Reports of the benefits of drug use from individuals with substance use disorders

Abstract Background: The perceived benefits of drug use are not currently integrated into the treatment of substance use disorder. This omission appears paradoxical and is unsubstantiated by empirical research. As the perceived benefits of drug use are catalysts for drug initiation, relapse and continuous use, increased knowledge about these benefits seems crucial to efficacious treatment. Aims: To investigate the perceived benefits of drug use in substance use disorder. Method: The study is a phenomenological-hermeneutical investigation using thematic analysis of interviews with 30 long-term recovered adult service users. Results: Our thematic analysis resulted in three themes and several sub-themes: (1) Benefits of drug use; (2) Necessity of intense experiences; and (3) Importance of being unconventional. Conclusions: Findings indicate that the benefits of non-problematic and problematic drug use are motivated by similar individual and social needs. An absolute distinction between problematic and non-problematic drug use thus seems arbitrary and potentially counterproductive for clinical practice. The benefits of drug use should be researched as a possible add-on treatment module, as this knowledge may be of significant clinical value in treatment frameworks.

scarce in the literature, metonymic mechanisms also seem evident in SUD, where drug distributor contacts, expert drug knowledge and social skills may lead to an increase in social positioning and street capital within the drug tribe (Grønnestad & Lalander, 2015).
Benefits associated with these three dimensions appear to be an important part of the problematic and non-problematic drug-user lifestyle. Accordingly, without access to the benefits that problematic drug use provides, it seems critical to replace these benefits with a drug-free alternative for successful recovery (McKay, 2017). Currently, SUD treatment primarily focuses on reducing drug use (Tiffany et al., 2012). Addressing the benefits of drug use explicitly is generally considered to increase cravings and chances for relapse, and is therefore downplayed (or actively suppressed) as a topic of conversation. Although some methods incorporate positive druguser experiences and the feelings of ambivalence associated with quitting drugs, e.g., Motivational Interviewing (Madson, Schumacher, Baer, & Martino, 2016), a framework that explicitly, openly and systematically incorporates discussion of drug benefits is lacking. There are no empirical reasons for omitting drug benefits, thus, it may stem from moral concerns (Manderson, 1995). However, as research suggests that perceived benefits of drug use are catalysts for drug initiation, relapse and continuous use (Brook et al., 1998;Laudet et al., 2004;Petry, 2001;Roberts et al., 2015), increased knowledge about these benefits seems crucial to improving the ability of drug treatment to help patients find replacements for these benefits.
We have previously described long-term recovered people's recovery strategies and efforts  and the role their close relationships play in recovery processes (Veseth et al., 2019). Clearly, substance abuse and SUD entail a range of detrimental effects, loss-and trauma experiences, loss of function, and risks, which are all well-documented (Drake et al., 2004;Tiffany et al., 2012). Without neglecting the negative effects, we see a lack of studies exploring first-person positive experiences. Structured knowledge from such research could contribute important knowledge to integrative clinical work. Consequently, in this article we report results from our study on participants' experiences of the benefits of drug use, exploring the question: What are the perceived benefits of drug use among SUD patients?

Method
We used a thematic analytic approach (Braun & Clarke, 2006) within an interpretative-Psychotherapy Research 719 phenomenological framework (IPA) (Smith, Flowers, & Larkin, 2009). The interpretative approach entailed that the study data were generated both from a reflexive dialog between participants and researchers, and from a member-checking procedure throughout the interviews. The phenomenological element entailed the collection of significant knowledge from individuals with lived experience of SUD, to discover and interpret the meaning of such experiences within their broader contexts (Binder, Holgersen, & Moltu, 2012;Fossey, Harvey, McDermott, & Davidson, 2002). We developed objectives and procedures within a user-involved research framework (Trivedi & Wykes, 2002;Veseth, Binder, Borg, & Davidson, 2017); we recruited two service users with first-hand knowledge of long-term SUD recovery (authors seven and eight), who contributed to the interview guide, the interview and analysis process, and finalizing results (Veseth et al., 2019).
The study was reviewed and approved by the Regional Ethical Committee (2011/1877-REK Vest) and conducted according to its guidelines and those of the Helsinki Declaration (1975). Participants gave their informed written consent.

Sample and Recruitment
The sample was recruited as part of the ongoing STAYER study (n = 202), a prospective naturalistic follow-along study of SUD change trajectories in Rogaland, Norway. The STAYER team recruited individuals who had used services between March 2012 and December 2015 in outpatient and residential treatment facilities. Inclusion criteria were that participants must be starting a new treatment sequence; fulfilled criteria for SUD; and were aged 16 or older (Hagen et al., 2016;Svendsen et al., 2017). We recruited our participants at their four-or fiveyear follow-ups, after the STAYER team conducted a screening process based on objective criteria for stable abstinence from substance use and social recovery. Thirty-four eligible candidates were contacted, of whom four refused to participate. Sample size was decided on the basis of the stability of findings (Hill, Thompson, & Williams, 1997), reviewed after 19 and then 26 participants. We stopped recruiting at 30 participants, after deciding that the last four interviews did not contribute with any substantially new information.

Long-term Recovery
We operationalized drug abstinence as a DUDIT-C (The Drug UseDisorders Identification Test) score equalling 0 and AUDIT-C (The Alcohol Use Disorders Identification Test) scores of ≤2. Relapse was defined as scores above the cut-off for either alcohol or drug use during the past two years. Social functioning was operationalized using four variables related to social functioning status: housing, income, friend without addiction and work/school (Derogatis, 1992;Diener, Emmons, Larsen, & Griffin, 1985;Roth, Isquith, & Gioia, 2005). Patients scoring yes on all four social variables were categorized as adequately socially functioning. We coded long-term recovery as a single variable of yes for all individuals who met criteria for both stable substance abstinence and adequate social functioning for the past two years .

Procedure
We conducted interviews between October 2017 and April 2018 (two pilot interviews were conducted with two long-term recovered service users). We developed a semi-structured interview guide following Miles, Huberman, and Saldaña (2013). The interview guide was based on research on factors facilitating SUD recovery (McKay, 2009(McKay, , 2017Moos & Moos, 2007;Orford et al., 2006), focusing on the following themes: (1) person-specific factors; (2) environmental factors; and (3) treatment-related factors (12 predefined main questions and 14 predefined follow-up questions). We introduced each theme with an openended question, e.g., "What helped you the most to recover" OR "Why did you continue using drugs?", using follow-up questions when necessary, encouraging participants to relate their experiences to relevant contexts, e.g., "Can you tell me more about the connection you felt between yourself and your friends in the drug-user community?" OR "What type of support did you find most useful?" At the end of each session, we invited participants to contribute any information they felt was important but had not been covered in the interview. See Supplementary material for the full interview schedule.
All interviews were conducted by authors seven and eight, who received training from author 1 in semi-structured interviewing (Miles et al., 2013). The interviews (mean duration: 57 min; range: 27-96 min) were conducted at Stavanger University Hospital (n = 25), at the participant's home (n = 1), and by telephone (n = 4). Interviews were audiorecorded and transcribed.

Data Analysis
For our thematic analysis, we employed a seven-step meaning condensation procedure (Braun & Clarke, 2006;Braun, Clarke, & Rance, 2014), outlined in Table 1. To strengthen the credibility of the study, four of the researchers conducted the analytic procedure separately. During collaborative meetings, the same researchers compared their interpretations, agreed on themes with accompanying quotes, and validated the findings through consensus decision, dedicating special attention to steps four through six presented in Table 1 and using the following pre-established rules: (1) resolving minor disagreement by the principle of parsimoniousness; (2) resolving major disagreement by (i) an inductive principle using the raw data as a compass, aiming to select the descriptions most closely reflecting the experience of the specific phenomena, and (ii) further applying the principle of best argument as described above.
Authors 7 and 8 were selected as critical auditors to review and provide detailed feedback during the analysis and writing process. Following suggestions by Hill (2012), the critical auditors' role was to ensure the structural validity of findings and that themes successfully represented any important material. Both auditors received basic textual analysis training and participated in several collaborative analysis meetings.

Thematic Analysis
While the focus of the interview guide was on elements contributing to participants' recovery, participants spent a substantial amount of time (voluntarily) describing their positive experiences with using drugs. Analyses of this set of experiences will be reported. The thematic analysis produced three themes with several sub-themes.

Benefits of Drug Use
The participants were teenagers when they began using drugs. They perceived drugs to increase their feelings of having fun, associating them with positive physical effects. Also, they saw drugs as a natural extension of their worry-free, sensation-seeking mindset, ignoring potential negative consequences and long-term planning.
No, and after all, you never take it up because it's shit. You take it up because it's damn fun. P7 In my class, in lower secondary, I was also the first one to start drinking, and as we got older, I was also the first one to get rather hammered … there's something that I lack … I've always been the one thinking that drugs were really cool and I just loved stepping out of things, sort of. P2

Loving the Lifestyle
The participants explicitly stated that they generally loved the drug-user lifestyle. This included the idea of being a free spirit and the thrilling aspects linked to criminal activities, such as stealing and dealing. These perceptions led to an ambivalence about quitting drugs that remained strong even after several years into recovery.
That's right, it's badass, sitting there saying that it's so bloody cool, like. I've told everybody that if I had been given the chance to choose again, I would have taken the same course as today. P3 The last years were some of the coolest. I felt fine … I had a place to live and lots of sickness benefit paid. I think I had more than twenty-five thousand (Norwegian kroner) paid to me every month. So I could just go ahead. But all the time I told myself that soon I will get a letter from somewhere, from the local council or such, saying that "now you will go into rehab", and that's what I told myself, too-you have about a year's time to get high, then that letter will come, and then you need to take those steps that you saw that you needed to take when you sat crying in your (1) Becoming familiar with the data through careful reading of the transcribed interviews, forming a main impression of the experiences of the participants, and identifying potential important themes. A theme was defined as a verbalization capturing an important element of the data in relation to the research question, representing a patterned response in the data set.
Generating initial codes, which were defined as the most basic segments of the raw data that could be assessed in a meaningful way regarding the specific phenomenon.
Searching for and developing candidate themes and subthemes. Remaining codes were set aside at this phase in a separate category for the purpose of being further analysed and incorporated when appropriate.
Reviewing themes to develop a coherent thematic map and considering the validity of individual themes in relation to the data set.
Defining and naming themes: further refining and defining themes, identifying the essence of themes, identifying sub-themes and summarizing the contents of the main themes into what each researcher considered to best represent participants' experiences. When refinements no longer added substantially to the themes, the analytic process was closed. (6) Determining the relevance of a particular theme by counting the frequency of the relevant meaning units and combining this with our interpretation of how central the theme was perceived to be to the recovery process. (7) Having two fully recovered service users serve as critical auditors of our preliminary model of findings (with illustrative quotes), assessing interpretations made through our descriptions of the central organizing concepts.
employer's office. So you just need to use the time available to you now, be it 6 or 12 or 14 months, before going into rehab. So you can get high, but when that date comes, it's all over. P17

Drugs: Connecting People
Drugs functioned as a glue between those interested in the drug-user lifestyle. In fact, the participants saw drugs as a key element of their social life. They described a rapidly-progressing bonding process founded on the glorification of irresponsibility, easy money, drug use and criminality. Doing drugs and criminality covered their need for excitement and social contact. "Stealing with my buddies" was described in unconditionally positive terms, and the social process framing drug use was assessed as having an equal value to the drug use itself.

Saying Goodbye to a Dear Old Friend
The participants were aware of the dangers associated with the drug-user lifestyle, and knew they needed to stop using drugs to avoid serious and lasting damage or death at a young age. They described quitting as a kind of grieving process, with associated unpleasant symptoms like anxiety attacks, existential emptiness and social rootlessness. They saw quitting drugs as similar to ending a relationship with a dear old friend or life partner.
No, I had a lot of time to myself, I dunno. And starting to be in the company of others again, I had forgotten how to be social … and being social with others without being high, it was sort of, I thought: "Jeez, this is really dumb", but then it isn't really. I can recall that it was hard to speak normally with people. I spent a long time practicing that. P27 … I just hadn't come to the end with drugs, really, because you sort of need to be. I love being high too much to give it up before I had to give it up … But I would feel so good … that is when I romanticize it-imagine that it would be possible to do it one Saturday … just one Saturday. P19

Necessity of Intense Experiences
The need to keep in motion was explicitly interlinked with avoiding boredom and the dissatisfaction of being alone. Conventional activities often elicited these types of negative feelings and led to the conclusion that "straight" people and "straight" activities were insufficient. Drug-use and the drug-user community were seen as a remedy.
Yeah, I stayed clean for quite some time, but it was when I was sitting too much at home staring at the wall. I was trying to stay away from all those who were completely out of their heads, right, and then hang out with your few straight mates, right, it just doesn't work. You need something more. At least I do. P24 The participants also perceived the thrilling elements of the drug-user lifestyle as increasing their need for thrilling non-drug-related activities, such as extermination (pest removal), getting tattoos or huntingthese, however, were usually seen as a poor substitute for replacing drugs and the drug-user lifestyle entirely. They struggled with too weak stimuli in their recovery process, which often increased their bodily agitation, drug cravings and chances of relapse; obtaining thrilling feelings from sources other than drugs was thus seen by as a precondition for recovery.
It's sort of the same as when I didn't understand that it's possible to feel fine. I thought that I can't do it, I can't take it … that long-term perspective … how much time it will take before I find a job, before I

Importance of Being Unconventional
The participants felt like social outsiders before beginning to use drugs. They had psychological problems-e.g., anxiety and depression-and struggled with memories of adverse childhood events, including emotional neglect and abuse. They also reported having poor energy levels and attention problems.
Drugs helped them regulate difficult emotions and functioned as an activating tool that enabled the participants to perform daily activities.
Yeah. I'm wondering about that. Is it true that it can be some sort of liberation in it, that you don't need to keep a facade, now you can give yourself space to be "Ronny the addict" who can keep doing what he likes. P28 It started on the weekends, and that was the fun part. But then we started doing it on weekdays too, so … yeah. It was fun to have that energy that I … because I have always been a slacker, or, I have a lot of energy, but I never get anything done, since I have this ADD thing, so I never got started on anything. But it caused me to get going with things, when I felt like it, when I started to clean up I was unable to stop cleaning up, and suddenly my room was spotless and … I got sort of much better results with things, and that was fun. P17 A drug-free and "straight" lifestyle was often seen as a necessary evil, even after several years in recovery. The participants did not want to follow a conventional lifestyle. They felt a need to act authentically, in line with "the odd person inside", even when this entailed a passion for unorthodox activities, such as collecting illegal exotic animals or growing extremely hot chilli peppers. Accepting these unconventional personal characteristics increased self-acceptance and self-care.
Perhaps I'm a little crazy about the things I engage in, that I become sort of possessed. So when I start doing something, it's like 110%. So it has been important for me not just to do it to see how it goes. When I'm on a "mission", I get completely absorbed in it, totally hooked. So that's been a thing for me, it has. Well … because I met a new network there, and as I eventually came out of rehab I went into a full-time job in the oil industry, and that was good for me to be one hundred per cent in a job plus a lot of overtime. P11 But there was a guy who once told me that you cannot stop completely being a little criminally-minded. You need to have that kind of spirit inside you, or else things will soon go to hell again. It will be much too boring. When you're used to having things going full speed. And I believe that's quite smart. P20

Discussion
In this study, the benefits of drug use seemed to play a key role in different aspects of SUD (start-up, maintenance, increase in severity and recovery). Given its importance, we propose that the effect of a new treatment module that explicitly focuses on what social needs drug cover during periods of problematic drug use be tested. Such an approach could reveal clinically valuable knowledge allowing to target treatment efforts in order to identify non-problematic approaches to cover similar needs.

Conventional Lifestyle as Inferior, and Drugs as Innocuous
Echoing SUD research (Dennis & Scott, 2007;Dingle, Stark, Cruwys, & Best, 2015;Fazel, Bains, & Doll, 2006;Scott, Dennis, & Lurigio, 2017;van der Pol et al., 2018), a previous analysis on this sample  highlight several negative effects of drug use and membership in a drug-using community, including physical damage and cognitive and social problems. To a large extent, criminality, the severity of drug use and functional and social decline are key issues that separate the lifestyle of study participants from that of nonproblematic drug-users. Findings also suggest that participants generally perceived a conventional lifestyle to be an unattractive alternative, particularly when they first began using drugs. Here, the participants reported a general need for strong stimuli to achieve psychological balance, and they experienced the drug-using lifestyle as stimulating, fun and pleasurable, with few disadvantages.
Teenagers who develop SUD often have more extensive cognitive limitations in the reflexive capacity, emotional regulation and ability to consider consequences before acting, when compared to their peers (Blakemore, 2018). In addition, these teenagers have often been subjected to other negative experiences including trauma (Roberts et al., 2015) and psychological problems (Brook et al., 1998;Laudet et al., 2004;Phillips & Johnson, 2001). This heightens their propensity to perceive the benefits of drug use as attractive. Our results support these findings -and findings regarding perceived positive benefits of psychiatric disorders (Barbic, Durisko, & Andrews, 2014;Carson, 2011;Davidson, Shahar, Lawless, Sells, & Tondora, 2006;Power et al., 2015;Veseth et al., 2012). Moreover, our findings indicate that drug-user communities may be perceived as fulfilling the participants' need for social affirmation. Followed by a strengthening of prodrug and pro-criminality attitudes, which are corroborated by the lack of corrective factors in the druguser community, receiving (perceived) gains without (perceived) negative consequences seems to result in a self-reinforcing system that confirms the drug-user lifestyle as viable. Over time, this system seems to gradually erase personal responsibility and bring the study participants closer to SUD.

A Similar Framework for Problematic and Non-problematic Drug Use
The three dimensions the pleasure dimension, drugs as performance enhancers, and the symbolic value of drugs were mentioned in the interviews. They also Psychotherapy Research 723 contained metaphoric and metonymic elements (Nesvåg & Duckert, 2017;Rosen, 1988). With regards to the two first dimensions, drugs were used as a social facilitator and a "quick fix" for psychological problems and poor energy levels. Drugs were also used to have fun, to get the physical sensations associated with drugs, and overcome boredom or other negative feelings. Similar findings have been revealed in dual recovery which are people with combined SUD and mental health issues- (Davidson et al., 2008). It has also been associated with non-problematic drug use (Nesvåg & Duckert, 2017), indicating that it occurs across different kinds of substance usage.
Experiences, such as "stealing with my buddies" or "drugs as a social catalyst", were mentioned by all of the participants. While criminal content is different from problematic drug use to most of the non-problematic drug use, the superordinate content-drugs as a social catalyst-appears similar across both types of drug use. However, it is more difficult to conclude with regards to the metonymic elements. The participants referred to members of the drug-using community as possessing higher status and special skills. This is consistent with both previous research on dominant individuals within the SUD sub-culture (Grønnestad & Lalander, 2015) and with metonymic elements, such as equipment, appearance, sub-group affiliation and social hierarchy (Bourdieu, 1986;Connell, 2009;Giulianotti, 1997;Goffman, 1959;Hammersley et al., 2002).
Findings confirm that the benefits of non-problematic drug use and SUD are similar (Nesvåg & Duckert, 2017) rather than qualitatively different phenomena. The differences in the conceptualization of drug benefits between these two groups may, therefore, be due to other factors. The tendency to classify pathological behaviours as radically different from "normal" behaviours is well documented throughout the history of psychiatry (Foucault, 2013). However, such a in-group-out-group thinking may be unwarranted and counterproductive in a clinical setting.

Clinical Implications and Future Research
Mental health research suggests that recognition of the complex interplay of different factors involved in SUD can have a restorative power and increase chances of recovery. This includes positive life events during periods of illness strengthens (Davidson et al., 2006). Our findings indicate that drug benefits may be a treatment element with similar potential. However, this requires an explicit investigation of the benefits of drug use, traditionally conceived as risky and hence often downplayed in a treatment context. As a consequence of this omission, and as our findings indicate, service users, professionals and other helpers are deprived of the opportunity to: (1) understand the important individual and social needs fulfilled through the SUD lifestyle; and (2) identify important non-intoxicant stimulation alternatives.
A treatment method focusing explicitly on druguse benefits could, for example, address both the positive functions of the drugs and the needs they meet for the individual. Our findings suggest that drugs fulfil the individual's need for strong stimuli, and further illuminate how this need cannot easily be met through conventional stimuli (e.g., watching Netflix, walking tours or even talk therapy) Dennis & Scott, 2007;McKay, 2017). Conversely, structural changes and external regulation (e.g., cultivating extra-hot chilli peppers or extreme sports) do seem to meet these needs. However, also mainstream needs, such as having fun and the need to socialize are highly relevant. Tailoring treatment to these types of individual factors may, therefore, increase treatment motivation and recovery. Here, a benefit module could be framed as a critical and reflexive dialog aiming to increase the service user's ability to understand drug-use benefits in a wider context-one that includes downsides, reconcilability with a responsible social life and possible non-toxic benefit replacements. Another approach would be to systematically add an explicit benefit module to a pre-existing treatment framework. Here, Motivational Interviewing seems a suitable alternative as this method, already incorporates positive druguser experiences through the method of working with ambivalence associated with quitting drugs (Madson et al., 2016).

Reflexivity
Pre-understandings are the experiences, hypotheses, perspectives, prejudices and frames of reference of the researchers that influence any part of the research process (Malterud, 1993). To make our own pre-understandings clear, we briefly note that the authors work in a well-organized welfare state with a single-payer free-of-charge health care system. Authors include trained clinical psychologists from various clinical and academic backgrounds. Two of the authors have lived experiences with SUD, from which they today are long-term recovered. Our pre-understandings may, on the one side, contain elements of a disease model because of our background working in the health care system, and, on the other, include a recovery model based on our practice and research oriented toward this understanding. We attempted to approach a merging of horizons (Gadamer, 1989) by constantly reflecting on our own pre-understandings before, during and after the interviews. Further, interviewers were trained with a particular focus on being curious and open-minded about the experiences that the participants shared with us. Another specific feature of the design that allowed for concrete reflexive processes in the implementation of the study was the collaboration with people with service user background from SUD. During the close readings of the text material and during the detailed analyses we deliberately discussed our own possible preconceptions and how these may have coloured the interpretations.

Limitations
The main limitation concerns the representativeness of the sample. This was a clinical sample recruited at the beginning of a new treatment sequence. We do not know if the same findings would be obtained with people who had recovered without formal treatment. Four eligible patients did not want to participate, and we do not know what opinions they might have offered. This can be considered as another limitation to the study. Moreover, a high percentage of participants had good functioning levels prior to SUD. Thus, it was a homogeneous group of patients with good prognosis, as would be expected when using social recovery as an inclusion criterion. However, this is not to say that these patients were not at risk of long-term functional disability. In addition, this does not compromise the validity of the findings, even if it could limit the generalizability with regards to the most severe and prolonged SUD conditions.

Supplemental Data
Supplemental data for this article can be accessed at https://doi.org/10.1080/10503307.2019.1677965.