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I have spent more than four decades providing, studying, promoting, and defending addiction treatment, but remain acutely aware of its limitations. As currently conceived and delivered, most addiction treatment programs facilitate detoxification, recovery initiation, and early recovery stabilization more effectively and more safely than ever achieved in history, but most fall woefully short in supporting the transition to recovery maintenance and the later stages of recovery, particularly for those who need it the most--those with the most severe and complex problems and the least recovery support within their natural environment.
Addiction treatment as a stand-alone intervention is an inadequate strategy for achieving long-term recovery for individuals and families characterized by high problem severity, complexity, and chronicity and low recovery capital. In isolation, addiction treatment is equally inadequate as a national strategy to lower the social costs of alcohol and other drug-related problems. Here's why.
Specialized addiction treatment as a system of care in the U.S.:
1) attracts too few--only about 10% a year of people in need of it and only a lifetime engagement rate of 25%,
2) begins too late--with years and, in some studies, decades of dependence preceding first treatment admission,
3) retains too few (less than 50% national treatment completion rate),
4) extrudes too many (7.3% of all annual admissions--more than 130,000 individuals--administratively discharged, most for confirming their diagnosis),
5) ends too quickly, e.g., before the 90 days across levels of care recommended by the National Institute on Drug Abuse,
6) offers too few evidence-based choices,
7) fails to engage and support affected family members and friends,
8) is too disconnected from indigenous recovery community resources,
9) offers minimal continuing care--far short of the five-year point of recovery durability, and
10) fails to alter treatment methods in response to patient non-responsiveness, e.g., blaming substance use disorder recurrence on the patient rather than the treatment methods. (Click here for elaborations and citations related to the above points.)
As a result, we as a country invest billions of dollars in repeated episodes of addiction treatment (59% of people admitted to addiction treatment in the U.S. have at least one prior treatment episode, and 34% have 2 or more prior treatment episodes). We are providing respites within addiction careers for far too many but sustainable recovery for far too few. The current acute care model of intervention could be significantly improved by re-engineering addiction treatment to provide early screening and intervention and long-term care (sustained monitoring, support, early re-intervention), as is increasingly done with other chronic conditions whose acuity waxes and wanes. As a country, we have invested inordinate attention on person-focused interventions (clinical models) to the exclusion of interventions focused on shaping recovery landscapes (public health and community development models).
Professionally-directed addiction treatment should not be the first resort for AOD-related problems; it should be the last resort--a safety net to protect individuals, families, and communities. The first line of response should be support imbedded within relationships that are natural, reciprocal (non-hierarchical), non-professionalized, non-commercialized, and potentially enduring. Such relationships are to be found, not within a treatment center, but within the larger community environment. However, significant effort is required to build and sustain such natural resources.
It is time we nested clinical models of care within larger efforts to develop, mobilize, and sustain sources of support for resilience and recovery within the larger community. Grassroots recovery community organizations and new recovery support institutions offer vehicles for long-term recovery support that bridge the clinic and the community. The clinic can bolster the will to recover and the means to recover, but it is the community that must provide the welcoming space in which one can live as a person in long-term recovery. It is time we balanced recovery support within the clinic with recovery support within the community. The good news is that such a balancing is underway as state after state and community after community wraps acute care models of intervention within larger models of sustained recovery management nested within recovery-oriented systems of care--with the "system" being the community rather than just netowrked treatment resources. This shift marks a revolution in the design and delivery of addiction treatment in the United States. What in its isolation addiction treatment has failed to achieve may well be achieved within newly emerging partnerships with the community.