Redefining Sobriety: Shaking Up the Field of Addiction Medicine

Mike Reed, a musician and Uber driver in Arizona, said he quit drinking alcohol more than a decade ago when his roommates got so fed up with his unruly behavior that they threatened to kick him out.

Sobriety became such a core part of Mr. Reed’s identity that he launched an online dating website called “Single & Sober,” but in 2020, Mr. Reed, a Navy veteran, said he found himself struggling as his sister, who had Down syndrome, was dying of cancer.

Mr. Reed, 43, began smoking marijuana. More recently, he went to a clinic for infusions of ketamine, and tried tiny doses of psychoactive mushrooms. Mr. Reed said those substances improved his mood — and he still regards himself as sober, because he remains alcohol free.

Notions of what constitutes sobriety and problematic substance use have grown more flexible in recent years as younger Americans have shunned alcohol in increasing numbers while embracing cannabis and psychedelics — a phenomenon that alarms some addiction experts.

Not long ago, sobriety was broadly understood to mean abstaining from all intoxicating substances, and the term was often associated with people who had overcome severe forms of addiction. These days, it is used more expansively, including by people who have quit drinking alcohol but consume what they deem moderate amounts of other substances, including marijuana and mushrooms.

“Just because someone has a drinking problem doesn’t mean they have a problem with every single thing,” Mr. Reed said.

As some drugs come to be viewed as wellness boosters by those who use them, adherence to the full abstinence model favored by organizations like Alcoholics Anonymous is shifting. Some people call themselves “California sober,” a term popularized in a 2021 song by the pop star Demi Lovato, who later disavowed the idea, saying on social media that “sober sober is the only way to be.”

Approaches that might have once seemed ludicrous — like treating opioid addiction with psychedelics — have gained broader enthusiasm among doctors as drug overdoses kill tens of thousands of Americans each year.

“The abstinence-only model is very restrictive,” said Dr. Peter Grinspoon, a primary care physician at Massachusetts General Hospital who specializes in medical cannabis and is a recovering opioid addict. “We really have to meet people where they are and have a broader recovery tent.”

It is impossible to know how many Americans consider themselves part of an increasingly malleable concept of sobriety, but there are indications of shifting views of acceptable substance use. Since 2000, alcohol use among younger Americans has declined significantly, according to a Gallup poll.

At the same time, the use of cannabis and psychedelics has risen as state laws and attitudes grow more permissive, even as both remain illegal under federal law.

A survey found that 44 percent of adults aged 19 to 30 said in 2022 that they had used cannabis in the past year, a record high. That year, 8 percent of adults in the same age range said they had used psychedelics, an increase from the 3 percent a decade earlier.

Dr. Nora Volkow, a psychiatrist who since 2003 has led the National Institute on Drug Abuse, a division of the National Institutes of Health, said she was trained to think that “the only way out of an addiction is total and full sobriety.” Over the years, she said, she came to see that as unrealistic for some patients. Reduced use, or replacing highly addictive drugs like opioids with cannabis, may be a decent outcome for certain people, she said in an interview.

“You come to realize that there are people that are able to recover and yet they are not absolutely free of every substance,” Dr. Volkow said.

Weighing Risks

The concept is shaking up the field of addiction medicine.Adherents of the full-abstinence model, which include Narcotics Anonymous, follow a 12-step process that includes turning to a higher power to regain “sanity.” Members often celebrate sobriety milestones with tokens or coins to reflect how long they have abstained from using alcohol or drugs.

The danger of abusing opioids and alcohol has become increasingly clear in recent years. But questions remain in the medical community about the risks of some drugs now often touted as wellness enhancers rather than guilty pleasures — cannabis products as sleep aids, ketamine infusions to treat depression, and psychoactive mushrooms to ease anxiety.

Addiction specialists say the legal status of cannabis and psychedelics has made it hard to rigorously study their risks and medicinal potential, even as more people turn to them to self medicate. Doing so carries risks. Cannabis can be addictive, some doctors note. Psychedelic trips can be psychologically destabilizing, they say, and in rare cases have triggered psychotic episodes.

The N.I.D.A. has begun backing research exploring whether psychedelic trips might be effective in the treatment of addiction to other drugs. Dr. Volkow said that although recent clinical trials involving psychedelics were promising, she worried that the hype surrounding the therapeutic use of that class of drugs, along with medical cannabis, has outpaced the science.

“It’s clear that for some people an experience with some of these substances can be very revealing, but for others it can be very traumatizing,” she said.

Addiction treatment centers have responded with concern to the shifting definitions of sobriety.

Dr. Joseph Lee, the president of the Hazelden Betty Ford Foundation, the nation’s largest nonprofit addiction treatment provider, said that people with severe substance use problems are generally the least equipped to make wise decisions about drug use.

“One truth about risk in people is that we all do a very poor job of assessing our own risk,” he said. He added that he had grown concerned about claims from new cannabis and psychedelic ventures as they compete for business. “They know exactly who they are targeting, and those people who are being targeted are misassessing their risk,” he said.

Individual Paths

Maya Richard-Craven, a journalist from Pasadena, Calif., said she has thought a lot about mitigating risk since she went to rehab in 2019 after her alcohol use became a problem.

She said she relapsed in 2020, consumed by anxiety early in the pandemic, and later turned to cannabis, regarding it as a healthier way to take the edge off. By 2021, she said she was smoking excessively, “to the point where I wanted to not feel anything.” That prompted her to “put down the pipe” and publish an essay warning about the risks of California sober.

More recently, Ms. Richard-Craven, 29, said she has resumed using marijuana but with greater restraint, typically smoking no more than half a joint at the end of the workday and the rest before bedtime. She credited cannabis with helping regulate her appetite, improving her sleep and, most of all, easing distress after a sexual assault. Still, Ms. Richard-Craven said she believed people with serious addictions should steer clear of all substances for at least their first year of recovery.

“That first year, you’re all over the place,” she said.

Others, like Connor Hunter-Kysor, 29, of Philadelphia, said that while he does not doubt that some people who have struggled with addiction can find a healthy approach to substance use, he has concluded that full abstinence is the right answer for him.

Addiction runs in his family, he said, and past efforts to consume drugs in moderation always failed.

“It’s a disease,” Mr. Hunter-Kysor said. “I know myself and I don’t want to play with fire any longer.”

Tiffany Fede, of Austin, Texas, once held similar views, but her outlook changed after her husband died in 2020.

Seeing him struggle with opioid addiction, Ms. Fede said she did what she had learned in the addiction recovery circles where their romance began years earlier: She watched him like a hawk, persuaded his dealer to stop supplying pills and balked when her husband suggested that taking psychoactive mushrooms might be helpful.

“I put my foot down,” said Ms. Fede, 43. “I was indoctrinated by this belief system that held that that would be harmful.”

Still, Ms. Fede said, her husband died of a methadone overdose.

Grieving, Ms. Fede said she began using magic mushrooms herself, an experience that led her to recalibrate her approach to mind-altering substances. Ms. Fede said she took three grams of psilocybin mushrooms, a trip that “helped me to not feel lonely for the first time.”

Ms. Fede said she no longer regards terms like sobriety useful and has ceased to think of herself as a recovering addict. These days, she said, her use of mushrooms and other mind-altering compounds is intentional and often done ritualistically. They have eased her grief, brought her joy and made her a better parent, she said.

“These deep journeys have made me more patient, more loving and more graceful with myself,” she said.

Ms. Fede said she had stopped obsessing over the events that led to her husband’s death. One question, though, continues to tug at her: If she had indulged his desire to try treating his opioid addiction with magic mushrooms, would he still be alive?