Overdose death related to opioid use is major public health issue in the US, with numbers increasing following the COVID-19 pandemic (1). Similarly, drug overdose deaths in Missouri have become a widespread health problem. Drug overdose is the number one leading cause of death in Missouri among adults aged 18–44 (2). In 2022, it was estimated that 778,000 Missouri adolescents and adults experienced substance use disorders (SUDs) during the past year (3).

Funding to address opioid-related overdose (4) has been beneficial in extending access to treatment. Yet, in 2022 only 55% of people in need of opioid use disorder treatment received any within the past year (5). Of those receiving treatment, many leave prematurely. For example, a 2021 study found that 64% of people receiving medication for opioid use disorder (MOUD) in outpatient settings leave treatment prematurely (6). A systematic review estimates that the MOUD retention rate is 57% at 12 months, and 38% at 3 years (7). In Missouri, these 12 months retention rates are much lower than the national average, at less than 10% in 2022 (8). Less is known about retention rates for non-MOUD treatment facilities.

Various psychosocial factors also complicate treatment and recovery outcomes. Being unemployed and uninsured makes it difficult for people with SUDs to continue maintenance of medical care (9) and many state-level Medicaid programs do not provide comprehensive coverage of issues related to SUDs (10). A lack of perceived social support has also been found to be related with poorer mental health and stigma among people with SUDs (11)—both factors that can negatively impact recovery outcomes (12, 13). Additionally, healthcare providers face their own challenges when treating people with SUDs. A 2024 systematic review found that physicians most often reported a lack of institutional support (81.2%), a lack of personal cognitive capacity to manage complexities of care (73.5%), a lack of specific skills (73.9%), and inadequate knowledge (72%) as barriers to adequately treating substance use (14).

Due to the nature of early termination of treatment and the transient lifestyles of many people who use substances, many providers may not know why their clients made this decision or which factors may have impeded treatment engagement at all. For example, Trujols and colleagues (15) found a significant difference between patient-reported and clinician-reported improvement of methadone maintenance treatment, as patients documented greater improvement in their condition versus the assessment by the clinical care providers. Similarly, Mitchell-Foster et al. (16) reported a disconnect in how pregnant women who use substances and providers recognized stigmatizing situations in the delivery of care. Thus, this likely disconnect may only contribute to the disparity in treatment engagement (17). Ideally, treatment providers and addictions researchers need a more in-depth understanding of intrapersonal (e.g., one’s own thoughts and self-reflection) and interpersonal (e.g., communication and interaction with others) factors that impact recovery that are in the words of the client (18–20).

A recovery-oriented approach emphasizes the importance of integrating the experiences and voices of people who use substances in the planning and the delivery of care (21, 22). Driven by this approach, recovery support services are non-clinical and medication-based treatments and may include peer support, mutual aid groups, and community centers that offer support with attending to risk factors that can threaten recovery (e.g., housing instability, unemployment, lack social support, food insecurity) (23–25). Emerging evidence demonstrates that recovery-oriented services that address these factors, especially stable housing and social support, may promote better recovery outcomes (26, 27). In the recent years, recovery community centers (RCCs) have expanded rapidly across the U.S. and have emerged as a social recovery hub that increases recovery capital such as employment and housing (28). As more addiction services adopt a recovery-oriented approach, there is a growing need to formally incorporate peer support into recovery support services (29). Peer recovery support services, delivered by individuals with lived experience, aim to strengthen social connectedness, enhance quality of life, improve education and housing, and reduce involvement with the criminal justice system (30).

The study aimed to explore intrapersonal and interpersonal factors that support and impede recovery from substance use disorders based on the perspectives of adults living in Missouri. Findings may offer providers working in Missouri and similar states a nuanced understanding of clients’ barriers and strengths contributing to recovery, which may lead to more collaborative treatment planning, the integration of recovery services, and, overall, better recovery outcomes.

Twenty-four adults at risk of opioid-related overdose (e.g., had ever used opioids, stimulants, and/or hallucinogens) completed semi-structured interviews (see Table 3). Half of the sample (n = 12, 50%) was between the ages of 31–50 years old and most (n = 18, 75%) identified as female. The majority (n = 21, 87.5%) identified as white and Non-Hispanic/Latino (n = 24, 100%). About 71% (n = 17) stated that they were currently unemployed, and 87.5% (n = 21) disclosed that they were recipients of Medicaid. Twelve participants (50%) described stimulant use as their primary substance use issue, followed by opioid use (n = 10, 42%), and hallucinogen use (n = 2, 8%). Participants who described opioid use as their primary substance use issue were asked if they were taking MOUD and 70% (n = 7) responded yes. Among those participants, 6 were currently taking Buprenorphine and one person was taking Methadone.

The following demonstrates the major and minor subthemes identified regarding the following topics: how to take care of daily needs, factors that help with recovery, sources of support, most difficult part of recovery, worries and concerns about recovery, the impact of substance use on relationships, and stigma because of substance use. Table 2 illustrates these themes and exemplar quotes from participants.

Within the context of the ongoing role of fentanyl in overdoses and poisonings (45, 46), and the lower receipt of SUD treatment among people in need, this study identified various interpersonal and intrapersonal factors that may play a critical role in recovery. Financial stressors, worries about daily needs, damaged social relationships, and stigma (either being the receipt of or internalized) were critical challenges that trigger cravings or recurrence to substance use, while healthy relationships with loved ones and peers and motivation for financial stability are critical factors that may shape success in recovery. This research contributes needed insight on the client experience, which can inform how providers problem solve barriers to treatment while emphasizing factors that promote treatment engagement. The study also highlights the necessity of recovery-oriented approaches to care, as findings indicate which factors may be better handled by a peer or counselor within a recovery service or treatment setting.

Most participants described challenges related to substance use and recovery, and many relied on the treatment team or loved ones for accountability and modifying destructive behaviors. The majority of participants reported concerns regarding access to employment and financial independence after treatment, which aligns with recent findings that participants with a history of a substance use disorder were less likely to be employed or retired than the general population (47). We identified one participant who did not have worries or concerns about recovery. While this person may feel prepared for handling recovery, their response may also reflect a hesitancy to consider what may go wrong. Taken together, our findings demonstrate to the field that providers should seize the opportunity to discuss and plan for independence and boost personal agency with clients, while being mindful of a person’s fear of considering future setbacks.

Amidst challenges, participants described motivation to make the most of treatment, and how they can work towards successfully caring for themselves by budgeting and using public programs. Many participants stated an eagerness to repay loved ones for financial support or for funds misused when they had been using. Treatment teams may refer clients to recovery RCCs that can offer support with job readiness. Interventions such as the Customized Employment Supports (CES) model (48) and the Vocational Problem-Solving Skills (VPSS) intervention (49) have shown promise in helping individuals with substance use issues obtain employment and improve employment functioning. Previous research has demonstrated that access to employment is one of the major predictors of positive treatment outcomes and sustained engagement in recovery (50, 51).

Many participants identified their relationship with loved ones, especially their children, as a significant factor that helps with recovery and motivates progress. They likewise mentioned peers from treatment or at mutual support groups as a major source of social support. Such groups offer hope and motivation in their recovery journey. This is emphasized by available research, which demonstrates emotional support from loved ones and from peers may be vital to staying engaged in substance use treatment (40, 52, 53). Individuals who attended RCCs have given high ratings of recovery support groups in terms of perceived helpfulness, suggesting those early in recovery may benefit from interactions with peers and these interactions may help to foster a sense of belonging that can decrease feelings of shame and self-stigma (54). Thus, RCCs are may be ideal settings to reinforce the importance and usefulness of peer support and strengthening relationships with loved ones in achieving and maintaining recovery.

At the same time, our participants experienced significant stigma surrounding substance use from family, friends, and care providers, which is consistent with prior research (55–57). One participant reported that they had only experienced stigma specific to mental health issues, which suggests that individuals are vulnerable to different types of discrimination when seeking help. Our findings add to the literature surrounding awareness that stigma is a major barrier in the recovery process (58). Healthcare systems have the potential to mitigate providers’ attitudes towards substance-use and adults in recovery, but such strategies can be complex and require a nuanced approach (59). Prior research has indicated that successful components of stigma reduction include the use of “person-first” language, emphasis of substance use as a treatable condition, utilization of messaging with sympathetic narratives, and emphasis of societal rather than individual causes of addiction (60). Providers may develop more opportunities for loved ones to receive psychoeducation about substance use and recovery, where they can also receive support as a caretaker, parent, or partner.

Our findings also suggest that individuals experience emotional turmoil about past social relationships that can impede recovery. Studies show that loss of identity and relationships with others are common during addiction recovery (61) and may result in shame and guilt (62). Our study is impactful for signaling that individuals in recovery may benefit from discussions on how to process past experiences, how to rebuild or develop new relationships, and how to develop a quality life without substances. Our results stress the need for guidance on how to view oneself beyond substance use.

Demographic characteristics lend to the current psychosocial strengths of the sample’s individuals while highlighting factors that may test the recovery process. For example, most participants had at least a high school diploma but were currently unemployed and insured through Medicaid. About 70% of our sample was interviewed in at least their second instance of substance use treatment. At the time of sampling, about 33% of participants lived in their own home, while about 58% were living in someone else’s home or at a treatment facility. Most participants with a primary diagnosis of OUD were currently taking MOUD to support recovery.

Lastly, it is important to acknowledge that loved ones and family appeared in multiple major and minor subthemes. As demonstrated by these themes, loved ones and family could provide resources such as housing, and financial support, or emotional and social support. At the same time, they could be a source of anxiety and stress for a client when anticipating how they would react to finding out about the person’s SUD for the first time. Interactions among loved ones and family could also feel stigmatizing once the client had become identified socially as an individual with an SUD. Thus, the multiple roles that loved ones and family members could play in a client’s recovery demonstrate how complicated it must feel internally to navigate relationships and the feelings that they evoke. Providers may find value in asking about the purpose and nature of client’s relationships beyond only assessing for the presence or absence of supports in general.

Overall, these findings emphasize a nuanced and evolving recovery experience among individuals who are at risk of opioid-related overdose, which may be less evident in interactions with clinical treatment. Our study highlights the strengths of people in recovery, such as taking care of basic needs, changing destructive behaviors, and utilizing treatment and medication. Clients will likely benefit from additional guidance in preparing for life after substance use treatment, such as rebuilding relationships and finding new social supports, and navigating pervasive stigma. Services that offer a recovery-oriented approach may be opportune settings for clients to have non-clinical needs met.