunification). This study sought to expand the definition of recovery to include non-abstinent pathways by exploring non-abstinence-based outcomes desired by people who use methamphetamine (PWUM).

Methods

Participants (n = 100) were recruited from existing National Institute on Drug Abuse (NIDA) projects including a treatment-seeking sample of people recently released from prison (all of whom endorsed recent methamphetamine use) and a sample of people using syringe service programs. In a convergent survey design, participants responded to closed-ended questions regarding recovery outcomes, followed by open-ended items to gain a better understanding of PWUM and their conception of recovery. The importance of non-abstinent outcomes was measured in five categories (substance use, physical health, cognitive functioning, mental health, and financial/social/relationships).

Results

Participants were primarily White (88%), male (67%), and an average age of 40. Approximately two-thirds of participants agreed that people need to stop all mood- or mind-altering substances to be in recovery (64%). Nevertheless, participants indicated a variety of desired non-abstinent recovery outcomes, both substance-related (e.g. reductions in methamphetamine use) and non-substance-related (e.g. improved economic stability). Specific non-abstinent outcomes endorsed as “absolutely essential” by PWUM included: preventing legal trouble (92%), employment stability (82%), improved quality of life (80%), housing stability (78%), improved coping skills (78%), improved relationships (75%), economic/income stability (74%), ability to think clearly (73%), less impulsivity (73%), less depression (71%), less stress (70%), improved hopefulness (70%), and improved sleep (70%). Open-ended responses emphasized employment stability, economic/income stability, improved coping skills, improved relationships, as well as improved energy, appetite, and sleep.

Conclusion

Our findings indicate the importance of non-abstinent recovery outcomes among PWUM, suggesting high acceptability of non-abstinent recovery targets by people with lived experience. Further, the essential importance of non-abstinent outcomes, especially in the financial/social/relationship and mental health domains, were highlighted, providing novel targets for delivering SUD treatment/recovery.

Background

Harms related to methamphetamine use are a growing public health problem. In 2021, 1.6 million Americans met the criteria for stimulant use disorder (methamphetamine type), hereafter called methamphetamine use disorder (MUD; 1). Recent research indicates methamphetamine overdose mortality and patterns of risky use have increased in recent years, particularly for those with socioeconomic risk factors and comorbidities [1]. Accordingly, methamphetamine-related harms are also a health equity issue. MUD prevalence rates more than doubled in White, Hispanic and Asian/Native Hawaiian/Other Pacific Islander populations from 2015 to 2019, with prevalence in Black people increasing approximately six-fold during that time [1]. Although White people have experienced increased overdose deaths involving methamphetamine, minoritized populations have been especially hard hit [1, 2]. Further, recent evidence points to “twin” opioid and methamphetamine epidemics, particularly in rural communities, where methamphetamine surpassed opioids as the most injected substance [3].

Each year, approximately 90% of individuals with substance use disorders (SUDs) in the U.S. do not engage in treatment [4]. Further, people who use methamphetamine (PWUM) engage in treatment at particularly low rates [5]. This is especially true in rural areas, where unlike opioids, there are fewer evidence-based treatments for MUD, nor trained behavioral health professionals with which to provide such care [3]. However, this treatment gap is improperly framed as merely a problem of treatment accessibility. According to estimates from the National Survey on Drug Use and Health (NSDUH), of the 39.7 million adults in the US with SUDs who did not receive treatment in 2022, 94.7% reported that they did not perceive a need for treatment or did not desire the exclusively abstinence-based treatment options that were provided [4]. In order to reach individuals who are potentially interested in treatment, it is important to focus on treatment acceptability, which is a critically overlooked aspect of the treatment gap.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), recovery is defined as a “process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential” (p. 3) [35]. It is noteworthy that SAMHSA’s conception of recovery identifies neither substance use nor abstinence as features of recovery and instead underscores the importance of supporting individual autonomy. However, although SAMHSA’s definition of recovery is not abstinence-based, in treatment and recovery spaces in the U.S, it is frequently interpreted this way. Often, complete abstinence remains the standard for demonstrating treatment efficacy for SUDs, with the exception of alcohol use disorder (AUD), where non-abstinent outcomes for success are increasingly recognized (e.g., percentage of days with no heavy drinking; 6). Further, many SUD treatment providers incorporate 12-step recovery support into program requirements, and the 12-step philosophy predominates the addiction recovery support community in the U.S [7, 8]. Within 12-step philosophy, recovery is conceptualized as abstinence from all mind- or mood-altering substances, including FDA approved medications for the treatment of opioid use disorder [9]. This abstinence-only approach is too steep of a treatment target for many PWUM [4]. Indeed, research shows that when given a choice of abstinence or moderation as a goal for treatment, even those with severe SUDs are much more likely to reach their selected goal if given the choice of a treatment goal [10, 11].

In recent years, there has been an increasing openness among leading experts in the addiction treatment and science field to consider non-abstinent outcomes as clinically meaningful treatment targets [12, 13]. However, many treatment professionals continue to endorse abstinence as the goal of SUD treatment, particularly for people with severe SUDs and for legal substances other than alcohol, cannabis, and tobacco [14]. In a review of studies that assessed service providers’ acceptance of moderation (over abstinence) across substances and client characteristics, most rated moderate drug use as acceptable when it was the client’s intermediate, rather than final, outcome goal. Among drug classes, moderate use of cannabis was more often rated acceptable as an outcome goal, especially as an intermediate goal by clients with lower severity, than was moderate use of almost every other specific illicit drug. Findings also varied by nationality: for service providers from the United States, controlled drug use as an acceptable outcome goal was less supported than in any other country investigated. The U.S. has lagged behind other nations in research and implementation of non-abstinent treatment and support of harm reduction-based goals [15, 16].

There has also been a growing acceptance of non-problematic substance use as a marker of recovery among people with lived experience [17]. Although many individuals with SUDs still define recovery as total abstinence, there is also increasing recognition of other important non-abstinent indicators of recovery, including an ongoing process of self-improvement [18]. Non-abstinent outcomes of interest include reductions in substance use and other biomedical outcomes (e.g., sleep, immune function) as well as psychosocial outcomes (e.g., employment, relationships with family/friends) which are relevant to individuals with MUD.

There is a need for additional research to advance the acceptance of non-abstinence outcomes specifically for MUD. As a first step, it is important to understand the perspective of PWUM on clinically meaningful treatment outcomes including desired psychosocial and biomedical outcomes. The purpose of this study was to examine desired non-abstinent outcomes among a sample of PWUM across the following recovery outcome categories: substance use-related, physical health, cognitive function, mental health, and financial/social/relationship. Our approach examined responses to closed ended questions (Likert scale) with embedded open-ended questions to gain a fuller understanding of PWUM’s beliefs about recovery using convergent analyses for contextual data and for added breadth and depth of understanding of the topic.

Methods

Data were collected as part of an institutionally funded pilot study to advance research on non-abstinent outcomes in MUD and to pursue extramural funding opportunities for support to expand this line of inquiry.

Sampling and recruitment

Recruitment for the pilot was twofold. First, a group of participants were recruited from an existing US NIDA-funded study called the Geographic Variation in Addiction Treatment Experiences (GATE) study [19] which examines social network correlates of SUD treatment use and treatment outcomes during prison re-entry. The project manager provided research staff with a list of names of participants enrolled in the GATE study who indicated a recent history of methamphetamine use to screen for eligibility. Second, a group of participants were recruited for screening from another existing US NIDA-funded study called RISE (Research Informing Syringe Exchange) examining the acceptability of Pre-Exposure Prophylaxis (PrEP) care among rural persons who inject drugs attending syringe service programs. Trained research staff determined eligibility for the pilot based on three criteria: [1] 18 years of age or older [2], self-reported methamphetamine use within the past three months (or three months prior to incarceration if recruited from the GATE study after prison release), and [3] not currently incarcerated.

Data collection occurred in-person or telephonically depending on the participant’s choice. Individuals voluntarily participated in the pilot study. Those who completed the survey in-person signed a written informed consent form before data collection began. Individuals participating over the phone provided a waiver of documentation of informed consent. Participants received a $30 incentive for participating in the pilot. The university’s Institutional Review Board provided approval for the study.

Data collection

From December 2022 to June 2023, 100 participants were enrolled. Survey data were collected and managed using the web-based research software Qualtrics. Surveys included open and closed ended questions on the following topics: substance use history, substance-related recovery outcomes, physical health recovery outcomes, cognitive functioning recovery outcomes, mental health recovery outcomes, and financial/social/relationship recovery outcomes.

The selection of non-abstinent outcomes for examination was guided by review of the scientific literature, to identify specific biomedical and psychosocial outcomes for which there is strong evidence of harm associated with methamphetamine use, including sleep, cardiovascular and immune health and psychosocial functioning [36,37,38,39,40]. As a subsequent step, we engaged a Community Advisory Board of people who use drugs to review and prioritize our curated list of non-abstinent outcome domains and wording for open-ended questions for examination in the pilot study.

Participants were asked, “What does recovery look like to you?” Subsequently, questions for each of the recovery outcome categories required a 4-point Likert style response, which was followed by an open-ended question to gain contextual data on participants’ priority recovery outcomes. For example, participants were asked, “For people who use methamphetamines, being in recovery may result in improvements in physical health. How important is an improvement in _____ as a recovery outcome? [general health, sleep, cardiovascular health (e.g., reduced risk of heart disease, stroke, arrhythmia), immune health (e.g., the body’s ability to fight off disease-causing bacteria and viruses), appetite (adequate nutrition), and energy level].

Analytic strategy

To analyze quantitative data, continuous data were summarized using means, and categorical data were summarized using frequencies and percentages. Data collected with open ended questions were manually categorized in Microsoft Excel. This was done by developing a codebook that focused on the selected outcomes, which was also informed by the lived experience of two members of the research team, including personal experience with SUD and years of experience overseeing direct recovery support services at a recovery community center. These two coders independently reviewed the open-ended responses, and iteratively classified responses across the emerging categories to reach consensus on the resulting themes. Other members of the team audited the resulting themes for consistency and construct validity. Exemplar quotes were selected to describe how participants conceptualized recovery, as well as the most important recovery outcomes in each category (substance-related outcomes, physical health recovery outcomes, cognitive functioning recovery outcomes, mental health recovery outcomes, and financial/social/relationship outcomes).

Results

The 100 participants were primarily White (88%), male (67%), employed or in school (70%), and 40 years old on average (Table 1). Furthermore, most participants had been on community supervision in the last 90 days (76%) and about half of the sample lived in a rural area (52%). Most participants expressed a need for methamphetamine treatment (68%). Three-quarters of the sample reported lifetime injection drug use (76%) and over half (57%) reported experiencing an overdose. Also, the vast majority (93%) of participants considered themselves to be in recovery.

Table 1 Demographics (N = 100)

What is recovery?

About two-thirds of the participants agreed or strongly agreed that people need to stop all mind- or mood-altering substances to be in recovery (64%; Table 2). Similarly, most reported that methamphetamine recovery cannot include the use of other drugs (69%). However, when asked about specific substances, participants exhibited more acceptance for non-abstinent outcomes, as a sizeable minority endorsed that recovery from methamphetamine can include the use of legal substances with alcohol use at 39% and tobacco at 89%.

Table 2 Substance use history and opinions on recovery (N = 100)

Participants were also offered an open response to describe what recovery means to them. Five themes emerged from participants’ responses (Table 3). Of the 95 open responses, 39 mentioned “abstinence”, “sobriety”, or “not using mood- or mind-altering drugs”. These findings are congruent with the results of Table 2, which also indicate wide-spread characterization of recovery as abstinence. However, of those 39, only 10 mentioned abstinence alone. The other 29 participants endorsed abstinence in addition to other domains which characterize recovery (Table 4).

For these 29 participants, and many of the others who did not explicitly mention abstinence, recovery was often defined by taking action and building recovery capital (RC, referring to all the internal and external resources which a person can access in support of their recovery process; Cloud & Granfield, 2008). One participant shared “but it’s not just drugs and alcohol, it’s actions too. It’s like mind, body, and soul. I have to stay connected to a higher power and I have to stay connected to my support group because I lose that then that’s a relapse before a relapse.” Similarly, many participants identified multiple dimensions of RC. For some, recovery is characterized by peacefulness, such as “just finding a comfort and a calmness in life. Relaxation, like a good sleep.” Similarly, other participants described recovery as life stability: “someone who’s living a manageable life, in control of it, back on top of it.” Only one participant mentioned non-abstinence, reporting “it has changed my life. I still smoke pot, not all the time.”

Participants’ explanations of why they chose abstinence from drugs and alcohol largely fell into two categories that also emphasized RC needs. First, participants reported a need to avoid a return to chaotic, problematic drug use. For example, one participant shared “Just being completely abstinent from all of it, because if I did a little I would be right back to doing all of it.” Second, other participants identified specific substances as posing a danger to them, such as one participant who shared “probably abstinent from the methamphetamine because it makes people pick their face and… it makes them really crazy if they already have an underlying condition …. like somebody with OCD cannot do meth because it makes them -- they will pick the skin off their bones.” For these participants, abstinence was not a goal of recovery in and of itself. Instead, abstinence was important precisely because it would prevent a return to chaotic drug use or prevent drug-related harm.

Table 3 Results pertaining to “What does recovery mean to you?”

Substance use-related recovery outcomes

Substance use-related recovery outcomes are reported in Table 4. Like the results reported in Table 2, these results indicate varying levels of acceptance of non-abstinent recovery, depending on the substance in question. Overwhelmingly, participants endorsed recovery as not using any methamphetamine (98%) and 88% of the sample reported methamphetamine use reduction as a “very important” or “essential part of recovery”. Similarly, 90% reported that not using substances is “very important” or “essential to recovery”. However, participants were more likely to endorse non-abstinent recovery when asked about the use of specific substances, especially legal substances. For instance, 80% of participants reported not using alcohol is “very important” or “essential”, 65% reported not using cannabis is “very important” or “essential”, and 18% reported not using tobacco is “very important” or “essential”. Lastly, participants reported that reducing cravings (91%) and identifying as a person in recovery (81%) were also important substance use-related recovery outcomes.

Table 4 Substance use-related recovery outcomes (N = 100)

Participants were then asked to describe in an open-ended question which substance-related outcomes are most important. Four themes that emerged from their responses, with counts of unique and exemplary responses, are displayed in Table 5. Here, participants added nuance by expressing widely varying degrees of acceptance for different substance-related recovery outcomes. Some participants characterized recovery as complete abstinence. In contrast, other participants limited important substance-related recovery outcomes to abstinence from “harder drugs” such as one who shared “every one of them except the marijuana, tobacco, and suboxone. You can definitely recover being on suboxone. I take that and it helps me. Marijuana isn’t that bad; it doesn’t alter your mind. I smoke that and I smoke tobacco and I can still recover so I’d have to say all but those three.” Also, some participants limited their important drug-related outcomes even further by focusing specifically on abstinence from methamphetamine. For example, one participant reported “reducing methamphetamines because that’s my drug of choice. If I was gonna do anything…that’s why I went to prison. They take you down and they take you down hard too so yeah, that’s why it’s important to not use meth and not want to use meth.” Additionally, participants identified “recovery identity” as an important element of their recovery. Summarily, the drug-related recovery outcome open response offered much more nuance in terms of acceptance of non-abstinent recovery outcomes.

Table 5 Results pertaining to “What drug-related outcomes are important to you?”

Non-drug-related recovery outcomes are displayed in the supplementary data in Table S6, including physical health, cognitive functioning, mental health, and financial/social/relationships. Participant’s physical health concerns centered on having adequate energy. Almost all (95%) of the participants reported energy level was “very important” or “absolutely essential.” Accordingly, a majority of participants endorsed the importance of sleep (91%) and appetite (83%). Study participants were also asked to describe which physical health recovery outcomes are most important to them and why. Open-ended participant responses also pointed to the importance of appetite and sleep as an avenue to replace the energy lost by no longer using a stimulant.

In terms of cognitive functioning, there was little variability in terms of responses as participants endorsed all four domains as “important” or “very important” to recovery. Even though the open-ended questions asked about non-drug-related recovery outcomes, it is worth noting that participants clarified that their concern was ultimately drug-related. This was especially true for cognitive functioning domains, which were tied directly to drug use. For instance, many participants described impulsivity as a vehicle for relapse. One participant shared “probably not being impulsive because that just gets you into a lot of trouble [slight laugh] and sometimes I feel like being a drug addict is impulse control -- where you lack that.” For these participants, cognitive functioning domains were only important insofar as they prevented a return to use.

Similarly, there was also little variability in responses to mental health prompts as all mental health domains were rated as “important” or “very important” to recovery. Many of the open responses indicated a focus on reducing depression and, relatedly, improving coping. When asked which mental health outcome is most important to recovery, one participant shared “definitely coping skills ‘cause that goes right back to making the right choice.”

Finally, in terms of financial, social, and relationship outcomes, participants identified not getting in trouble with the law as their primary concern. In addition, participants reported various forms of stability as important to recovery including employment stability, economic or income stability, and housing stability. For example, participants described recovery as “someone who’s living a manageable life, in control of it, back on top of it” and “sober. stable. uh… that’s about it. sober and stable, a better life.” The desire for stability pervaded open responses in terms of financial, social, and relationship stability.

Discussion

The goal of this pilot study was to identify desired non-abstinent recovery outcomes and explore conception of recovery among PWUM. This research is a response to the call for further investigation of non-abstinent recovery outcomes [12] in the hopes that findings will help advance such outcomes as accepted treatment targets to better meet the needs of PWUM and accelerate treatment development. In comparison to prior research [14, 18], the results of this study indicate relatively greater acceptance of non-abstinent recovery outcomes and shifting conceptions of recovery that transcend abstinence. Previous research on non-abstinent recovery outcomes found moderate levels of acceptance among clinicians (11–68%) [14, 20, 21] but relatively lower levels of acceptance among people in recovery (5–14%) [18, 22]. In contrast, the results of this study indicate greater acceptance of non-abstinent recovery as participants reported greater acceptance of other mostly legal drug use (tobacco, alcohol, and cannabis) in recovery. This finding suggests that PWUM are open to reductions in use rather than complete abstinence alone, and is consistent with recent research which indicates reduced frequency of stimulant use is associated with improvements in clinical indicators of recovery [23].

Despite the growing acceptance of non-abstinent recovery outcomes, it is important to note that about two-thirds of participants characterized recovery as abstinence. Abstinence remains a central feature of recovery for many with lived experience. The disagreement among participants regarding the importance of abstinence to recovery may reflect the diversity and individuality of the recovery process. However, even among those who endorsed complete abstinence, a majority indicated that recovery was characterized by more than abstinence alone. Similarly, Laudet (2007) found that although most participants defined recovery as total abstinence, they also suggested that recovery is marked by improvements in biomedical and psychosocial outcomes. And although 93% identified as being in recovery in this sample, 68% indicated a need for treatment for their methamphetamine use. This dissonance may reflect further disagreement over the definition of recovery.

Participants in this study reported a variety of desired non-abstinent recovery outcomes. Almost all participants endorsed the importance of getting adequate energy from sleep and appetite in recovery, which is consistent with prior research indicating that methamphetamine is often used to regulate sleep and appetite [24]. Participants also strongly endorsed “not getting in trouble with the law” as a desired non-abstinent recovery outcome. This may not be surprising given that a majority of the participants in this study had prior involvement in the criminal legal system. Results also suggested that PWUM perceive various forms of stability to be valuable indicators of recovery, including relationship, financial, employment, and life stability. Relatedly, participants indicated the importance of psychological stability, in terms of both cognitive functioning and mental health. However, the relationship between these various forms of stability (financial, employment, etc.) and abstinence or non-abstinence was not within the scope of this study. It is unclear whether PWUM deem abstinence to be essential in order to accomplish this kind of stability. Nevertheless, the variety of desired non-abstinent recovery outcomes speaks to the dynamic, holistic, and individualized nature of the recovery process and offers further evidence that recovery transcends abstinence for PWUM.

Findings from this study indicate varying levels of acceptance of non-abstinent recovery outcomes depending upon the substance in question. Participants endorsed not using methamphetamine as “very important” or “essential to recovery” (98%) but were much less likely to require abstinence from other substances including cannabis (65%), alcohol (80%), and tobacco (18%). Moreover, open responses indicated participants perceived “hard drugs” or methamphetamine, in particular, as the substance from which they need to abstain. It seems logical that PWUM, many of whom have a MUD, are primarily concerned with cessation of methamphetamine. However, these gradients suggest exceptionalism surrounding certain substances and may further suggest that participants’ acceptance of various substances is ultimately dependent on their ability to function in a way that supports their goals and quality of life. Which substance PWUM find acceptable to use in recovery may also be related to the legality of substance (i.e. legalization of recreational cannabis) and subsequently the perception of how “hard” a drug may be.

Indeed, abstinence is associated with improved quality of life; however, it is important to recognize that non-abstinent recovery is also associated with improvements in quality of life [25]. And when given the choice between abstinence or moderation, even those with severe SUD are more likely to engage in treatment, reach their chosen goal, and derive the benefits of improved quality of life as a result of moderate use [10, 15, 23, 26].

In a recent systematic review, Paquette, Daughters, and Witkiewitz (2022) argued that research on non-abstinent recovery is critically needed. Rigorous research on non-abstinent recovery outcomes is crucial to advancing equitable treatment access because non-abstinent recovery is not uncommon [27]. In a nationally representative sample, half of people who resolved a significant alcohol and other drug problem continued to use substances [25]. In fact, only 20% of those surveyed were completely abstinent throughout their recovery. And yet, despite being an atypical pathway, abstinence remains the hegemonic paradigm for addiction recovery, and most treatments and recovery support services are designed to support it alone. The abstinence-only paradigm provides little to no support for those for whom abstinence has not been successful and often punishes them for their inability to achieve or maintain abstinence (i.e. kicked out of halfway houses, treatment, specialty courts, etc.). Consequently, the abstinence-only approach increases the risk for adverse consequences, including overdose [28, 29]. In contrast, non-abstinent based benchmarks foster a pathway of recovery for the substantial number of people with SUD who have any treatment goal other than abstinence.

Furthermore, there are additional important reasons for more research on non-abstinent recovery outcomes not addressed by Paquette and colleagues (2022). To begin, the establishment of non-abstinent indicators of recovery may foster greater acceptance of harm reduction, both in philosophy and in practice. The U.S. has been slow to adopt many evidence-based harm reduction strategies including syringe service programs [30], fentanyl testing strips [31, 32], and overdose prevention sites [33]. Where non-abstinent recovery gains can be realized and measured, the benefits of non-abstinent recovery and/or harm reduction may be more palatable to providers and the general public. Establishing non-abstinent outcomes for opioid use disorder (OUD) has been critical to garnering greater acceptance of medications for OUD and shifting the recovery paradigm from abstinence to remission [34]. Establishing desired non-abstinent recovery outcomes for PWUM may similarly be critical to the development and acceptance of interventions and other harm reduction strategies for MUD. While non-abstinence outcomes have been more broadly accepted for AUD [15], non-abstinence outcomes have been debated for OUD. Effective medications like buprenorphine or methadone are underused in part because 12-step programs often view these medications as replacing one drug for another [41]; thus, perpetuating the view that medications are not a valid pathway to recovery. Moreover, PWUM and people with other stimulant use disorders are overlooked by most treatment providers due to a lack of pharmacotherapies or widely implemented behavioral interventions. By highlighting the treatment interests of this population, these data open avenues for developing comprehensive treatment models for PWUM. Further, there has been a lack of guidance on non-abstinent recovery indicators from PWUD themselves. Involving PWUD in the development of programs and policies that affect them is a core tenet of harm reduction and a critical strategy to advancing treatments that are acceptable to PWUD. Additionally, the development and broader acceptance of non-abstinent recovery may bridge the treatment gap by encouraging more PWUM to access care. Finally, there is also a need for increased funding for holistic recovery support services that include programming focused on building recovery capital and supporting a broad range of recovery-oriented goals (e.g., nutrition, meditation, healthy relationships, and financial planning). Although abstinence remains the dominant paradigm for SUD recovery, findings from this study suggest that PWUM are more concerned with symptom remission than complete abstinence and may be more responsive to less demanding treatment targets.

Limitations and conclusions

This study has a number of limitations. First, the sample was primarily recruited from people involved in the criminal legal system (CLS) with high levels of polysubstance use in one southern state. Also, although part of the sample was also drawn from a rural SSP, 94% of the sample were recruited from the CLS. Second, despite the inclusion of open-ended questions which shed light onto participant’s experiences, there is still a need for in-depth interviews to probe deeper on this topic. Although this pilot served as an important starting point, more intensive qualitative research will center the lived experiences of PWUM and provide additional context. Additionally, to support the development of non-abstinent interventions, larger scale quantitative research is needed. Our sample is relatively small, and our descriptive cross-sectional data are somewhat limited in scope. Rigorous research is needed to discover the benefits of non-abstinent recovery including more robust and systematic data collection with improved sampling and geographic representation and continuing to include the perspective of PWUDs to amplify patient-centered non-abstinent goals for recovery. And finally, there was a lack of variability regarding participants’ responses to important non-abstinent recovery outcomes. This may be due to the fact that recovery is a dynamic, multidimensional process of change. This lack of variability presents an important opportunity for future research to assess more granular differences in desired non-abstinent recovery outcomes via rank ordering or investigation of lesser explored dimensions of recovery. However, despite these limitations, the study has several strengths, including the focus on an often-overlooked topic and the use of semi open-ended questions, which provides important qualitative insight. Results of this pilot study highlight the need for future investigations of non-abstinent recovery to include in-depth interviews of people with lived experience, as well as with providers, family, and concerned others to learn more about the experience of non-abstinent recovery and to identify additional outcomes.