Recovery, Rehabilitation, and Social Reintegration

"Various definitions of individual recovery have been offered nationally and internationally.^13-17 Although they differ in some respects, all of these recovery definitions describe personal changes that are well beyond simply stopping substance use. As such, they are conceptually broader than “abstinence” or 'remission.' For example, the Betty Ford Institute Consensus Panel defined recovery as 'a voluntarily maintained lifestyle characterized by sobriety, personal health, and citizenship.'¹³ Similarly, the Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as 'a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.'¹⁶

"The specific meaning of recovery can also vary across cultures and communities. Among some American Indians, recovery is inherently understood to involve the entire family¹⁸ and to draw upon cultural and community resources (see, for example, the organization White Bison). On the other hand, European Americans tend to define recovery in more individual terms. Blacks or African Americans are more likely than individuals of other racial backgrounds to see recovery as requiring complete abstinence from alcohol and drugs.¹⁹ Within some communities, recovery is seen as being aligned with a particular religion, yet in other communities such as the AA fellowship, recovery is explicitly not religious but is instead considered spiritual. Still other communities, such as LifeRing Secular Recovery, SMART Recovery, and Secular Organization for Sobriety, view recovery as an entirely secular process.

"Adding further to the diversity of concepts and definitions associated with recovery, in recent years the term has been increasingly applied to recovery from mental illness. Studies of people with schizophrenia, some of whom have co-occurring substance use disorders, have found that recovery is often characterized by increased hope and optimism, and greater life satisfaction.²⁰ This same research revealed that whether someone experienced such benefits was strongly related to their experience with broader recovery benefits, such as improved health, improved finances, and a better social life.²¹"

"Summarizing data from six large studies, one analysis estimated that the proportion of the United States adult population that is in remission from a substance use disorder of any severity is approximately 10.3 percent (with a range of 5.3 to 15.3 percent).²⁹ This estimate is consistent with findings from a different national survey, which found that approximately 10 percent, or 1 in 10, of United States adults say, 'Yes,' when asked, 'Did you once have a problem with drugs or alcohol but no longer do?' These percentages translate to roughly 25 million United States adults being in remission.²⁹ It is not yet known what proportion of adolescents defines themselves as being in recovery.

"Despite negative stereotypes of “hopeless addicts,” rigorous follow-up studies of treated adult populations, who tend to have the most chronic and severe disorders, show more than 50 percent achieving sustained remission, defined as remission that lasted for at least 1 year.²⁹ Latest estimates from national epidemiological research using the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for substance use disorder show similar rates of remission.^30,31 Despite these findings, widely held pessimistic views about the chances of remission or recovery from substance use disorders may continue to affect public opinion in part because sustained recovery lasting a year or longer can take several years and multiple episodes of treatment, recovery support, and/or mutual aid services to achieve. By some estimates, it can take as long as 8 or 9 years after a person first seeks formal help to achieve sustained recovery.^32,33

"In studies published since 2000, the rate of sustained remission following substance use disorder treatment among adolescents is roughly 35 percent. This estimate is provisional because most studies used small samples and/or had short follow-up durations.²⁹ Despite the potentially lower remission rate for adolescents, early detection and intervention can help a young person get to remission faster.²⁹"

"The target of recovery is about quality of life rather than abstinence, although abstinence may be a long-term goal for clients. However, the underlying theoretical model for much recovery work is the developmental or lifecourse model (e.g., Hser, Longshore, & Anglin, 2007), which would suggest a significant lengthening of the time scale for the recovery process and so the focus on change—whether to the point of abstinence—is a long-term journey that may well take up the rest of the person’s life. So abstinence orientation may well be something that either does not ever occur or at least is not a viable goal. It is also this approach to “addiction and recovery careers” that means harm reduction does not have to be characterized as the antithesis of recovery."

"The WHO Lexicon of alcohol and drug terms (1994, p. 55) defines ‘recovery’ as:

"Maintenance of abstinence from alcohol and/or other drug use by any means. The term is particularly associated with mutual-help groups, and in Alcoholics Anonymous (AA) and other twelve-step groups refers to the process of attaining and maintaining sobriety. Since recovery is viewed as a lifelong process, an AA member is always viewed internally as a ‘recovering’ alcoholic, although ‘recovered’ alcoholic may be used as a description to the outside world;

"whereas ‘rehabilitation’ is defined as:

"The process by which an individual with a substance use disorder achieves an optimal state of health, psychological functioning, and social well-being. Rehabilitation follows the initial phase of treatment (which may involve detoxification and medical and psychiatric treatment) […] There is an expectation of social reintegration into the wider community. (emphasis added)"

"According to these definitions there is a clear overlap between social reintegration and rehabilitation, whereby social reintegration forms an aspect of, but is not synonymous with, rehabilitation. Recovery, according to the WHO glossary, appears to be relatively unrelated to the term. However, since the publication of the WHO glossary in 1994, the understanding of the term ‘recovery’ has developed further and today it is much closer to the meaning of the term ‘rehabilitation’ as quoted above. As Best and colleagues (2010, p. 275) note: ‘The target of recovery is about quality of life rather than abstinence, although abstinence may be a long-term goal for clients.’"

"Drug use often develops from being occasional to problematic: ties with close family members and non-using friends are gradually severed, while school and professional performance can be seriously affected and may come to a premature end. As a consequence, the normal process of socialisation, the integration of an individual from adolescence to adulthood as an independent, autonomous member of society, is jeopardised and this often leads to a gradual exclusion into the margins of society. However, this is a two-sided process. At the same time, society is marginalising problem drug users, making their access to education, employment and other social support even more difficult. Also, one should not forget that, in many cases, social exclusion already precedes drug use. Drug use often then exacerbates the already difficult life conditions of excluded individuals, making integration efforts a real challenge for the individual and for those providing support. This aspect is particularly relevant during the current period of economic difficulties in Europe, with high levels of unemployment among young European citizens and their gradual impoverishment.

"In order to protect problem drug users or recovering users from further social exclusion and to support them in their integration efforts, it is crucial that we provide individuals with opportunities and tools that are efficient, adequate and acceptable both for them and for their social environment."

"Research shows that drug treatment contact impacts positively on clients’ physical and psychological health, reduces drug use and criminal activity, reduces injection and lowers the risk of non-fatal overdose (e.g. Gossop et al., 2000a,b; Prendergast et al., 2002; Stewart et al., 2002; WHO, 2009). Thus, accessing and adhering to drug treatment is a significant step towards recovery from drug dependence, but additional social support is often required. Indeed, drug use affects many spheres of life, including family and relationships, housing, education and employment, and it is also associated with social and economic exclusion. This can undermine the gains people have made while in treatment. It is therefore increasingly recognised that, in order to improve treatment outcomes, prevent relapse and ensure successful integration into society, drug dependence must not be treated in isolation; instead, the wider context in which drug use and recovery take place must also be considered and addressed (UNODC, 2008; Neale and Kemp, 2010). The United Nations Office on Drugs and Crime (2008a, p. 18) describes this approach as ‘sustained recovery management’, as a positive alternative to the current common approach of ‘admit, treat, and discharge’, often resulting in revolving-door cycles of high dropout rates, post-treatment relapse and readmission rates.

"Consequently, the aim of social reintegration measures is to prevent or reverse the social exclusion of current and former drug users (including those who are already socially excluded and those who are at risk of social exclusion), but also to facilitate the recovery process and help sustain the outcomes achieved during treatment."

"Drug dependence treatment—within an acute care, symptoms-focused paradigm—has fallen short of properly addressing the complex, multifactorial nature of drug dependence that often follows the course of a relapsing and remitting chronic disease. There is disillusionment with the 'admit, treat, and discharge', revolving door cycles of high dropout rates, post-treatment relapse, and readmission rates. As a response to this situation there is a shift towards a more long term perspective of sustained recovery management (White 2007; White and Davidson, 2006) that is much broader and holistic in scope (Bradstreet, 2004) than linear recovery models."

"A number of barriers, both social and systemic, prevent people with OUD from accessing the life-saving medications they need. Making headway against the opioid crisis will require addressing barriers related to stigma and discrimination, inadequate professional education, overly stringent regulatory and legal policies, and the fragmented systems of care delivery and financing for OUD.

"The stigmatization of people with OUD is a major barrier to treatment seeking and retention. Social stigma from the general public is largely rooted in the misconception that addiction is simply the result of moral failing or a lack of self-discipline that is worthy of blame, rather than a chronic brain disease that requires medical treatment. Evidence demonstrates that social stigma contributes to public acceptance of discriminatory measures against people with OUD and to the public’s willingness to accept more punitive and less evidence-based policies for confronting the epidemic. Patients with OUD also report stigmatizing attitudes from some professionals within and beyond the health sector, further undercutting access to evidence-based treatment. The medications, particularly the agonist medications, used to treat OUD are also stigmatized. This can manifest in providers’ unwillingness to prescribe medications due to concerns about misuse and diversion and in the public’s mistaken belief that taking medication is “just substituting one drug for another.” Importantly, the rate of diversion is lower than for other prescribed medications, and it declines as the availability of medications to treat OUD increases.

"Despite the mounting crisis, the health care workforce in the United States does not receive adequate, standardized education about OUD and the evidence base for medication-based treatment. This has created a shortage of providers who are knowledgeable, confident, and willing to provide medications to patients. Many rural areas are being overwhelmed by the opioid epidemic and have very few, if any, trained and licensed providers who can prescribe the medications. Misinformation and a lack of knowledge about OUD and its medications are also prevalent across the law enforcement and criminal justice systems."

"Stringent laws and regulatory policies pose substantial barriers to methadone and buprenorphine access. Laws and regulatory requirements restrict outpatient methadone treatment to state- and federally certified OTPs, which is detrimental to long-term treatment adherence for many patients. Unlike methadone, buprenorphine is approved to be prescribed in officebased settings, but only by providers who undergo specialized training and obtain a waiver from the Drug Enforcement Administration. Few providers in the United States have such waivers (estimated at less than 3 percent), and additional regulations limit the number of patients that each provider can treat with medication. To compound the problem, most waivered providers prescribe buprenorphine at well below the capacity they are allowed. These policies are not supported by evidence, nor are such strict regulations imposed on access to life-saving medications for other chronic diseases.

"The system of care delivery for OUD is fragmented and poorly integrated into the broader health system in the United States. Treatment settings and financing streams for SUDs are generally detached from primary care, further obstructing access to medications for OUD, especially among people with other co-occurring conditions. Many providers are reluctant to treat people with OUD because they do not receive timely and sufficient reimbursement by public and private insurance coverage, which often limits or excludes evidence-based medication treatment services for OUD. These barriers are compounded by other restrictions, such as prior authorization policies, dose limitations or forced dose tapers, counseling requirements, and annual or lifetime limits on the amount of OUD medication a person can receive. Almost half of nonelderly adults with OUD are covered by Medicaid, which has been shown to help connect people with medicationbased treatment for OUD and to improve treatment retention. However, Medicaid coverage for OUD medications varies widely by state, with some states excluding methadone and buprenorphine entirely."

"The recognition of drug dependence as a multi-factorial health disorder, which often follows the course of a relapsing and remitting chronic disease, has spurred calls to shift the focus of drug dependence treatment from acute care to an approach of sustained recovery management in the community. Sustained recovery management applies many of the central components of recovery capital and the Sustainable Livelihoods framework. Service wise, a sustained recovery management approach offers the following:

"• Uses a strengths-based approach, considering the resources available in the clients life;
"• Takes into account the main areas of life/the eight domains of recovery capital (and their potentially compounding interrelationships) that can support rehabilitation and social reintegration for drug dependent persons;
"• Integrates a broader range of drug dependence rehabilitation and social reintegration support services, to strengthen human, vocational, and social capital necessary for a healthy, stable and meaningful life.
"• Uses broad, family- and community-focused, strengths-based, continual assessment processes;
"• Implements early and assertive engagement by service professionals;
"• Develops client- and family-generated recovery plans;
"• Includes assertive management of co-occurring disorders and challenges to recovery;
"• Uses peer-based models of recovery support and community resource development and mobilization;
"• Shifts the centre of service activity from the institutional environment to the client/family’s natural environment in the community;
"• Puts emphasis on sustained monitoring, recovery coaching, assertive development and linkages to the community services for recovery support and, as needed, early re-intervention;
"• Focuses on long-term evaluation of the effects of service combinations and sequences.
"• Establishes a sustainable health care partnership between service providers and clients;
"• Aims at easy access to services by shifting their location from remote institutions to the client/family’s natural environment in the community;
"• Emphasizes the importance of policy change and advocacy to reduce social stigma attached to drug dependence, and to promote recovery supportive policies and programmes (White, Boyle, and Loveland, 2002);

"Building social capital is a visible, central element of sustained recovery management. It encompasses four of the eight domains of recovery capital in Figure III above, namely, family and social supports; peer-based support; community integration and cultural renewal; and healthy environments."

"In this context, “recovery capital“ is the sum of personal and social resources at one’s disposal for addressing drug dependence and, chiefly, bolstering one’s capacity and opportunities for recovery” (Cloud and Granfield, 2001).

"Recovery capital can be used as a tool for drug dependence treatment professionals practitioners, to identify the strengths of their clients, support them in building up and maintaining a sustainable livelihood, while looking holistically at all domains of life. This approach meets individuals 'where they are' and supports them along the continuum of treatment, rehabilitation and social reintegration.

"Building recovery capital is a strengths-based approach. It involves identifying and building upon the client’s major personal and social assets, which may have been developed earlier in life or are newly acquired. These assets can support treatment engagement and enhance motivation for treatment, the treatment process and ongoing recovery from drug dependence problems.

"The eight domains of recovery capital identified by the Treatnet working group (shown in Figure III) are:
"1) Physical and mental health;
"2) Family, social supports, and leisure activities;
"3) Safe housing and healthy environments;
"4) Peer-based support;
"5) Employment and resolution of legal issues;
"6) Vocational skills and educational development;
"7) Community integration and cultural support; and
"8) (Re)discovering meaning and purpose in life.

"A lack of such assets could hamper the recovery process and desired outcomes."

"In the context of mental health, recovery is often described as a personal journey or process that has three core principles: agency (a sense of control over one’s life), opportunity (having a life beyond illness, including being part of society) and hope (belief that one can have a fulfilled life and should not settle for less) (SLAM/SWLSTG, 2010).

"However, the term ‘recovery’ in the field of addiction is still surrounded by controversy. It was associated historically with the ‘12-step’ Alcoholics Anonymous mutual aid programme and with abstinence. The World Health Organization still defines recovery as ‘maintenance of abstinence from alcohol and/or other drug use by any means’ (WHO, 2017).

"Many authors advocate that abstinence alone is not recovery, and that recovery is a wider concept involving a process of both voluntary control of substance use plus working towards positive outcomes in a range of other recovery capital domains. Granfield and Cloud (2001) consider these domains to be social capital (family and group relationships); human capital (health and well-being, aspirations, educational achievements, etc.); physical capital (housing and money); and cultural capital (values, beliefs and attitudes, and the ability to fit into dominant social behaviours) (Figure 2)."

"Cloud and Granfield delineate four dimensions to recovery capital: social, physical, human and cultural.
"Social capital: The sum of resources that each person has as a result of their relationships, support from and obligations to groups to which they belong
"Physical capital: Tangible assets such as property and money that may increase recovery options
"Human capital: Personal skills and education, positive health, aspirations and hopes
"Cultural capital: Values, beliefs and attitudes that link the individual to social attachment and the ability to fit into mainstream social behaviour"

"The research literature on substance abuse treatment has consistently reported evidence to support the view that the relationships people maintain with their families, friends and other social contacts are critical to understanding why people start to abuse drink and drugs, why they persist to the point of addiction, and how they respond to treatment designed to move them to abstinence.

"The most successful treatment programmes are those that recognise the role of social capital and develop interventions that provide support via self-help groups, peer support, and families. Effective recovery programmes need to address other elements of substance abusers’ social environments, including the need for stable accommodation, the capacity to manage financial affairs, and constructive activities that provide a positive alternative to relapse. While good cost-benefit analyses have yet to be done, the available evidence suggests that recovery programmes are likely to be cost-effective. Savings can be made by reducing demand for health care, enabling people to make a positive contribution to their communities.⁶³"

"Although drug courts provide an alternative to the immediate incarceration of drug users, these courts are still connected to a criminal justice system that treats drug use as a crime. Therefore, when participants enter the drug courts, there is an institutionalized stigma attached to drug use.¹⁹² Drug courts perpetuate this stigma because they are based on a system of rewards and punishments. When participants act 'badly' (either by testing positive for drugs or breaking other imposed conditions that create a presumption of drug use), they are treated as pariahs, not patients. For continuing 'bad' behavior, drug court participants can be eventually incarcerated, which is the ultimate representation of societal segregation and ostracism."

"Overall, lower levels of acquisitive offending and high-cost offending were recorded at follow-up. Among those who continued to offend, improvements in offending behaviour at follow-up, in terms of a decrease in its volume and/ or the costs associated with it, were observed. Crack users, injecting users, users with high SDS [Severity of Dependence Scores] scores, and those with previous treatment experience were more likely to offend than others at any point. However, neither referral source nor the type of treatment modalities received, were significantly associated with the level of acquisitive offending at any point (within the adjusted model)."

"The Drug Treatment Outcomes Research Study (DTORS) was one example of European research with encouraging results regarding employment (Jones et al., 2009). This study investigated drug use, health and psychosocial outcomes in 1 796 English drug users attending a range of different types of treatment service. Follow-up interviews were conducted between 3 and 13 months after baseline (soon after initial treatment entry). Regardless of the type of treatment received or drug use outcomes, employment levels increased from 9 % at baseline to 16 % at follow-up. This was accompanied by a corresponding increase in the amount of legitimate income earned per week. The proportion reporting being unemployed but actively looking for work decreased slightly from 27 % to 24 %, reflecting the increase in employment and a 5 percentage point increase in those reporting being unable to work (because of long-term sickness or disability). The proportion of participants classed as unemployed and not looking for work also fell from 24 % to 11 %. Treatment attendance was also associated with changes in housing status; the proportion staying in stable accommodation increased from 60 % to 77 % at follow-up. It should be noted that the findings of this study were weakened by use of a non-experimental design, failure to separate outcomes according to client type and treatment modality, and insufficient detail on the nature of the employment obtained."

"The marginalization of medical care for opioid dependence and the stigma attached to this diagnosis and methadone maintenance treatment play an important role in untreated opioid dependence. Current federal regulations restrict the care of opioid-dependent patients to federally licensed narcotic treatment programs (NTPs) with little to no involvement by community-based physicians. Recent calls from federal and scientific bodies, including the Institute of Medicine, a National Institutes of Health consensus panel, and the Office of National Drug Control Policy, have recommended restructuring the regulatory processes involved in the treatment of opioid-dependent patients, including increased involvement of primary care physicians."