Since beginning in 1989, SAMHSA’s National Recovery Month has celebrated the millions of Americans who have achieved recovery from a substance use or mental health disorder. It’s also a month to shine a light on the hard work of those who work in treatment and recovery services. Here, treatment professionals and researchers reflect on how recovery has changed over the past 30 years.
Pat Stilen, MSW
As what is commonly referred to as a “two-hatter” –a woman in long term recovery and a clinical social worker, my journey began almost 40 years ago at a time when there were few – if any – specialized addiction treatment programs for single, pregnant and/or parenting women. Women’s specific services emerged in the 1970s, yet most treatment programs were designed for male clients. Gender-specific treatment programs initiated in the mid-1970s were reduced significantly following a federal shift in combining alcohol/drug treatment and mental health services into one block grant (Finkelstein, 1994). Within the treatment mileu, the traditional adage insisted women needing treatment put their recovery first (i.e., “go to treatment”) and put their children second (i.e., leave your child in foster care or with family members).
Fortunately, I didn’t need to make that untenable decision to choose. I, along with my three pre-schoolers, was able to access residential and community-based services through efforts of a determined and progressive counselor. By the mid-1980s, I had completed an MSW and entered the workforce at a time when treatment approaches were becoming more sensitive to the needs of women and family members. The concept of “family recovery” led to the introduction of family programs (primarily educational in nature) as an optional resource for those with family members in addiction treatment.
While we have made considerable progress in developing services for women and their families, recent data shows that we still have a way to go. In 2015–2017, there were 4,500 opioid treatment programs in the United States—but only 12 programs for pregnant women. And while 22% of substance use disorder treatment programs offer at least one special program or group for pregnant/postpartum women, only 3% offer residential beds for clients' children (SAMHSA N-SSATS, 2017).
At the Mid-America ATTC, we're trying to close that gap: training and technical assistance to support treatment and recovery services for pregnant and parenting women is one of our special areas of focus, and we continually strive to help organizations make recovery possible for the whole family.
References
Finkelstein, N. (1994). Treatment Issues for Alcohol- and Drug-Depending Pregnant and Parenting Women. Health & Socal Work, 19(1),8. Retrieved from http://search.ebscohost.com.proxy.library.umkc.edu/login.aspx?direct=true&db=edb&AN=9406010858&site=eds-live&scope=site 09/28/2019
Substance Abuse and Mental Health Services Administration, National Survey of Substance Abuse Treatment Services (N-SSATS): 2017. Data on Substance Abuse Treatment Facilities. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2018.
Patricia (Pat) Stilen, MSW is a clinical social worker and Project Director in the Collaborative to Advance Health Services at the University of Missouri-Kansas City’s School of Nursing and Health Studies. Stilen has led the Mid-America Addiction Technology Transfer Center since 2000. She also served as the s PI/Director of the ATTC Center of Excellence on Behavioral Health for Pregnant & Postpartum Women and Their Families (2015-2017).
Fred Dyer, Ph.D
So much has taken place in 30 years since the first national Recovery Month observation: parity legislation; treatment solutions as alternatives to incarceration; drug courts with emphasis on treatment and recovery versus incarceration; successful advocacy movements; the promotion of non-stigmatizing language; increased acceptance of medication for substance use disorders, the use of recovery coaches/specialists, recovery care organizations, a greater emphasis on recovery and recovery-oriented systems of care and not just acute care treatment; a humane response to the current opiate epidemic (as compared to the harsh response to previous crack cocaine epidemic); and a recognition of multiple pathways and styles of recovery that should be celebrated.
The past three decades have also seen an increase in research-based treatment solutions for adolescents. Adolescents seeking recovery have also become more involved in recovery activities. The enthusiasm generated by Recovery Month celebrations sends a message to teens and young adults that it is possible to live a healthy and rewarding life without drugs.
Fred Dyer, Ph.D., CADC, is a nationally known behavioral health trainer and consultant. He is a specialist in adolescent and emerging adult treatment and recovery and a regular contributor to the Online Museum of African American Addictions Recovery.
Dennis McCarty, Ph.D.
The total spend on treatment for alcohol and drug use disorders was $9.1 billion in 1986, and the projected spend for 2020 was $42.1 billion (Mark, Levit, Yee, & Chow, 2014). Figure 6.4 in The Surgeon General’s Report on Alcohol, Drugs and Health, Facing Addiction in American, illustrates how spending on addiction treatment changed between 1986 and 2014 (the most current data when the report was prepared). Multiple changes in the system of care for alcohol and drug use disorders are apparent. There was a dramatic reduction in the proportion of spending for inpatient care from about 45% in 1989 to 19% in 2014 (Office of the Surgeon General, 2016). The growth of managed care in the early 1990s promoted reductions in lengths of stay in inpatient and residential settings. Spending in outpatient increased from about 30% to nearly 50% and leveled off at about 40%. The lowest line highlights another important change in the treatment landscape. The spend on prescription medications to treat alcohol and drug use disorders climbed from 0% (1986 through 2005) to 5% beginning in 2006. The 2019 estimate may be higher because of increased use of buprenorphine and naltrexone for opioid use disorders and naloxone for opioid overdose reversal. In summary, total spending has increased despite the reduction in inpatient treatment and, more recently, the use of pharmacotherapy has become more available to support recovery. Despite the increase in access to medications, however, many programs fail to use these critically needed recovery supports.
Figure 6.4 Percentage Distribution of Spending on Substance Misuse Treatment by Setting, 1986-2014. Source: SAMHSA, 2016
Mark, T. L., Levit, K. R., Yee, T., & Chow, C. M. (2014). Spending on mental and substance use disorders projected to grow more slowly than all health spending through 2020. Health Affairs, 33(8), 1407 - 1415.
Office of the Surgeon General. (2016). Facing Addiction in America: The Surgeon General's Report on Alcohol Drugs and Health. Retrieved from Washington, DC: https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf
Dennis McCarty, Ph.D., is a Professor Emeritus in the OHSU-PSU School of Public Health at Oregon Health & Science University, works at the intersection of policy, research and practice assessing the organization, financing, and quality of prevention and treatment services for alcohol and drug use disorders.
Michael Miller, MD, DFASAM, DLFAPA
I have practiced addiction medicine in Wisconsin since 1983. Over the past 30-plus years, I’ve seen a steady exodus of health systems from addiction services, and this has had an impact on the workforce. Hospitals in cities large and small that had designated inpatient detox units have closed them, and nurses who worked in alcohol detoxification in hospital settings have shifted to other units or retired, taking their knowledge and clinical skills with them. While alcohol withdrawal in hospitals has improved with the use of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol), the clinical skills of experienced detox nurses for assessment and management have gone away.
With the opioid epidemic, health systems are paying more attention to addiction. But we still have a long way to go for health systems to recognize that this is a problem they should be addressing instead of something for someone else, like a county social services department to address.
A huge change in the past 30 years has been the introduction of FDA-approved medications to treat addiction. For nicotine dependence, the deadliest addiction of all (contributing to almost 500,000 premature and avoidable deaths per year), we now have nicotine replacement therapy in the form of the “gum,” lozenges, and the patch–but insurance companies have decided to take these off their formularies and require patients to self-pay for them as over-the-counter medications. These medications can make a huge difference in population health and lead to great savings in health care utilization; I think insurance companies should be eager to cover nicotine replacement therapies.
We also now have naltrexone and acamprosate for alcoholism and a number of off-label medications being used for addiction involving alcohol use, which is encouraging. The biggest change is buprenorphine and its introduction in 2003 for opioid use disorder. Buprenorphine is now used in general medical care, unlike methadone treatment for addiction which was administered in free-standing clinics far away from health care campuses. Generalists as well as specialists can prescribe buprenorphine, and it has become a vehicle for helping generalists understand that addiction treatment needs to be part of their wheelhouse.
From a workforce standpoint, a huge and more recent change is the new certification for physicians in the specialty of addiction treatment. Not only is there now a credential physicians can receive that is recognized by the American Board of Medical Specialties (ABMS), there are also fellowship training programs accredited by the Accreditation Council on Graduate Medical Education (ACGME). This has gotten the attention of medical schools like never before. The
American Society of Addiction Medicine has doubled its membership in the last 30 years and is now accepting non-physician members, such as advanced practice nurse practitioners and physician assistants. Physicians and others in primary care providers working in the addiction arena are taking on more of the characteristics of the healthcare workforce that addresses other chronic illnesses. This bodes very well for the future.
Dr. Miller is a Director of the American Board of Addiction Medicine and the American College of Academic Addiction Medicine, and a past president of the American Society of Addiction Medicine. He is certified in addiction medicine by the American Board of Preventive Medicine (ABMS).
