Nora's Blog

Advancing Recovery Research

By Dr. Nora Volkow
Father and adult son with arms around each other on a meadow in the countryside.
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In a recent commentary in The New England Journal of Medicine, my colleagues John Kelly, Howard Koh, and I likened the addicted brain to a house on fire—a crisis requiring urgent efforts to contain the damage and preserve life.1 The drug crisis in America has demanded a sustained focus to extinguish those fires by expanding treatment access and overdose prevention and reversal strategies—and encouragingly, data show that overdose fatalities have been declining since 2023. However, a house that has had its addiction fire extinguished still smolders and can readily burst into flames again. After an initial remission of substance use disorder (SUD) symptoms, it can take as much as 8 years and 4-5 engagements in treatment or mutual support groups to achieve sustained remission, and risk for meeting SUD criteria can remain elevated for several more years after that.2

As addiction clinicians and researchers, we have an obligation not only to improve our abilities at fighting the fires of active addiction, but also to enhance our ability to facilitate the processes of rebuilding in the aftermath, to reduce their future recurrence. Increasing the number of people achieving long-term recovery from SUDs is a national policy priority and a major goal of the research supported by NIDA—from basic neuroscience to understand how the brain rewires and recovers after addiction to an intensified focus on the supports and services that can help individuals thrive as they build healthier lives.3

Fortunately, the very same adaptability and neuroplasticity of the brain that makes it susceptible to developing addiction in the first place also enables it to heal, especially when internal and external conditions are supportive of recovery. The neurobiology underlying remission from SUDs has long been a focus of NIDA-funded research. Over two decades ago, as a NIDA grantee, I and my colleagues at Brookhaven National Laboratory and SUNY-Stony Brook used PET neuroimaging to show the recovery of lost dopamine transporters in the striatum of people with methamphetamine use disorder after prolonged abstinence.4 More recent longitudinal neuroimaging studies of people in SUD treatment show structural recovery in frontal cortical regions, insula, hippocampus, and cerebellum, and functional and neurochemical recovery in prefrontal cortical and subcortical regions.5

As the individual learns new behaviors, goals, and rewards, the learning process reshapes synaptic connectivity across a range of circuits, ultimately outcompeting drug-related memories and automatic behavioral patterns, which weaken over time.6 Among ongoing NIDA-funded projects is a study homing in on the circuits associated with medication adherence in patients with opioid use disorder (OUD) and those that predict return to opioid use during medication treatment. Another project is using biweekly neuroimaging of patients taking medications to treat OUD to characterize neural trajectories of remission.

NIDA has also made a major investment in research on services and supports that can make it easier for people in recovery to continue to choose non-drug rewards and thereby facilitate this neural rewiring. Such services may prove to be at least as important as treatment or overdose reversal in maintaining the recent gains made in reducing overdose deaths. A 2022 dynamic modeling study funded by the FDA projected that people returning to opioid use after a period of remission will account for an increasing proportion of OUD cases over the coming decade, compared to people newly developing OUD.7 Consequently, the authors found that, of 11 strategies to reduce OUD and fatal overdoses, services that help people stay in remission from OUD were likely to be among the most impactful.

Over the past few years, NIDA has funded several grants with the aim of building the infrastructure necessary to advance the science of recovery support. They included grants in 2020 and 2022 that supported the development of networks of recovery researchers working to establish key measures for the field, as well as clinical trial planning grants that establish the foundation necessary to conduct future large-scale clinical trials to understand the effectiveness of various recovery support services. NIDA is also supporting research on how to deliver services to groups like adolescents and young adults and people involved in the criminal-justice system, and to identify factors that are most predictive of recovery outcomes like recovery identity and meaningfulness.

One defining feature of recovery support services is the central role of peers who have lived or living experience of SUD. It can involve individual support by recovery coaches, living or working in settings with others in recovery such as recovery housing or recovery community centers, or mutual-aid groups like traditional 12-step programs and newer models like SMART Recovery. Among the many questions being addressed by NIDA grantees, therefore, are ways to support peers and their professional advancement to foster a more sustainable recovery workforce. NIDA is also working with startups to develop apps and other digital tools that can be used to facilitate connecting to peers, including mobile apps and digital peer-support platforms accessible in treatment settings for patients who are socioeconomically disadvantaged.

In whatever way recovery services are implemented, access and engagement over a longer duration of time than typical stints of addiction treatment can be crucial to help a person maintain remission and provide support when times get tough. Yet there is limited data on the optimal duration of recovery supports services, how the intensity or focus of services should change over the course of recovery, and, in the case of people taking medications for OUD, if and when medications can be safely discontinued. NIDA-funded recovery research is exploring the crucial question of optimal duration of medication treatment for people with OUD and developing discontinuation strategies for people who want to stop medication.

As we described in our New England Journal of Medicine commentary, the positive shift from punishing people experiencing addiction towards treating them in the clinic seen over the past four decades is now shifting into a new phase where the clinic is integrated with the community.  The integration of support in the community is giving nonclinicians, including peers, friends, and family, an increasingly important role in the care of people with SUDs, facilitating the continuity of care beyond treatment. NIDA recently solicited applications for research projects on the role played by loved ones and other support persons in SUD recovery, with the goal of incorporating them into individuals’ recovery process as well as developing interventions to give support to those who are supporting a loved one in recovery.

As more addiction fires are extinguished through public health measures at the national, state, and community levels, we must direct more scientific attention to the end goal of long-term health and wellness for all people whose lives have been affected by addiction.

References
  1. Kelly JF, Volkow ND, Koh HK. The Changing Approach to Addiction - From Incarceration to Treatment and Recovery Support. N Engl J Med. 2025 Feb 27;392(9):833-836. doi: 10.1056/NEJMp2414224. Epub 2025 Feb 22. PMID: 39991938.
  2. Kelly JF. The Protective Wall of Human Community: The New Evidence on the Clinical and Public Health Utility of Twelve-Step Mutual-Help Organizations and Related Treatments. Psychiatr Clin North Am. 2022 Sep;45(3):557-575. doi: 10.1016/j.psc.2022.05.007. Epub 2022 Aug 1. PMID: 36055739.
  3. The White House, Executive Office of the President, Office of National Drug Control Policy. Statement of Drug Policy Priorities. 2025 Apr 1. 2025-Trump-Administration-Drug-Policy-Priorities.pdf
  4. Volkow ND, Chang L, Wang GJ, Fowler JS, Franceschi D, Sedler M, Gatley SJ, Miller E, Hitzemann R, Ding YS, Logan J. Loss of dopamine transporters in methamphetamine abusers recovers with protracted abstinence. J Neurosci. 2001 Dec 1;21(23):9414-8. doi: 10.1523/JNEUROSCI.21-23-09414.2001. PMID: 11717374; PMCID: PMC6763886.
  5. Parvaz MA, Rabin RA, Adams F, Goldstein RZ. Structural and functional brain recovery in individuals with substance use disorders during abstinence: A review of longitudinal neuroimaging studies. Drug Alcohol Depend. 2022 Mar 1;232:109319. doi: 10.1016/j.drugalcdep.2022.109319. Epub 2022 Jan 19. PMID: 35077955; PMCID: PMC8885813.
  6. Engeln M, Ahmed SH. Remission from addiction: erasing the wrong circuits or making new ones? Nat Rev Neurosci. 2025 Feb;26(2):115-130. doi: 10.1038/s41583-024-00886-y. Epub 2024 Dec 11. PMID: 39663409.
  7. Stringfellow EJ, Lim TY, Humphreys K, DiGennaro C, Stafford C, Beaulieu E, Homer J, Wakeland W, Bearnot B, McHugh RK, Kelly J, Glos L, Eggers SL, Kazemi R, Jalali MS. Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis. Sci Adv. 2022 Jun 24;8(25):eabm8147. doi: 10.1126/sciadv.abm8147. Epub 2022 Jun 24. PMID: 35749492; PMCID: PMC9232111.