Continuing care research: what we have learned and where we are going.

1. BackgroundThe concept of recovery lies at the core of the Substance Abuse and Mental Health Services Administration's (SAMHSA's) mission, and fostering the development of recovery- oriented systems of care and services is a Center for Substance Abuse Treatment (CSAT) priority. In support of that commitment, in 2005, SAMHSA's CSAT convened a National Summit on Recovery. Participants at the Summit represented a broad group of stakeholders, policymakers, advocates, consumers, clinicians, and administrators from diverse ethnic and professional backgrounds. Although the substance use problems and disorders treatment and recovery field has discussed and lived recovery for decades, the Summit represented the first broad-based national effort to reach a definition of recovery and a common understanding of the guiding principles of recovery and the elements of recovery-oriented systems of care.Through a multistage process, key stakeholders formulated guiding principles of recovery and key elements of recovery-oriented systems of care. Summit participants then further refined the guiding principles and key elements in response to two questions: 1) What principles of recovery should guide the field in the future? and 2) What ideas could help make the field more recovery oriented?A working definition of recovery, 12 guiding principles of recovery, and 17 elements of recovery-oriented systems of care emerged from the Summit process; these are subsequently defined in this paper and in the National Summit on Recovery: Conference Report. [1] These principles and elements can now provide a philosophical and conceptual framework to guide SAMHSA/CSAT and other stakeholder groups and offer a shared language for dialog.Summit participants agreed on the following working definition of recovery:Recovery from alcohol and drag problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.The guiding principles that emerged from the Summit are broad and overarching. They are intended to give general direction to SAMHSA/CSAT and other stakeholder groups as the treatment and recovery field moves toward operationalizing recovery-oriented systems of care and developing core measures, promising approaches, and evidence-based practices. The principles also helped Summit participants define the recovery-oriented elements and guided recommendations for the field.Following are the 12 guiding principles identified by participants (defined in this paper):* There are many pathways to recovery.* Recovery is self-directed and empowering.* Recovery involves a personal recognition of the need for change and transformation.* Recovery is holistic.* Recovery has cultural dimensions.* Recovery exists on a continuum of improved health and wellness.* Recovery emerges from hope and gratitude.* Recovery involves a process of healing and self-redefinition.* Recovery involves addressing discrimination and transcending shame and stigma.* Recovery is supported by peers and allies.* Recovery involves (re)joining and (re)building a life in the community.* Recovery is a reality.Participants at the Summit agreed that recovery-oriented systems of care are as complex and dynamic as the process of recovery itself. They are designed to support individuals seeking to overcome substance use problems and disorders across their lifespan. Participants at the Summit declared, "There will be no wrong door to recovery" and also recognized that recovery-oriented systems of care need to provide "genuine, free and independent choice" among an array of treatment and recovery support options. Services should optimally be provided in flexible, unbundled packages that evolve over time to meet the changing needs of recovering individuals. Individuals should also be able to access a comprehensive array of services that are fully coordinated to provide support to individuals throughout their unique journeys to sustained recovery. …

Guiding Principles and Elements of Recovery-Oriented Systems of Care: What Do We Know from the Research?*

Substance-abusing patients are frequently urged to participate in lower intensity continuing care interventions, also known as "stepdown care" or "aftercare," following an initial phase of treatment. Since 1988, 15 controlled studies of continuing care for alcohol or drug abuse have been published, with follow-up data on substance use presented in 14 of these studies. In the studies that featured an active control condition, only 1 of 7 yielded positive findings. In the studies that featured a minimal- or no-treatment control, 3 of 7 studies yielded positive findings. The relative paucity of continuing care studies, coupled with the lack of stronger evidence of clinical effectiveness, provides a convincing rationale for conducting evaluations of continuing interventions, as well as evaluations of combinations of various primary and continuing interventions. Methodological issues in the evaluation of continuing care and potential research questions that could be addressed in long-term follow-up studies are outlined and discussed.

Effectiveness of continuing care interventions for substance abusers. Implications for the study of long-term treatment effects.

Treating Substance Use Disorders with Adaptive Continuing Care

Sober living houses for alcohol and drug dependence: 18-month outcomes.

One hundred twenty-four male veterans were enrolled in the Birmingham VAMC Outpatient Substance Abuse Clinic (OSAC) aftercare program following inpatient treatment for alcohol, cocaine, or mixed alcohol-cocaine abuse/dependence. Forty-two of the patients were concurrently admitted to a nearby halfway house (HH) while the remaining 82 patients made community-based (CB) living arrangements. Chi-square analysis showed the two groups were matched, p >. 05, in regard to age, race, marital status, presenting problem, and referral source. The CB group experienced significantly, p <. 05, higher early dropout (40 vs 0%) from aftercare. Of the others engaging in treatment, the HH patients stayed in OSAC aftercare 60 days longer and had significantly, p <. 01, more clinic visits. A higher proportion, p <. 01, of HH patients completed each of four treatment milestones: education group, psychological testing, psychological interview, and treatment planning/update. On average, the HH patients remained in OSAC an additi...

Robert D Stainback

Papers

Effects of Halfway House Placement on Retention of Patients in Substance Abuse Aftercare